Obstetrics for Nurses

by Charles B. Reed

IMMEDIATELY AFTER LABOR

Perineorrhaphy must be done if required.

A lacerated cervix is not to be repaired at this time, except in case of hæmorrhage, for the tissues are greatly swollen, and if sutures are put in tight enough to allow for sufficient shrinkage, they will cut through; while if not tight, they will be useless in twenty-four hours.

Care of Mother.—

1. Cleanse genitals with lysol solution 0.5 per cent from above downward. 2. Put on sterile pad, with pad holder and binder. 3. Wash face and hands. 4. Take temperature, pulse, and respiration. 5. Glass of hot milk. 6. Keep on back four hours. Watch uterus for hæmorrhage and keep firm by occasional massage. 7. Put tape with case number on arm.

Care of Child.—

1. Clamp for the cord. 2. Place on right side with head lower than breech. 3. Keep warm and watch for cord hæmorrhage. 4. Treat eyes with silver nitrate solution 1 per cent, or argyrol solution, 15 per cent. Do not neutralize the 1 per cent silver nitrate solution. 5. Put tape with case number corresponding to mother’s on arm.

To preserve the perineum from rupture is an important duty, and in a definite percentage of cases, unsuccessful. Nevertheless, it is a duty, which, in the absence of the doctor, may fall upon the nurse. How shall she meet it?

The greatest danger to the perineum comes from a too rapid advance of the head; hence, the nurse retards the delivery by putting the woman on her side where she can not bear down so successfully, and instructs her to cry out with her pains. She may also delay the labor by holding the head back with a clean pad until the vulva stretches to its fullest capacity.

The rules which the doctor follows in protecting the perineum as the head advances, may be thus summarized.

1. Deliver the patient on her side. 2. Maintain flexion of head. 3. Delay extension of the head. 4. Give chloroform to retard delivery and to prevent precipitate delivery. 5. Deliver between pains, if possible, by Ritgen’s maneuver (modified). 6. Do episiotomy, if necessary.

Perineorrhaphy.—Lacerations of the perineum occur in about 30 per cent of all primiparas and in from 10 to 15 per cent of multiparas. They occur when the child is large or too rapidly delivered, and when the orifice is small or the tissues inelastic.

For convenience, the lacerations of the perineum are divided for description into three degrees.

The first degree involves only the fourchette and a small portion of the mucosa. It is rarely more than one-half an inch in depth and requires no attention except cleanliness by the nurse.

The second degree may tear a variable distance into the perineal body, sometimes so deeply as to expose the sphincter ani. It is usually on one side, but may appear on both sides, and be accompanied by prolongations into the vagina.

The third degree passes through the sphincter and sometimes well up the rectal wall. This is also called a complete tear.

The lacerations of the perineum which require sutures should be attended to at once unless the patient’s condition is critical. In such cases the repair may wait from twelve to twenty-four hours.

For this operation the nurse will assemble and boil for fifteen minutes:

2 pairs of scissors.

2 tissue forceps, one with teeth and one without.

1 bull-dog forceps.

3 artery forceps.

6 needles, 3 full and 3 half-curved.

1 dressing forceps.

1 needle holder.

Suture material of catgut and silkworm gut should be ready in sterile containers. The catgut should be the twenty-day chromicized, No. 3 and 4. Even then the strands are quickly absorbed when the lochial secretions flow over them.

Silkworm gut is better, but hard to remove from the vagina; hence it is customary to use catgut inside the vagina and silkworm gut for the sutures outside.

The nurse renews the supplies of gauze and cotton sponges. Hot solutions are prepared, and the patient brought into a position on table or across the bed so that the best light may be had. The legs may be held by the husband or nurse, or both. If help is inadequate, a sheet sling can be utilized. This is made by twisting the sheet from corner to corner and passing it rope-like over the shoulders, and back of the neck. Then each end is tied above the patient’s knee on either side as the legs are flexed in an exaggerated lithotomy position.

The sutures are now introduced and tied loosely from below upward and from within outward. If tied too tightly, they will cut through. The success of the operation depends on two things: the care with which the levator ani, if torn, is found and restored; and the scrupulous cleanliness obtained by the nurse in her after-care. If the stitches become sore, a few drops of sterile glycerine should be applied with an applicator.

Fig. 58.—Sheet twisted into a sling. The patient lies on the unrolled portion. The rolled cords bearing against the shoulders are tied to the legs below the knees. See Fig. 102. (American Text Book.)

If catgut is used inside the vagina, the counting of the stitches is gratuitous, since they absorb without removal. If silkworm gut is used, the number of sutures must be recorded, lest one be overlooked in removal.

Binding the legs together after repair is not required, but the sutures must be given aseptic care after each bowel movement, each urination, and when the pads are changed, if they have become contaminated. The sutures are removed on the tenth day.

Fig. 59.—Repair of perineum. Sutures in place. (Hammerschlag.)

After complete tears, the bowels are kept constipated for two or three days, and then moved with a high enema of sweet oil, followed by castor oil by mouth. After the bowel movement, the nurse should wash out the rectum with normal saline solution. The nurse must look carefully at the stitches every time the pad is changed and note if the swelling is increasing or diminishing, if there is irritation or tenderness, or if they are cutting out through the tissues.

The external sutures are usually left long and tied together in a knot, to prevent the ends from sticking into the patient. If she complains of this, the ends may be wrapped in sterile gauze. During the progress of the case the nurse must watch for and report any sign of fluid passing from bowel through the vagina.

The perineorrhaphy being completed, the woman is permitted to rest though the nurse will make frequent examinations of pulse and respiration. She will note the look of the face and the hardness of the uterus. The pad should be watched and the amount of blood discharged, duly estimated. If the flow does not diminish or if the uterus should balloon up, the doctor should be notified and the nurse meanwhile should give a dram of ergot (fluid extract) by mouth or an ampoule of aseptic ergot hypodermically.

The doctor should remain within call of the patient for at least an hour after delivery.

In the hospital the following rules may be used as a concise guide for the conduct of the third stage:

Conduct of Third Stage.

Keep patient on back and keep a hand on fundus. Note amount of blood lost, its character, its flow, and whether steady or in gushes. The placenta should detach itself normally in thirty minutes. After thirty minutes, expulsion may be assisted by—

(1) Early expression.

(a) Massage, rub and knead the uterus, until it hardens under the hand.

(b) Seize contracted uterus by fundus with full hand, fingers behind and thumb in front.

(c) Push slowly but firmly toward the pelvic outlet.

