CHAPTER VII

PREPARATIONS FOR LABOR AND THE NORMAL COURSE OF LABOR

=The Nurse.=—Scientific obstetric nursing is a specialty that enlists the interest of exceptional women only.

It demands a high sense of duty, a strong physique, broad training, unusual judgment, and rare tact. The nurse must be professionally aseptic and personally clean. She should keep herself free from odors, and bathe at least three times a week. The presence of pus anywhere on her body disqualifies her _at once_, and she should report off duty.

The compensation should always be somewhat higher than for other work, because there are two patients to be cared for.

An obstetric nurse should specialize in her work, and not take infectious cases. Unhappily the haphazard character of the onset of labor presents a difficulty. The patient frequently can not afford to have the nurse for a long time in advance of labor, and the nurse whose income is limited by the number of her cases can not afford to be idle. Hence, it is better for two nurses to work in alternation with one another, so that one is always available in an emergency.

Both doctor and nurse should visit the lying-in room before labor begins, and plan its rearrangement. At least a week before the expected confinement, the chamber selected should be thoroughly cleaned and the woodwork wiped off. Curtains, draperies and bric-a-brac and all useless furniture should be removed. Carpets must be taken up, or at time of confinement, well protected. Rugs can be easily managed. A chair, a bed, and the various tables for instruments and solutions are all that are required.

The nurse usually is called to the case first, and upon her falls the responsibility of the diagnosis and the burden of the preparation. As soon as she arrives and satisfies herself that the patient is really in labor, she puts the final touches to the room. In her own mind she goes over all possible emergencies and prepares to meet them.

The following supplies should be in the house for the labor:

3 hand basins, 10 inches in diameter. 3 hand brushes. 1 two-quart douche bag. 15 yards nonsterile gauze. 2 lb. each of cotton batting and absorbent cotton for making bed pads. 2 pieces of rubber sheeting 1 by 2 yards. 5–yd. jar of borated gauze. 4 oz. lysol (or ziratol). 100 c.c. of Squibb’s chloroform. 2 oz. green soap. 2 oz. solid albolene. 8 oz. alcohol. ½ oz. ergotol. ½ oz. bismuth subnitrate and ½ oz. boric acid powder mixed. 1 nail file.

=Nurse’s outfit consists of the following:= Nail file, surgical scissors, catheter (silver is best), hypodermic syringe with tablets of morphine, strychnine, and digitalis; two fever thermometers, one for mouth and one for rectum; a pair of tissue forceps and a razor.

Some time before the labor, the nurse should call on the patient and establish a working acquaintance. It adds greatly to her authority and to the patient’s confidence in her. Her advice will be sought on a multitude of subjects, partly real and partly to try her out.

=Sterilizing= may be done in a hospital, or, if this is not feasible, the nurse should go to the house two or three weeks before the expected labor and sterilize in an Arnold or Rochester sterilizer the following articles:

½ doz. sheets. 3 doz. towels. 2 pillow slips. 3 abdominal binders of unbleached cotton, 16 in. wide and 36 in. long, folded and hemmed. 4 T bandages. 3 breast binders. 2 jacket parts of pajama suits. 3 pairs of long white stockings. 3 packages of vulvar dressings (see Preparation of Supplies, p. 326). 2 obstetric pads 1 by 36 by 36 inches. 1 pillow slip full of cotton pledgets for sponges. 1 jar applicators (cotton twisted about toothpicks). 1 jar of gauze pledgets for perineorrhaphy and cord dressings. Everything must be neatly wrapped and labeled.

