ILLUSTRATIONS

FIG. PAGE
1.The normal female pelvis[18]
2.The planes of the brim, the cavity, and the outlet[19]
3.Visceral relations[20]
4.Uterus and appendages[22]
5.Normal position of pelvic organs[24]
6.The external genitals[25]
7A.Varieties of hymen[27]
7B.Varieties of hymen[28]
8A.The excreting ducts of the mammary gland[29]
8B.Lobules and duct of the mammary gland[29]
9.Nipple, areola, and the glands of Montgomery[30]
10.Supernumerary milk glands in the axillæ[31]
11.The three ages of the breast[31]
12.Development of the ovary[34]
13.Graafian follicles[35]
14.Human spermatozoa[36]
15.The chorionic villi about the third week of pregnancy[38]
16.Diagram illustrating relations of structures of the human uterus at the end of the seventh week of pregnancy[39]
17.Maternal surface of the placenta and membranes[40]
18.Fœtal surface of human placenta[41]
19.The egg at term with uterus removed[42]
20.Normal attitude of fœtus[43]
21.Fœtal skulls showing sutures[44]
22A. and B.Child’s head at term, showing diameters[45]
23.The fœtal circulation[49]
24.Gravid uterus at the end of the eighth week[52]
25.Striæ gravidarum[54]
26.Bimanual examination[60]
27.Abdominal enlargement at different months of pregnancy[63]
28.Height of the uterus at various months of pregnancy[64]
29.Twins[83]
30.Diagram representing the sites for the various forms of tubal pregnancy[90]
31.Abdominal binder with crosspiece to hold vulvar pads[100]
32.T-binder, used in all cases after the fifth day post partum[100]
33.Breast binder[101]
34.Baby’s dress with winged sleeves[102]
35.The bag of waters begins to act on the cervix[111]
36.The effect of the pains. The cervix before labor begins[112]
37.The effect of the pains. The cervix begins to be “effaced”[112]
38.The effect of the pains. The cervix is effaced, and the dilatation of the os begins[113]
39.The effect of the pains. The cervix is effaced and the os continues to dilate[113]
40.The cervix is effaced and the os dilated[115]
41.Child in second stage of labor[116]
42.The head passing over the perineum[117]
43.Normal expulsion of the placenta according to Schultze[118]
44.The child in left-occipito-anterior position[122]
45.The child in right-occipito-anterior position[123]
46.The descent of the head in right-occipito-anterior position[124]
47.Internal anterior rotation and extension of the head in a left-occipito-anterior position[124]
48.Extension[125]
49.Extension completed. Expulsion[125]
50.A cephalhæmatoma[127]
51.Points of greatest intensity of fœtal heart tones[130]
52.Handling forceps, kept sterile in a jar of alcohol[132]
53.Palpation. What is in the pelvis?[134]
54.Palpation. What is in the fundus?[135]
55.Palpation. Where is the back? Where are the small parts?[136]
56.Patient draped for internal examination[137]
57.Delivery in side position[141]
58.Sheet twisted into a sling[147]
59.Repair of perineum[148]
60.The progress of involution[152]
61.The breech. Left-sacro-anterior position[166]
62.The breech. Left-sacro-posterior position[167]
63.Extraction of the breech[170]
64.Breech delivery. Extraction of the trunk[171]
65.Breech delivery. Delivering the shoulder[172]
66.The delivery of the after-coming head by the Smellie-Veit maneuver[172]
67.Shoulder presentation[173]
68.Face presentation[175]
69.Descent of the chin in face presentation[176]
70.Delivery in face presentation[177]
71.Exaggerated lithotomy position[181]
72.Dorsal position when assistants are available[182]
73.Instruments for artificial delivery of the head[183]
74.Forceps operation. Introduction of the left blade[186]
75.Forceps operation. The introduction of the right blade[187]
76.Forceps operation. Locking the handles[187]
77.Forceps operation. The way the blades should grasp the fœtal head[188]
78.Forceps operation. Traction on the handles[189]
79.Forceps operation. The delivery of the head[189]
80.Version. Seizing a foot[190]
81.Version. The child rotates as pressure is made upon the head and traction upon the foot[191]
82.Version is complete when the knee appears at the vulva[192]
83.The Walcher position[194]
84.The Wiegand compression of the child’s head to force it into the pelvis[195]
85.The Naegele perforator[196]
86.Apparatus for getting a sterile specimen of urine from an infant[201]
87.Tampon of the uterus[203]
88.Tampon of vagina[204]
89.Pean forceps[208]
90.Hand bulb syringe; and Vorhees bags; bag rolled and grasped by Pean forceps ready for introduction[209]
91.Vorhees bag in place[210]
92.Episiotomy[212]
93.Various forms of pelvic deformity[215]
94.The pelvimeter[216]
95.The various diameters of the inlet[216]
96.Measuring the distance between the anterior superior spines of the pelvis[217]
97.Measuring the external conjugate[218]
98.Measuring the diagonal conjugate with the finger[219]
99.Various forms of placenta prævia[229]
100.The knee-elbow posture[236]
101.The knee-chest posture[236]
102.The exaggerated lithotomy position obtained with a sheet sling[237]
103.The improvised Trendelenburg position[237]
104.The dorsal position with stirrups[238]
105.Dorsal position across the bed[239]
106.Flexed dorsal position with feet on the table[240]
107.The Sims position[241]
108.Examples of imperfect nipples[245]
109.A standard nipple shield[246]
110.A standard breast pump[251]
111.Germs most frequently found in cases of puerperal fever[256]
112.Rubber bath tub[266]
113.The Pettit cord clamp[268]
114.Standard breast pump; Standard nursing bottle; the breast tray; the Wansbrough lead nipple shield; the Brophy nipple for harelip and cleft palate[271]
115.Proper position of mother while nursing child[274]
116.Proper method of taking rectal temperature[276]
117.Method of passing the tracheal catheter[279]
118.Byrd’s method of artificial respiration. Extension and inspiration[280]
119.Byrd’s method of artificial respiration. Beginning flexion and expiration[280]
120.Byrd’s method of artificial respiration. Flexion and compression[281]
121.Method of giving gavage[284]
122.Apparatus for gavage or lavage[286]
123.Cleft palate nipple[288]
124.The device for feeding the child with cleft palate[288]
125.Device for assisting the cleft palate child to nurse[289]
126.Method of strapping an umbilical hernia[290]
127.Proper position for introduction of a suppository[299]
128.Hydrocephalus[307]
129.Anencephalus[308]
130.Elements of human milk[312]