(2) Credé expression.

Same maneuver as above, except that the fundus is compressed between thumb and fingers while the downward movement is progressing.

Conditions for Credé expression:

(a) Uterus must be contracted.

(b) Uterus must be in median line.

(c) Bladder must be empty.

If not successful, wait ten minutes and then repeat maneuver. Never make traction on the cord. Never use ergot until uterus is empty.

If placenta does not come away within an hour, manual removal must be considered. In case of hæmorrhage, it must be removed at once.

Carefully inspect placenta and be sure it is complete. (See Post Partum Hæmorrhage, p. [232].)

When the patient is put to bed, the bloody sheets and towels are put to soak in cold water, and after several rinsings, may be sent to the laundry. Drapings stained with fæcal matter must be cleansed separately.

CHAPTER X
THE NORMAL PUERPERIUM

The puerperium is the name given to the period succeeding the birth of the child as far as the time of the complete restoration of the genitals. It may last from six to ten weeks, or even longer if complicated.

When the labor is completed, the most urgent desire of the patient is for rest. She is thoroughly exhausted in nerves and body. A post partum chill may appear,—a slight shiver that may last a quarter of an hour. Since the pulse and temperature remain unaffected, this phenomenon may be regarded merely as a sign of prostration or nervous revulsion.

In the course of the first three days, the temperature may rise to 100° F. in a case entirely normal. It has no pathological significance unless persistent or increasing. The temperature should be taken night and morning, and in complicated cases every four hours. All temperatures over 100° F., after the initial rise and descent just described, must be regarded as septic.

The pulse does not rise with the temperature of the first three days, but remains firm or even falls a little. When the pulse rises and the temperature sinks, it means hæmorrhage.

The urine is usually increased for the first few days and then returns to the normal for that patient. The labor affects the patient like a surgical operation.

The digestion is disturbed. The appetite is gone, and the stomach must be treated gently until its tone is restored. The body in repose is less urgent in its demands for food. Liquids in abundance form the staple diet for the first two days. For the next three days, semisolids may be added, and after the milk is well established, a general diet is desirable; but so long as the mother nurses her child, the liquids must preponderate in most cases.

Fig. 60.—The progress of involution on the various days of the puerperium. (von Winchkel, from Knapp.)

Meanwhile, certain changes are taking place in the pelvis that are highly important.

Involution is the process undergone by the uterus in returning to its normal nonpregnant state. This shrinkage can be followed abdominally and is registered by the nurse in the number of finger-breadths or centimeters above the symphysis pubis.

Edgar gives the rate of shrinkage as follows:

After delivery,	5.92 in. long, or	15.8  cm.
2nd day,	4.63 in. long, or	11.30 cm.
3rd day,	4.37 in. long, or	11.10 cm.
6th day,	3.42 in. long, or	8.48 cm.
8th day,	2.55 in. long, or	6.40 cm.
10th day,	2.22 in. long, or	5.60 cm.

The rate of involution not only varies greatly with different women, but varies much after the different labors of the same woman.

Ordinarily at the end of the first week the fundus should lie midway between the navel and the pubes, and should shrink rapidly thereafter.

The necessity for watching the rate of involution is imperative for a number of reasons. If involution is slow, or stops, it may indicate fatigue of the muscle from multiparity or over-distention (twins, hydramnios, etc.) or it may follow a post partum hæmorrhage. Subinvolution may also indicate infection, the retention of clots, or pieces of placenta. It happens also when the woman gets up too soon or does not nurse her child and thereby delays the restoration of her waistline, as well as diminishes her resistance to disease.

The binder is objectionable to some doctors on the ground that it favors retroversion of the uterus during involution.

This would be a plausible theory when the uterus is high, if it were not that the vertebræ of the patient and the pelvic brim keeps the uterus from being pushed out of its place and after the uterus descends into the pelvis the gentle pressure of the binder evenly distributed over the abdomen can not affect it appreciably. Furthermore, the uterus in involution shows a persistent tendency toward anteflexion and anteversion.

The binder is merely a girdle put on just tight enough to hold in place the bandage that supports the perineal pads and to allow the patient more easily to grow accustomed to the sudden change in intraabdominal pressure which the delivery of the child creates. However, if the doctor objects to a binder, it may be left off with safety.

The Lochia.—When the placenta is delivered, the uterus normally closes down and all gross hæmorrhages cease; but for the next two weeks or possibly longer, a vaginal discharge continues. For the first few days it is hæmorrhagic in character and it is called lochia rubra, and consists mostly of fluid blood with occasional small clots. By the fourth day, usually it has become brown and thinner. It is now called lochia serosa. By the tenth day, it is yellowish-white, and is called lochia alba.

The lochia is the wastage from the shrinking uterus, and is made up of red blood corpuscles, epithelial cells, leucocytes, and pieces of broken-down deciduæ. The entire lining of the uterus is loosened, discharged and a new one formed during the puerperium. The lochia is regularly infected by bacteria in the vagina. If involution is slow, the lochial discharge may be prolonged.

The After-Pains.—The puerperium is not infrequently accompanied by painful contractions of the uterus called after-pains. These are more common in multiparas and serve a useful purpose in maintaining a definite contraction of the uterus.

If the pains are at all severe, they are a suggestive symptom of the retention of blood clots, a fragment of placenta, or of membrane. This, of course, will occur either in a primipara or multipara. In all cases the after-pains must be differentiated from gas and from the pains of pelvic inflammation.

Gas pains can be relieved by hot spiced drinks, asafœtida and the high rectal tube.

Subinvolution is treated by the administration of fluid extract of ergot, in twenty to twenty-five drop doses, three or four times daily. This will bring about the discharge of the irritating fragment or clot, and the nurse can aid the process by gently massaging the uterus several times daily or by giving a hot vaginal douche. Codeine may be used for after-pains if absolutely necessary.

Diet in Normal Cases.—There is no restriction on the kind of food the patient may take, so long as she can digest it cleanly and without gas. Acids or alkalies, cold or hot, rich or otherwise, fruits, meats or vegetables, all go to the formation of good milk if properly digested. The old idea that acids should not be eaten is fallacious. There is more acid in the stomach normally, than could be added in a meal made up entirely of citrus fruits. At the same time, the heavy foods should be avoided on account of the serious demand on the liver and kidneys in the absence of exercise.

On the other hand, if the breasts are engorged, the fluids must be reduced to a minimum, and a relatively dry diet enforced.

The patient loses about one-ninth of her previous body weight in the course of labor and the puerperium.