=Infant’s Outfit.=—

12 plain slips 27 inches long of dimity or nainsook (with winged sleeves). 3 long sleeve shirts, silk and wool (size No. 2). 6 pinning blankets, made of outing flannel, if it is a winter baby. 3 bands, 6 by 18 inches, clip or notch edges, do not hem. 3 petticoats, flannel bottoms and muslin waists, without sleeves and with small button on shoulders. 3 outing flannel wrappers. 6 plain, soft muslin dresses. 3 (Arnold) knitted night gowns, light weight. 4 doz. light weight cotton diapers, 20 x 40 inches. Bird’s-eye linen is the best. Wash and dry these in the air before using. 4 soft towels (linen preferred). 2 quilted pads. 4 soft wash cloths. 4 wool wrapping blankets. 1 pair scales that weigh ounces and fractions thereof. 4 oz. of olive oil or benzoated lard. 4 oz. of alcohol (95 per cent). ¼ lb. boric acid crystals. ½ lb. absorbent cotton. 1 cake of castile soap. 2 oz. solid albolene. ½ oz. subnitrate of bismuth powder and ½ oz. of powdered boric acid mixed. 1 bed pan. 2 basins, holding 2 quarts each. 1 papier mache, rubber, or enamel ware bathtub.

=Anæsthetics.=—Excessive pain is destructive and disintegrating to the vital forces. Many a woman who has passed through a particularly severe labor remembers her experience with a horror that forever precludes its repetition.

This is the day of relative painlessness in labor, and all the world is striving to make childbirth easier and less lethal. No woman, unless she herself requests it, should be permitted to go through the agony of labor without an anæsthetic, judiciously selected and carefully administered.

Pain-deadening agents are numerous and inexpensive, and it is only a matter of experience and judgment to choose a method that will reduce the suffering of childbirth to a minimum. The second and first stages of labor, in the order named, demand the most in the way of relief.

A prolonged first stage with nagging, violent and apparently useless pains may devitalize the patient more than short, but acute pains of the second stage. In the first stage, under proper selection of cases and experienced supervision, “Twilight Sleep” will be successful in seventy to eighty per cent of the cases.

By success, is meant that the patient is relatively free from pain. When the drugs do not relieve pain, the case is a failure (fifteen per cent), although in no case, when properly given, is the mother or child endangered. Morphine solution ⅙ gr. and scopolamine hydrobromid 1/200 gr. to 1/150 gr. is the customary dosage for the first injection. Another injection of 1/200 gr. is given in a half or three-quarters of an hour. The room is darkened, talking is forbidden, and the family exiled. The patient gets red in the face and very thirsty, the pulse is rapid but full. She answers questions very slowly and drowsily, awakes for her contraction but goes right off to sleep again. In this condition she is kept through bi-hourly repetitions of the scopolamine until the delivery. It is this half waking and half sleeping condition that suggested the name of “Twilight Sleep.”

Morphine and scopolamine will relieve the pains of the first stage without greatly protracting the labor. The same drugs may and probably will prolong the duration of the second stage. The first dose should be given as soon as the patient is well started in labor.

“Twilight Sleep” is at present a hospital procedure, and the technic so exacting as to weary the attendants greatly. It can not be employed until the woman has definitely gone into labor and is at least three hours away from delivery. It is not serviceable where the pains are weak and shallow; and it must be used with wise circumspection, if at all, in the presence of complications.

For the second stage, there is a choice of three drugs: gas, chloroform, and ether. Like twilight sleep each is open to some objection, but each may be of the greatest assistance if used under appropriate indications and conditions.

Gas has one advantage, in that it in no way interferes with the pain activities; and Lynch and Davis have shown that with a proper admixture of oxygen, it may be given with comparative safety for the two or three hours which may mark a normal second stage. To administer it a competent machine for mixing the gas is necessary. It should not be given to patients who have bad hearts, high blood pressure, or toxæmia. Neither is it a satisfactory anæsthetic when the head delivers, for the mother being less relaxed and more rigid, the legs and muscle action are harder to control and unnecessary perineal lacerations are liable to occur. The patient is instructed to take several deep breaths just as the uterine contraction comes on and the gas bags supply about 75 per cent nitrous oxide and 25 per cent oxygen. As the pain passes off the oxygen is increased and the nitrous oxide diminished until the mind is again clear.

To save the perineum and better to control the patient, when the head is about to pass the vulva, it is wiser to abandon the gas for chloroform or ether.