OBSTETRICS FOR NURSES

CHAPTER I
ANATOMY

The study of obstetrics is an investigation of the passage, the passenger, and the driving powers of labor, as well as of the various complications and anomalies that may attend the process of reproduction.

The passage is composed of a bony canal, called the pelvis, and the soft tissues which line and almost close its outlet.

The pelvis is made up of four bones; the sacrum, the coccyx, and two other large structures of irregular shape, called the hip, or innominate bones. Joined by cartilage and held in place by ligaments, they form a cavity or basin which, in the male is deep, narrow, small and funnel-shaped, while in the female, slighter bones, expanded openings and wider arches make a broad, shallow channel, through which the child is born.

The bony pelvis is divided for description into two parts, the upper or false pelvis, and the lower or true pelvis. The upper pelvis is formed by the wings of the innominate bones and has but two functions of importance to child-bearing. It acts as a guide to direct the child into the true passage, and when measured by the pelvimeter, it gives information as to the shape and size of the inlet to the true pelvis. The true pelvis is of most concern to the obstetrician, because anomalies in its size or shape may impede the progress of labor or render it impossible. The pelvis is divided conveniently into three parts: the brim, the outlet, and the cavity.

The brim, inlet, or upper pelvic strait, is the boundary line between the false and true pelvis. It is traced from the upper border of the symphysis along the iliopectineal line on both sides to the promontory of the sacrum. The shape and size of this opening varies much in different races and individuals, both normally and through disease; and when pathologically altered, both shape and size may exercise a marked influence on the course of labor. In American women, the outline of the brim is roughly heart-shaped, like an ovoid with an indentation where the promontory of the sacrum impinges upon the opening.

Fig. 1.—The normal female pelvis. (Eden.) The lines ab and cd divide the pelvis into the right and left anterior and the right and left posterior quadrants. ab indicates the anteroposterior diameter of the brim, cd shows the transverse diameter while gh and ef represent, respectively, the right and left oblique diameters.

The brim or inlet has four important diameters to be remembered; important because the hard, round head of the child must pass through them by accommodating its diameters as favorably as possible to those of this opening. These diameters are named respectively the anteroposterior or conjugate diameter, the transverse, and the right and left oblique diameters. The two oblique diameters attain their greatest importance when the pelvis is irregularly distorted, but the others are essential in every case where labor impends. It is to secure an estimate of these latter diameters that the bony prominences are measured. This upper opening lies not horizontally, but in oblique relation to the body in standing position, and the weight of the abdominal viscera rests largely upon the bones and in consequence does not crowd into the inlet unless forced in by corsets or faulty habits.

Fig. 2.—The planes of (a) the brim, (b) the cavity and (c) the outlet. (Eden.)

Passing through the brim, a cavity is found below it, midway between the inlet and outlet, which is nearly round in shape. This is the “excavation,” or the true pelvis. Then comes the outlet, bounded in front by the pubic arch and soft parts, and behind by the coccyx pushed back as far as it can go. It is ovoid in shape, but the long axis of this ovoid lies at right angles with the axis of the ovoid inlet.

We find, therefore, a succession of three geometric figures or planes through which the head must pass by means of a spiral motion called rotation. These figures are inclined to one another so markedly in front that a line drawn through the center of each will curve forward at both ends, one end passing out near the umbilicus, the other through the vulva. This is known as the axis of the pelvis or the curve of Carus.

Fig. 3.—Visceral relations. (Redrawn from Gray.)