The breasts are made ready for lactation twelve hours after delivery by cleansing with sterile green soap and warm water and bathing in 50 per cent alcohol. Next, the nipple is attended to, and the infant is put to the breast.

The nipple is prepared by cleansing it with an applicator soaked in fresh boric acid solution, and after nursing, the same process is repeated. This is routine, whether the mother is in bed or walking about. In the latter case, the mother must be taught to care for her own breasts.

The child is put to the breast every three hours and given six feedings a day. This leaves a six hour interval at night, which is very necessary for the mother’s rest and for the child. If the babe is feeble, seven or eight feedings in the twenty-four hours may be required for the first two weeks.

At first the breast only secretes a thick, yellowish secretion called colostrum, of which the child gets from a drachm to an ounce. It is a mild laxative.

The irritation of the nipple by the child’s mouth is begun as early as possible in order to stimulate the breasts to secrete milk and the uterus to contract, and thus aid involution and the preservation of the maternal figure.

The milk usually “comes in” on the third day and is accompanied by a sense of distention and moderate pains in the breasts. The glands may be hot, hard and swollen, but normally there is no rise of temperature with the inflow of the milk, except with nervous women who stand pain badly. There is no such thing as milk fever. If fever appears at this time, an infection must be suspected.

The engorgement of the glands may become so great that the nipples are drawn in and nothing is left for the child to grasp. If the engorgement becomes too painful, fluids are removed from the diet list, and saline cathartics administered, while ice packs are applied to both breasts. Heat should never be used except for the purpose of hastening suppuration.

This engorgement, or so-called “caking” of the breasts is not due to the milk, but to the infiltration of the connective tissue around the glands with serum and blood which stimulate the glands to secrete. The distention usually disappears in twenty-four or forty-eight hours, especially if the child is sturdy. Massage of the breasts only increases their activity and tends to make the trouble worse.

The weight of the glands may be considerable and require the application of a light supporting breast binder. Pillows under them will also give relief at times.

In putting the child to breast, the mother should lie on the side with the arm raised and the child is dropped into the hollow thus created, facing the mother (see Fig. 113). In this position the nipple will most easily and conveniently slip into the child’s mouth. The child should nurse fifteen or twenty minutes and then be removed. The toilet of the nipple is made by cleansing with boric solution as previously described, and then placing not gauze but a piece of aseptic cotton cloth over it, after which the binder is readjusted. (See Breast Covers, p. [326].)

The menstrual flow ceases during lactation as a rule, but not invariably. The flow returns in from four to six weeks after delivery, if the child is not nursing, and about the same time after lactation ceases. There is a popular idea that conception can not occur during lactation, and many women injuriously prolong lactation in the hope of avoiding another child. The theory is fallacious and conception during lactation is not uncommon.

The Bowels.—A lying-in woman is regularly constipated. Lack of exercise, a nutritious diet, but one with a minimum of wastage, together with relaxed abdominal walls, contribute to a condition that is primarily due to changes in intraabdominal pressure, which follow the delivery. For weeks the intestines have been under pressure and irritation by the growing uterus, and when this is suddenly removed the intestines become sluggish.

On the morning of the second day the patient should receive an ounce of castor oil. This dose, suspended in black coffee, beer, orange juice, or sherry wine can be taken by nearly everyone. In from four to six hours a normal saline, or soapsuds enema is given. The enema may be repeated daily, or if this is objectionable to the patient, the castor oil or Russian oil, may be given as a routine. Saline cathartics should not be used unless there is an oversupply of milk.

There is sometimes a good deal of gas following labor, which can be removed by the 1–2–3 enema (see Enema, p. [335]). In giving enemas, the nurse must use great care to avoid touching or infecting an injured perineum.

Many women secrete less gas and are agreeably influenced mentally by a five grain pill of asafœtida taken thrice daily.

Urination.—One of the commonest difficulties after labor concerns micturition.

Owing to the swollen and bruised condition of the urethra and the nerves supplying the neck of the bladder, the usual stimuli do not act and the woman, conscious of a painful distention, is unable to pass water. The helplessness is increased by her position in bed.

The nurse must make every effort to have the bladder emptied naturally. The process is aided by letting the water run from the faucet into the toilet basin, by using hot applications to bladder or vulva, by allowing warm, sterile water to run down over the vulva and perineum, by an enema, by putting smelling salts to the nose, by using slight pressure over the bladder, or by having the patient sit up on the bedpan.

If these measures fail and moral suasion is fruitless, the bladder must be catheterized at the end of twelve hours. The two dangers of catheterization are injury to mucous membrane, and infection. Many cases of cystitis have resulted from an unclean catheter or the improper use of a sterile instrument.

To catheterize a patient, she is first given aseptic care during which particular attention is paid to the meatus. This should be cleansed with an applicator dipped in a solution of boric acid. Next, the nurse prepares her hands by scrubbing ten minutes in hot running water with sterile nail brush and green soap. The catheter either of soft rubber or glass, is boiled for fifteen minutes and passed, not by touch, but by sight, and the flow is received in a clean basin and the amount recorded. As soon as the urine ceases to flow freely, the tip of the index finger is placed tightly over the end of the catheter and the instrument is gently withdrawn. The finger is placed over the end of the catheter not only to avoid the dripping of urine as it is removed, but especially to prevent the disagreeable sensations produced by the inrush of air.

Usually one catheterization is sufficient, and every time the bladder fills, the nurse must take the time and trouble to make the patient urinate spontaneously, if possible, for some women form a catheter habit, from which it is difficult to break them. After natural urination and after catheterization, the aseptic care should be repeated.

The Genitals.—The vulvar pads should be changed as often as they are soiled. Four a day is an average number, and six or eight in the first three days is not unusual. Every time the pad is changed, the nurse should give aseptic care, and extra attention whenever the bowels and bladder are emptied.

The dried secretions should be washed off with sterile sponges, wiping always toward the rectum and throwing away the sponge. Smegma collects in the folds of the labia and about the clitoris. This should be carefully sponged away. If it becomes dry and hard, oil or albolene will soften it and facilitate its removal. Plenty of soap and warm water should be used, then with a pitcher or douche point, the whole area is irrigated with a solution of lysol 1 per cent. Especial care is given to the stitches if any are present. No traction must be made on the ends of the sutures, and if unusual soreness is complained of, the doctor should inspect them at his next visit.

The nurse should be careful not to get lochia on her hands as the discharge contains germs which she may carry to herself, to the baby, or to the patient’s breasts or eyes.