Obstetrical operations, such as forceps and version, require ether or chloroform, and not gas. The dangers vary with the anæsthetic chosen, as well as the amount and the method of administration. Ether affects the respiration, chloroform attacks the heart. Ether must not be given near an open flame. Chloroform is not explosive but is decomposed by fire into an irritating gas. Chloroform must be diluted with 90 per cent of air, hence the mask must be open, or the napkin held free from the face, so that plenty of air can enter. Ether and chloroform, when given “_a la reine_;” i. e., a few drops on the mask at the beginning of each pain and increased up to the acme, is relatively free from danger. They have the additional advantage that the sleep may be instantly deepened if operation is required. Chloroform, it is now believed, predisposes mildly to post partum hæmorrhage. Davis has shown that neither ether, gas, nor chloroform affects the child injuriously if the administration is intermittent and not too greatly prolonged.

To summarize: Morphine and scopolamine combined is a first stage analgesic, which has too much value to be neglected.

Gas, if an apparatus is to be had, may work well for the greater part of the second stage, while for operations, or for the period of expulsion, during which the head passes the perineum, chloroform and ether give bests results. Moreover, chloroform “_a la reine_” may be given safely and efficiently by a competent nurse and in many instances _must_ be given by the nurse, if at all.

When the perineum bulges, or the head becomes visible at the vulva, the nurse should anoint the lips, cheeks and tip of the nose with cold cream or olive oil, to avoid burning the skin, and lay two or three thicknesses of handkerchief or gauze over the nose (an inhaler is best). An abundance of room must be left underneath and at the sides of the mask for air to enter.

At the beginning of the pain a few drops of chloroform are poured on the cloth and the patient instructed to breathe vigorously. The cloth is removed as soon as the pain ceases and when the next contraction comes on, the process is repeated. As the head passes the perineum, the chloroform should be pushed to complete anæsthesia, both to save suffering and to give the doctor full control of the perineum. When the nurse gives the anæsthetic, she should watch the doctor for his signal to increase the vapor or remove the mask.

_Summary._—Cover the eyes with a wet towel and anoint the face with cream or oil before using chloroform. Remove false teeth, if present.

Obstetric degree—a few drops on mask at beginning of each pain.

Surgical degree—complete anæsthesia.

Watch pulse and respiration.

A nurse should never leave a patient who has had an anæsthetic until she is conscious. Vomiting is especially dangerous.

=Normal Labor.=—Labor is the process by which a fœtus of viable age is expelled from the uterus.

By normal labor is meant a case where the fœtus presents by the vertex and terminates naturally without artificial aid, or complications. It varies greatly in severity, duration and danger to mother and child. A first labor is more prolonged and difficult than later confinements. A woman in her first delivery is called a primipara, in subsequent cases, a multipara.

The _date_ at which labor comes on is difficult to determine accurately. The average duration of pregnancy is from 275 to 280 days, forty weeks, or ten lunar months, but conception does not occur necessarily at the time of coitus, nor is it possible to know with any certainty when it does occur.

Labor may occur two weeks earlier than calculated, with benefit to the mother, and no harm to the child; but if the woman goes over time, the child becomes much larger and the labor harder and more dangerous to both.

=Causes of Labor.=—Why labor should occur at all is not known. Many theories have been advanced, none of which is entirely satisfactory. Some of the best known are the growing irritability of the uterus accompanied by an increase in the frequency and strength of the intermittent uterine contractions or increasing distention of the uterus. Thus it is believed that when the uterus is distended up to a certain point, it will try to relieve itself like the bladder, or a baby’s stomach. It may be that any one of the following factors, or all of them acting together, are influential.

Dilatation of the cervix by the presenting part.

Increasing distention of the lower half of the uterus with pressure on neighboring nerve structures.

The circulation of fœtal products of metabolism (toxins) acting on the nerve centers.

The menstrual periodicity.

Heredity and habit.

Physical and emotional causes.

The onset of labor probably is not purely accidental, and yet it is so inconstant in appearance and so indifferently early or late, that it has every appearance of being an affair of chance. The time when labor will come on is highly speculative in general, but the phenomenon is preceded by certain definite symptoms:

The lightening.

False pains.