Painful swelling of the vulva, or edema of the rectal protrusion may be relieved by hot boric dressings or by ice bags to the anus.

The vaginal douche is rarely employed at present except under specific indications.

If the involution is slow, it is safer to use ergot by mouth, rather than the hot vaginal douche, as sometimes recommended. The douche is a frequent source of infection, as well as a useless procedure. Nevertheless, a dainty woman gets much comfort mentally, as well as physically, if she is kept clean and free from odors; hence if the lochial discharge becomes offensive on the fifth day or sixth day, as sometimes happens, a single hot vaginal douche may be permitted. A 1:5000 solution of potassium permanganate, or a teaspoonful of formaldehyde to a quart of water, or a chinosol solution 1:1000 may be used.

Rest.—Since the patient will be in bed from eight days to two weeks in normal cases, she must be made as happy and comfortable as possible, and nothing contributes so much to her satisfaction as a cheerful, competent nurse. Her mind is at ease about herself and her child, and the companionship of the nurse can be made one of the pleasantest recollections of her illness.

Any patient who is at all reasonable can be managed by a tactful nurse without the consciousness of being opposed or directed. Gossip, hospital stories, criticism of other cases, other nurses, or of doctors should be avoided. The patient is deeply interested in her own case, and the private troubles of the nurse do not concern her nor enlist her attention for more than a few polite but unpleasant moments.

The nerves of the patient are highly sensitized, and therefore she should sleep as much as possible at night, and take an additional nap in the afternoon. Only the members of the family should be allowed to see the patient the first week, and they but for a short time. It takes the strength of the patient unnecessarily to see guests even though they be close friends. Importunate visitors may be pacified frequently by a view of the baby. The patient must be spared all household responsibilities, and if necessary, the nurse must take charge. Tact must be used to avoid being dictatorial, either to family or servants. If anything unusual arises, the nurse must show no surprise, annoyance, or bewilderment. Everything is attended to quietly, firmly, and without friction.

Getting Up.—It is a tradition that the woman is lazy who does not get out of bed by the ninth day.

There are three factors to be considered, the progressive involution of the uterus, the strength of the patient, and the presence of stitches. Involution may be complete on the fifth day, but the prostration from the labor may make the woman indifferent to arising. She may be strong enough to rise on the third day, but the uterus is large and heavy, and the erect position will put an unnecessary strain on the supports which may retard involution and cause displacement or disease later. Also, it is not desirable for a woman to sit up until her perineum is well on the road to restoration.

In general, the woman should not get up until the uterus has gone down into the pelvis and is nonpalpable. If this is the case on the fifth day and she feels strong, she may get up. If she is not strong, time will be saved by staying in bed until her vigor returns, whether it is ten days or twenty.

Getting up may be followed by a return of the bloody discharge. This may come from subinvolution, from a relaxed and flabby uterus, from a cervical tear, or from change in posture.

If there has been a retroversion before pregnancy, lying prone with an occasional knee chest position for a few moments will aid. Massage and passive exercises while in bed will aid the patient to recover and to maintain her strength. Even after she is up and about, she should lie down frequently during the day and always when nursing the babe, until she feels quite normal again.

For the hospital the following standing orders may be followed:

Standing Orders—Puerperium

Breasts:

1. Prepare for lactation 12 hours after delivery.

(a) Clean breasts and nipples with soapy water and green soap.

(b) Sponge with sterile water.

(c) Sponge with boric solution.

(d) Sterile compresses over nipples and adjust binder.

2. Babe to breast immediately after breast preparation.

3. Every morning apply fresh compresses over nipples and oftener, if necessary.

4. Cleanse nipples with boric solution (use applicator) before and after each nursing.

To dry up milk:

Restrict fluids; give saline cathartics; apply ice bags to breasts, as needed; for pain give codeine solution ¼ to ½ gr. hypodermically, if necessary.

Do not massage, do not bind, do not pump. Let breasts alone.

When breast is inflamed:

Apply ice bags constantly until pain subsides and temperature goes down. Watch for signs of suppuration.

Genitals:

1. S.S. enema each morning, followed by aseptic care.

Cleanse from above downward—1 per cent solution of lysol and cotton pledgets.

1 pledget for each side.

1 pledget for center.

1 pledget for rectum (last).

External douche of sterile water.

Dry sterile pad.

2. Aseptic care following all bowel movements and urination.

Routine:

1. Record pulse and temperature twice a day, unless otherwise ordered.

2. Bladder must be emptied in twelve hours. If all persuasive means fail (may sit up in bed), catheterize.

3. Make daily records of conditions of uterus (firmness and height), breasts and nipples.

4. No vaginal douche unless ordered.

5. Diet: liquid two days; semisolid two days; then general.

6. Watch for hæmorrhage.

7. Keep uterus firm by occasional massage.

8. All cases to have castor oil, 1 ounce within thirty-six hours after delivery (before noon).

9. Woman may get up as soon as uterus can not be felt above pubes, if there is no contraindication.

The history sheet should be kept accurately and should show every incident in the course of the lying-in period.

The condition of the bowels, bladder, and lochia, the temperature, pulse and respiration and the height of the fundus above the symphysis from day to day must be set down in finger-breadths or centimeters.

For the hospital, the following system will be found useful in establishing a routine.

Nurse’s Record

First Stage.

1. When pains began.

2. Frequency and duration of pains.

3. Character vaginal discharge.

4. Time membranes ruptured.

(a) Artificial.

(b) Spontaneous.

Second Stage.

1. Time second stage began and ended.

2. Anæsthetic.

3. Mode of delivery.

4. Who delivered.

5. Sex of child.

(a) Living.

(b) Dead.

6. Perineum.

(a) Condition.

(b) Repair.

Third Stage.

1. Method.

(a) Spontaneous.

(b) Early expression.

(c) Credé expression.

(d) Manual removal.

2. Placenta delivery.

(a) Time.

(b) Size.

(c) Complete or incomplete.

(d) Length of cord.

3. Note.

(a) Hæmorrhage.

(b) Quantity.

(c) Color.

(d) Clots.

General condition—was case number put on mother and child?

Other treatments.

Medications.

Condition of uterus.

Temperature, pulse and respiration before leaving delivery room.

Signed ..........................

(Nurse’s Name.)

CHAPTER XI
UNUSUAL PRESENTATIONS AND POSITIONS

Breech Presentation.—The pelvic pole enters the inlet first, once in thirty cases and more commonly in primiparas than otherwise.

Etiology.—Anything that interferes with or deranges the laws of normal gestation will predispose to, or produce this anomaly.

Thus, if the head is too large, as in hydrocephalous, or if the fœtus is too movable, as in hydramnios, or if an obstacle, like placenta previa, contracted pelvis or tumors prevent the proper approach of the head to the inlet, the mechanism will be disturbed and a breech or possibly a shoulder presentation will result.

Abnormal flaccidity of the uterine or abdominal walls, prematurity or twins also contribute definitely to its occurrence.

The attitude of the child generally retains its normal aspect of complete flexion. This pose, however, is not maintained invariably for on occasion the buttocks and genitals may rest upon the inlet while one or both feet may be extended on the thighs and lie beside the neck, or the thighs may be extended while the knees remain flexed, and what is known as a knee presentation, or if the foot comes down, a footling presentation results.

Positions.—The sacrum is the most prominent bony landmark of the breech, hence the positions are named from the relation this bone bears to the four quadrants of the inlet.

Fig. 61.—The breech. Left-sacro-anterior position. (Lenoir and Tarnier.)

We have therefore in their order of frequency the following designations: Left-sacro-anterior, where the sacrum lies to the left of the median line of the mother’s body and in front; right-sacro-anterior, where the sacrum lies to the right and in front; right-sacro-posterior, where the bone lies near the mother’s vertebral column, and on the right side; and the left-sacro-posterior position, where the bone occupies a corresponding place on the left side.

Diagnosis.—The recognition of this presentation is most easily secured by external abdominal palpation in pregnancy, which may be reinforced during labor by the internal examination.

Fig. 62.—The breech. Left-sacro-posterior position. (Lenoir and Tarnier.)

Externally the palpating fingers at the pelvic brim will note the absence of the hard, round head, and feel a mass, softer, quite irregular in shape, and less defined than customary. Movements also may be appreciated that would be too far down in the uterus if the head was presenting.

Next the hard, spherical tumor of the head can be outlined somewhere in the fundus, and the heart tones, instead of being below the umbilicus will be on the same level or even higher.

Vaginally the cervix is not filled out, the presenting part does not come down, but after labor has begun the distinctive features of the breech gradually become more evident, as they are driven into the pelvis.

One or both feet, or the buttocks, may be recognized. The examining finger may possibly enter the anus and be stained with meconium or pinched by the sphincter, which differentiates this orifice from the mouth.

One after another the characteristic landmarks appear until the diagnosis can not be doubtful. As soon as the sacrum is found or the legs definitely placed, the position can be named.

Mechanism.—The hips always enter the inlet in one of the oblique diameters and the back is turned to the same part of the uterine wall as in the corresponding vertex positions.

The acts described in the mechanism for vertex deliveries show a somewhat different order. Descent is first, then comes internal anterior rotation, which brings the anterior hip under the symphysis and its delivery is quickly followed by the posterior hip, which rolls out over the perineum.

The body advances, as a rule, with the back toward the front of the mother. The shoulders with arms folded move under the pubic arch and then the head delivers in a state of flexion. The head, of course, has no caput and it is not moulded.

This mechanism may be greatly impeded or complicated at any stage of the movement. The advance may be retarded to a pathological degree, the belly may be large and as it passes along the canal one or both arms may be stripped up alongside the head or even into the back of the neck. The head may be arrested at the inlet by the arms, by its degree of deflexion, or by pelvic contraction.

The rotation may not take place, or it may be abnormal, and the belly of the child look forward toward the mother’s. Any of these variations adds further to the difficulty of the labor and to the danger of the partners in the event.

Artificial aid may be required which brings with it the possibility of sepsis.

The fœtal mortality which averages five per cent is due mostly to asphyxiation. Interference with the supply of oxygen begins as soon as the cord passes the vulva and the child must be delivered in eight minutes from that time, or perish. Partial detachment of the placenta may also cut off the oxygen to a fatal degree, and the child may be unable to breathe when born on account of mucus sucked into the trachea by premature efforts at respiration.

Minor accidents also occur, such as fractures, dislocations, and paralysis from injury to the nerve trunks.

Management.—In the interest of the child, this presentation is occasionally converted into a vertex by external version during the last weeks of pregnancy or in labor before the membranes have ruptured. It is difficult, however, to maintain the vertex over the inlet. The woman must be kept quiet in a horizontal posture and long roller splints applied to the side of the child in utero and bound on.

In primiparas, this is nearly impossible, and it is wiser, in the absence of some great necessity to warn the parents of the conditions and dangers and let them share in the responsibility.

Fig. 63.—Extraction of the breech. Traction on one leg. (Hammerschlag.)

When the labor begins, the bag of waters must be kept from rupture as long as possible and when it finally breaks, an internal examination should be made to see if the cord has come down. If this happens it may be necessary to expedite the delivery by external assistance.

Fig. 64.—Breech delivery. Extraction of the trunk by pulling on the hips. (Hammerschlag.)

The doctor brings down a foot, if it is not already down, or pulls on the breech until the feet drop out. Compression of the cord must be always in mind. It is always compressed after the umbilicus has passed the navel. The shoulders are delivered by seizing the feet with the operating hand and swinging the body out of the way. This brings the posterior shoulder, which should be first, into the hollow of the pelvis. Extraction is then completed by what is called the Smellie-Veit maneuver. The child is put astride one arm, the first finger of which is hooked into the child’s mouth to maintain flexion. The fingers of the other hand then grasp the shoulders of the child astride the back of the neck and traction is made downward in the axis of the inlet until the head slips into the excavation.

Fig. 65.—Breech delivery. Delivering the shoulder. The body is swung strongly upward and outward to bring posterior shoulder into the pelvis. (Hammerschlag.)

Fig. 66.—The delivery of the after-coming head by the Smellie-Veit maneuver. (Hammerschlag.)

If the head is delayed at the inlet, it may be necessary to put the woman in the Walcher position (q. v.) and for the nurse to use the Wiegand compression (q. v.). The feet must not be fastened in stirrups for breech cases.

Fig. 67.—Shoulder presentation. Left-scapulo-anterior position. (Lenoir and Tarnier.)

Forceps are not recommended for application to the breech as they do not fit and are liable to slip off and injure both child and mother. The fingers are best.

Forceps are not recommended for the after-coming head unless the child is dead. If the child lives, the Smellie-Veit is more-successful; and if the child dies, the cranioclast, if possible, will save the mother much suffering and avoid some injury to the tissues.

Transverse or Shoulder Presentations.—These are cases in which the long axis of the child lies directly across or obliquely across the long axis of the uterus.