Show.

Rupture of membranes.

The pains.

_Lightening._—About two weeks before labor, especially in a primipara, the uterus and the head sometimes descend into the pelvis. The body of the child falls forward and the abdomen protrudes, the stomach is flatter, the patient breathes easier and feels, as she says, “lighter.” But walking is more difficult, the bladder is stimulated to frequent evacuations and the rectum is compressed.

This occurrence is a premonitory sign of labor, and also favorable inasmuch as it demonstrates that this particular head is not too large to pass this particular pelvis.

_False pains_ may appear, especially in multiparas, from two to four weeks before labor. In some of these cases the pains may be due to gas or indigestion and respond to hot applications and enemas, or there may be definite uterine contractions, as shown by the hardness of that organ during a pain, but the phenomena are irregular and therefore not typical of labor pains.

Usually they pass off in a few hours, but if the patient is nervous, the doctor or nurse may be called needlessly. The patient, therefore, should be instructed to have the pains timed by the watch for half an hour or an hour. If they are regular during this period, the physician should be notified. Upon his arrival, an internal examination will reveal the true character of the disturbance by the condition of the cervix and os.

_The show_ is a discharge of thick, white mucus, slightly stained with blood. This is the mucus plug which occludes the cervix during pregnancy and when the os begins to dilate, the mass is released and passes out. Labor usually comes on vigorously within twelve hours.

_The membranes_ may rupture before labor begins and much fluid escape. The advantage of the dilating bag of water and lubricating qualities of the liquor amnii are thus lost. Such a labor is called a “dry birth” and is frequently slow, exhausting, and extremely painful.

_The pains_ are the subjective manifestations of the powers of labor. The forces concerned are uterine and abdominal muscles, principally assisted by those of the back, legs, and arms. Their constricting action on the nerve fibers in the walls of the uterus is the cause of the pains in the first stage. The onset may be violent and go on to a quick delivery, but generally the inception is more insidious.

The _irregular_, _painless_ contractions, (of Braxton Hicks) that were mentioned on an earlier page, gradually at term change their character and become _regular_ and _painful_.

At first they may be slight and vague, lasting only half a minute and separated by intervals of ten or fifteen minutes and scarcely attract the patient’s attention. They are felt chiefly in the abdomen.

More or less rapidly they increase in frequency, severity and duration. They last from a minute to a minute and a half and come every three minutes. The whole uterus hardens and its outline is clearly defined during the contraction; it relaxes and becomes soft in the interval. The woman is now in labor. The pains become grinding and the patient feels that she is not accomplishing anything, yet under the influence of these contractions the cervix is effaced and the os is dilated.

=The Course of Labor.=—Labor is divided for convenience into three stages as follows:

The _first stage_, from the beginning of pains until the complete dilatation of the os.

The _second stage_, from the complete dilatation of the os to the delivery of the child.

The _third stage_, from the delivery of the child to the expulsion of the placenta.

The _first stage_ is the stage of dilatation.

Usually at term, the cervix is columnar and unshortened, the canal intact, and closed at both ends, as shown in Fig. 36.

In multiparas the outer opening will usually admit the tip of the finger.

As labor proceeds, the cervix is _effaced_, the os slowly dilates, and the bag of waters forms.

_The Bag of Waters._—When the cervix is effaced and only the os remains, the lower end of the egg with its fluid restrained by the membranes, bulges forward into the canal. The fœtal head, or breech presses into the pelvis, and the fluid in the membranes, compressed between the presenting part above and the cervix below, is called the bag of waters.

When the contraction comes on the longitudinal muscular fibers of the uterus are drawn upward and the bag of waters becomes tense and pushes farther and farther down into the opening; and by its even and universal pressure, mechanically and slowly increases the size of the opening which the muscular traction is pulling apart. At the same time, the fluid around the child prevents, for a time, direct and injurious compression on the body. When no definite cervical projection can be felt, and when the teat-like protrusion of the cervix has disappeared, the cervix is said to be effaced.