The shoulder (scapula) is the bony landmark, and the part which most frequently impends over the inlet. This presentation probably occurs once in two hundred labors.

It is due to the same conditions that were given for breech cases; namely, weak abdominal or uterine muscles, pelvic contraction, placenta previa, hydramnios, and twins.

It is easily recognized in pregnancy, and must not be neglected, for it is impossible of delivery without first changing it into a longitudinal presentation. If this correction is not done, rupture of the uterus is liable to occur, with the consequent death of both mother and child.

The treatment is invariably version.

Face and Brow Presentations.—The face presents once in about three hundred labors. In this case, the head is completely extended so that the occiput rests against the back of the neck. The trunk and spine are straightened out while the legs and arms remain in the normal attitude of flexion.

The causes of these anomalies must be sought in those conditions which bring about the deflexion of the chin. The most common are pelvic contraction, large child, placenta previa, hydramnios, goiter, anencephalus and multiparity.

Fig. 68.—Face presentation. (Bumm.)

Face positions take their names from the location of the chin (mentum—Latin). Thus the most frequent face position is the right-mento-posterior.

The diagnosis is not easy and may not be conclusive until the bony prominences of the face, such as the nose and orbital ridges can be distinguished by vaginal examination.

Fig. 69.—Descent of the chin in face presentation. (Bumm.)

The delivery is protracted from three to five hours beyond the average by this complication, and the mortality is higher both for mother and child. The face is badly swollen and disfigured, but the normal condition of the tissues will be restored by the end of a week. Most face cases terminate spontaneously, but operative interference is not infrequent on account of danger to mother or child.

Version or manual correction of the presentation may be done before engagement.

Forceps is the operation of choice after the head is fixed in the pelvis, but it may be necessary to precede the delivery by a preparatory pubiotomy, or in case of failure, to do a craniotomy on the dead child.

If the chin does not rotate forward under the symphysis, the labor is impossible without pubiotomy or the destruction of the child. In general, the case should be left to nature unless some definite indication to interfere develops.

Fig. 70.—Delivery in face presentation. (Bumm.)

The brow presents much more rarely than the face, possibly once in a thousand labors. It is due to the same conditions as bring about the presentation of the face. The mortality for both mother and child is higher than in face cases. The whole labor is harder and longer, besides being more dangerous to life and to tissues.

This presentation, if recognized before the head is fixed, should be converted into a breech by version, but after the head comes down, it may be possible by hand or forceps to deliver either as a face or as an occipito-posterior, but otherwise the cranioclast must be considered.

Occipito-posterior position is the name given to vertex cases wherein the occiput lies in one or the other of the two posterior quadrants of the pelvic inlet.

These labors are necessarily prolonged, both in the first and second stages, because the mechanism of delivery is deranged by the larger diameters brought into relation with the bony canal and by the ineffectiveness of the contractions.

The pains in the second stage may become violent and extremely painful, but the labor does not advance appreciably. After a little experience, mere observation of the course of the labor will cause the suspicion to arise in the mind of a competent nurse that the occiput is posterior. The diagnosis will be cleared up by the doctor’s internal examination, which shows the large fontanelle anterior and the sagittal suture running backward.

The head is partially deflexed and it may not be possible at first to find the small fontanelle.

The position terminates by delivery uncorrected, by spontaneous rotation into an anterior position, or is corrected by the doctor.

Correction should not be attempted until it is apparent that the anomaly will not right itself, which it will do in four cases out of five.

CHAPTER XII
OPERATIONS

Complications during labor may arise from abnormal positions of the head, such as face or brow; from abnormal presentations of the child, such as breech, transverse or shoulder; from twin labors; or from prolapse of a part like the foot, arm or cord.

The mother may be responsible for some of these abnormalities through having a contracted pelvis, a rigid os, or a rigid pelvic floor.

The uterus, too, may functionate abnormally by acting too vigorously, as in precipitate labor, or too slowly, as in uterine inertia. The membranes may rupture prematurely and produce a dry birth.

There may be hæmorrhages before labor (ante partum hæmorrhage) during labor (intra partum), and after labor (post partum hæmorrhage), or the labor may be preceded, accompanied, or followed by that extreme example of toxæmia known as eclampsia.

Face and brow presentations are rare and come to the attention of the nurse only when an operation is required for their relief. Further conditions may arise, such as danger to mother or child, which demand an acceleration of the labor.

If the head is engaged, forceps is the operation most commonly undertaken, and if not engaged, the problem may be solved either by an early version and extraction or by forceps later. The dangers to the mother are not usually difficult to diagnose if the case has been followed carefully.

Signs of danger to child must be looked for constantly. Such are:

(a) Alteration of the heart tones.

(b) Retardation of pulse in cord between pains.

(c) Escape of meconium is not significant unless occurring in the pain-free interval, when it may signify hypercarbonization of blood and a threat of asphyxiation.

The preliminaries for the performance of these operations may now be described, and the indications and conditions briefly tabulated.

The preparation should be standardized so that the same set-up of the room will do for all of the major obstetrical operations, except Cæsarean section.

The kitchen table is generally regarded as a satisfactory operating table. Its length is sufficient for delivery when the legs are doubled up. The table should be covered with a blanket or comfort on which it laid a clean sheet. A rubber blanket or piece of oil cloth is put on, so folded above the place for the patient’s hips, and so pinned at the sides, that all drainage will flow off into a bucket or jar at the foot.

In front of the table is placed a straight-backed chair with flat seat. To the right of the operator, as he faces the table, stands a bench, or two chairs, side by side; or, if possible, another table. This is covered with a clean sheet for the reception of the instruments. To the operator’s left, another table similarly prepared carries the solutions, sponges, etc. Every operation for delivery should have tape and cord scissors within easy reach, as well as facilities for the resuscitation of the child.

The light should come from behind the operator and fall full upon the field of operation. The room should be warm.

The patient is laid upon the table and her knees elevated in the exaggerated lithotomy position. If there are assistants enough, one can stand on either side and hold a knee, if not, a sheet sling can be made and slung round the patient’s shoulders and tied to the knees as previously described.

Fig. 71.—Exaggerated lithotomy position. The legs are held by a sheet sling. The vulva should be shaved. (Williams.)

An anæsthetic will be required. If a doctor can not be had, this duty will fall to the nurse.

A sterile douche bag hangs near the table. A bath tub of hot water must be provided and a tracheal catheter must be ready for the removal of mucus from the child’s windpipe. An abundance of hot and cold sterile water must not be overlooked. In the hospital the following synopsis for the placing of the linen may be found useful:

Sterile Linen for Operative Case.—

Bring patient to foot of bed.

Put in the stirrups. (For breech deliveries do not use stirrups.)

Same order as for normal case except that feet are put in stirrups instead of on bed.

Fig. 72.—Dorsal position when assistants are available. (Hammerschlag.)

Sterile sheet under patient extends now from basin under bed to buttocks.

Combination pad over field of operation.

Sterile sheet over abdomen.

The genitals of the patient are now cleansed with all care and attention described for labor. If this has been done within an hour, she need only be sponged off thoroughly with lysol solution (1 per cent). The feet and legs are covered with stockings, the body kept warm, and protected by sheets and blankets, if necessary.

Every operative delivery is preceded by catheterization.

All instruments are boiled for thirty minutes and brought to the table in the same container in which they are sterilized. The hot water has been poured off and a cool, weak solution of lysol (0.5 per cent) added.

Fig. 73.—Instruments for artificial delivery of the head. A, Braun’s blunt hook; B, Cranioclast (Auvard); C, Axis traction forceps (Webster); D, Low forceps (Simpson).

Forceps.—Before using forceps it should be determined that the woman can not deliver the child unaided, or can not be permitted to do so without too great expenditure of physical and nervous energy. The exact conditions must be recognized as to the location and position of the head, the condition of the fœtal heart tones and the size of the pelvis. When the head is high up, the axis traction instrument is employed and patient put in Walcher’s position for the traction.

Axis traction forceps are extremely dangerous to mother and child, and should be avoided wherever possible.

The following instruments are required:

The obstetric forceps.

2 eight-inch forceps.

6 artery forceps.

1 vulsellum forceps.

1 tissue forceps.

1 needle forceps and 6 needles.

2 vaginal retractors.

1 pair dressing forceps.

1 douche point.

1 silver catheter.

Suture material—both catgut and silkworm gut.

Besides these instruments, the nurse will also have solution basins as described for normal labor. For operations outside of hospitals, the nurse need not be clean, as her duties will consist for the most part in changing solutions, refilling basins, handing towels, etc., all of which can be done with sterile forceps.

The following summary may be serviceable for advanced study or reference:

Preparation.—

Thorough asepsis, both subjective and objective.

Patient should be pulled down to the foot of the labor bed with feet in the stirrups, or put upon the kitchen table or across the bed with the legs held in the lithotomy position. (For breech cases, legs should not be fastened.)

Bladder and rectum must be empty.

Anæsthetic is necessary.

The position of the head must be accurately known.

Facilities for the treatment of asphyxia neonatorum must be at hand.

Conditions.—

Cervix effaced and os dilated, except when maternal or fœtal life is threatened.

Bag of waters must be ruptured.

The head must be engaged.

The child should be living.

Indications.—

Insufficiency of the powers of labor.

Deep transverse arrest of the head.

Complications in labor, such as:

Eclampsia.

Fever.

Acute or chronic disease.

Hernia—especially if incarcerated.

Placenta previa.

Prolapse of the cord.

Face and brow presentations.

Contracted pelvis.

Occipito-posterior positions.

Dangers From Forceps.—

Injuries to Child.—Overcompression, especially with axis traction forceps or in contracted pelvis.

Crushing of soft parts, or such lesions as abrasions, pressure marks, hæmatomata, swelling of face and eyelids.

Bone injuries: Spoon-shaped depression where the head has been dragged through a narrow inlet; fissures in the parietal or frontal bones; fractures. When axis traction forceps are applied antero-posteriorly, the occipital bone may be sprung inwards until it cuts the medulla.

Compression of the cord, especially if it is around the neck.

Hæmorrhage from the middle meningeal artery.

Injury to eye.

Erb’s paralysis.

Laceration of ears when the forceps are removed.

Facial paralysis from pressure of the blade.

Injury to Mothers.—

Infection.

Improper application of the blades outside the cervix uteri.

Soft parts torn by too rapid extraction. When os is not dilated, it is first pulled down and then torn. The tear may extend into the vaginal vault. Fistulæ may be produced.

Prolapse of the uterus from prolonged traction.

Vaginal tears from the blades or from malplaced head.

Slipping of blades. Traction must be not against the symphysis, but down.

The forceps commonly used in this country (Simpson or Elliott) are so made that the left blade must be introduced first on account of the lock.

The mortality for the child in forceps cases is about six per cent.

Fig. 74.—Forceps operation. The left blade, in the left hand, is introduced first into the left side of the mother so that the curve of the blade fits the child’s head (inside the cervix). (Hammerschlag.)

The axis traction instrument is used but seldom by good obstetricians, since the danger to mother and child in this operation is very serious and it should be reserved for emergencies of exceptional character. Pubiotomy may precede the operation with advantage in many cases. Asphyxia of the child and maternal hæmorrhage must be prepared for.

Fig. 75.—Forceps operation. The introduction of the right blade. (Hammerschlag.)

Fig. 76.—Forceps operation. Locking the handles. (Hammerschlag.)

Fig. 77.—Forceps operation. The way the blades should grasp the fœtal head. (Hammerschlag.)

Fig. 78.—Forceps operation. Traction on the handles. (Hammerschlag.)

Fig. 79.—Forceps operation. The delivery of the head. (Hammerschlag.)

Fig. 80.—Version. Seizing a foot. (Hammerschlag.)

Version (Turning).—Version is a maneuver for altering the presentation of the child while it is still in the uterus. A vertex may be converted into a breech, a breech into a vertex or a transverse into either a vertex or a breech.

Fig. 81.—Version. The child rotates as pressure is made upon the head and traction upon the foot. (Hammerschlag.)

Version usually means that a transverse or a vertex presentation is changed into a breech and is followed by the extraction of the child. The operation is serious and not to be undertaken without definite indications. There is always the risk of sepsis and rupture of the uterus as well as a high probability of a dead child. Perineorrhaphy is, if anything, more frequent after this operation than after forceps.

Fig. 82.—Version is complete when the knee appears at the vulva. (Hammerschlag.)

Preparations.—The room and patient are arranged as for forceps, except that the stirrups can not be put in. The legs must be held by assistants, for the delivery of the after-coming head may be complicated and require the Walcher position, which can not be quickly obtained if the legs are fast. Only eight minutes are allowed for the delivery of the child after the navel passes the vulva, if it is expected to live.

The bladder and rectum must be empty.

Asepsis must be rigid and both subjective and objective.

The dorsal position on a table is imperative.