The os now begins to stretch and widen, the bag of waters becomes more and more evident, vomiting occurs, and at last, when the os has expanded to a diameter of four inches (ten centimeters), the membrane can withstand the pressure no longer. It ruptures, a certain amount of fluid escapes, the presenting part comes down against the opening, and like a valve, prevents the outflow of the waters from above.

Sometimes the labor may be preceded by some hours (two or three), or days (two or three), even weeks (two or three), by the rupture of the membrane, and sometimes when the structure is thick and tough, the rupture may be delayed until well into the second stage, or even until the child is born. In the latter case, the head comes out, covered with membrane. In the old days, this was called being “born with a caul.” It was supposed to be a lucky omen, but it was lucky only that the babe escaped suffocation. The membrane should be torn open quickly.

The duration of this stage is variable. It is much longer in primiparas than multiparas. It averages sixteen hours in the former, and eight hours in the latter. Vomiting during this stage is quite common, but the pulse and temperature remain normal. The first stage of labor is usually under the entire control of the nurse. It is her responsibility.

With complete dilatation of the os, the _second stage_, or stage of expulsion, begins, whether the membranes rupture or not. The presenting part, usually the head, passes from the cervix into the vagina. The vagina in turn gradually dilates from above downward until uterus, cervix and vagina form a single, wide channel of the same diameter. The child is driven forward by the uterine contractions, strongly reinforced by the abdominal muscles, which the patient uses vigorously. The onset of each pain is accompanied by a deep inspiration, followed by straining or bearing down with the abdominal muscles as in a highly exaggerated bowel movement. The patient holds her breath, braces her feet, fastens her hands on bed or attendant, and uses all the trunk muscles in the effort. The face becomes congested, the pulse quickened, she perspires some, and groans deeply during the contraction. The pain is extreme and is due partly to the stretching of the vagina and vulva and partly to the distention of deeper sensitive structures.

When the head reaches the pelvic floor, the first change observed in the external genitals is the stretching (bulging) of the perineal body. Next, the anus becomes turgid, dilates slightly, the anterior wall becomes visible, and the hairy scalp of the child appears at the vulva. The actual expulsion of the head in a primipara is accomplished by a series of prolonged and severe contractions, accompanied by violent straining.

A short pause ensues, followed in two or three minutes by a return of the pains, which expel first the shoulders and then the trunk. As the body escapes it is followed by a rush of blood-stained liquor amnii. This is the fluid that has been pent up in the uterus by the obstructing body of the child. The second stage lasts about two hours in a primipara and from fifteen minutes to one hour in a multipara.

_The third stage_ is the delivery of the after-birth. The after-birth sometimes called the secundines, consists of placenta, umbilical cord, and membranes.

After the expulsion of the fœtus, the uterus undergoes a sudden diminution in size. It is about as large as the child’s head, and the fundus lies near the level of the umbilicus. The contractions still persist feebly, but they are practically painless, and the patient is greatly relieved, possibly sleeping.

In from ten to thirty minutes, the uterus becomes smaller, harder, more globular in shape and more movable. The patient brings the voluntary muscles of the abdomen strongly into action again. The nurse presents a sterile basin and the physician sustains and slowly twists the membranes free from their final attachment and out of the uterus. When the placenta passes the vulva, a moderate sized blood clot follows it.

The uterus is now much smaller, and hard and firm in consistency, but for some hours the contractions are intermittent, and while this continues, there is risk of hæmorrhage.

_General Effects._—The mother’s pulse is quickened during the contraction. The fœtal heart beats more slowly and feebly during a contraction, but quickly recovers in the interval.

The amount of blood lost during labor averages from ten to sixteen ounces. The temperature may be elevated one or two degrees in a woman of moderate physique, while one with a fragile body may present the signs and symptoms of surgical shock. The chill, pallor, cold limbs and body, rapid and feeble pulse with subnormal temperature, suggest to the nurse at once the proper _treatment_. Heat, to all parts of the body, warm covers and hot milk or coffee. If hæmorrhage is present and the uterus relaxed, the nurse should immediately inject pituitrin (15 ♏︎) into the deltoid muscle and notify her attending physician.