The diagnosis must be accurate and the anæsthesia carried to the surgical degree.

Facilities for treating asphyxia neonatorum must be provided.

The following summary of the indications and conditions may be convenient for reference.

Indications.—Contracted pelvis. (Consider pubiotomy.)

Abnormal position of the head. (Face position with chin posterior.)

Prolapse of cord or an extremity with a presentation of the head.

Placenta previa.

Transverse position after the seventh month.

Any condition requiring rapid delivery.

Conditions.—Cervix effaced and os dilated.

Uterus not in tetanus nor contracted down over the child.

The fœtus must be movable.

The head should not be engaged.

The Walcher position is produced by bringing the patient down to the end of the table so that the sacrum rests upon the edge. The thighs and legs are allowed to hang down of their own weight and the patient is restrained from falling off by traction upwards on the axillæ.

In the Walcher position the diameter of the pelvic inlet is increased from ⅓ to ½ inch (1 cm.) and thereby the delivery of heads that otherwise could not pass becomes possible.

In addition to the Walcher position other measures may be required to help the head through. Thus, traction from below may be carried to the limit of safety and in spite of the Walcher position the head may not pass the inlet.

Then pressure from above is added. This maneuver will have to be executed in many cases by the nurse.

The fingers palpate the head above the pubes. Then one or both fists are placed upon the abdomen over the head and force is exerted to crowd the head down into the pelvis. This is known as the Wiegand compression.

For the operations destructive to the child, craniotomy or decapitation, the same arrangements are made.

Fig. 83.—The Walcher position. (American Text Book.)

Cranioclasis is the crushing of the fœtal skull so that in its reduced condition the child can be delivered and the mother’s life spared. In addition to the solutions, the only instruments required are the Auvard cranioclast, a Naegele perforator, and a douche bag with glass, or any tip that can be sterilized.

In many of these cases, both mother and child could be saved if seen early enough to have a Cæsarean operation.

Decapitation is done to save the maternal life in cases of transverse or shoulder presentation. The preparations are the same as already described for forceps and version and the only instrument needed is a Braun blunt hook. (Fig. 73.)

Fig. 84.—The Wiegand compression of the child’s head to force it into the pelvis. (Hammerschlag.)

Cæsarean section is the delivery of the child through an opening in the abdomen.

It is made necessary by contraction of the pelvic bones, or by the presence of a fleshy or bony mass which diminishes the size of the inlet. It may be required on account of the closure of the vagina or cervix by scars or on account of urgent conditions of the mother, such as eclampsia, heart disease, and sometimes placenta previa.

The technic is simple, but good judgment must be used in knowing when to do it. Many operators find it so easy that they prefer it to the harder but safer obstetrical operations.

Fig. 85.—The Naegele perforator. (Hammerschlag.)

The time of election is when the woman is at term but not in labor. This, of course, can be determined by the history, but more certainly by careful measurements of the child.

When it becomes necessary to operate on a woman who has been in labor a long time and especially if she has been examined frequently, the mortality is disproportionately high.

It is a hospital operation, but may be done in the house. If not an emergency, the bowels are emptied by a laxative and enema the day before. Regular preparations for laparotomy are made, plus the equipment necessary for tieing the cord and resuscitating the child. A table must be found large enough to hold the patient in the horizontal position at full length. Solutions of lysol 1 per cent and sterile water are placed on each side of the table. The instrument table carries towels and suture material as well.

On a stand behind the operator is placed the hot bath and tracheal catheter. This center is presided over by someone skilled in the treatment of respiratory difficulties in the new born. Altogether, five assistants are required for the operation: an anæsthetizer, a clean nurse, and a nonsterile nurse to manage supplies, an operating assistant and one to take charge of the child.

Rubber gloves must be worn by the clean assistants.

Instruments.—

2 scalpels.

2 scissors.

8 eight-inch forceps.

10 six-inch artery forceps.

4 sponge carriers.

4 tenaculum forceps.

2 rat-toothed tissue forceps.

4 full curved round needles for uterine wall.

4 smaller needles for the fascia.

2 Hagedorn needles for the skin.

2 needle holders.

1 dressing forceps.

Plenty of suture material, both catgut (No. 3 and 4) and silkworm gut for the abdominal wall.

Supplies.—

1 doz. laparotomy sponges with metal rings sewed in or

a long tape attached.

6 large laparotomy pads.

1 large pillow slip full of sterile cotton.

Sponges.

1 laparotomy sheet.

1 dozen towels.

1 pair of leggins.

Gowns and head dressings (gauze will do) for the operator and assistants; rubber gloves, basins and accessories. All are sterilized.

If the woman has been examined, the vagina should be sponged out with tincture of iodine. The abdomen is shaved, scrubbed with green soap, nail brush, and hot water for five minutes. It is then rinsed with ether and painted with iodine.

The presentation of the child, the presence and location of the heart tones must be determined before operation.

The patient is anæsthetized with ether, chloroform or gas.

The incisions are made; the child delivered to the proper assistant; the placenta and membranes removed; the sponges counted; and the uterus and abdominal wall sutured.

After-care.—The nurse watches the patient for sighing respiration, rapid pulse, pallor, and other symptoms of hæmorrhage, either external or internal. Artificial heat is supplied. Hæmorrhage from vagina should be looked for. It is normal. Salt solution by hypodermoclysis may be required. Hot water by mouth in small sips or tap water by rectum (drop method) will relieve the thirst. Morphine may be given if pain is extreme. An enema may be given on the second day or calomel may be started in the morning of the second day. Distention from gas, with or without nausea and vomiting, hiccough and rise of temperature are all signs of danger. No milk should ever be given on account of the gas it causes.

The child is put to breast as usual after twelve hours.

The stitches are to be taken out on the tenth or twelfth day.

Symphyseotomy is a separation of the pelvis at the pubic joint and is done with a scalpel or a specially devised knife.

Pubiotomy is the division of the pelvis, three or four centimeters to the right or left of the pubic joint. The division passes through the pubic bone and is usually done with a serrated wire called the Gigli saw. It is introduced subcutaneously by a special instrument called a pubiotomy needle. Both symphyseotomy and pubiotomy are preparatory to delivery. Pubiotomy is the more desirable and successful operation. The ends of the severed bones separate from one and a half to two inches, and the child delivers easily through the enclosed opening. The after-care is usually simple.

Instruments.—

1 scalpel.

2 Gigli saws.

1 pubiotomy needle.

6 artery forceps.

3 eight-inch forceps.

1 needle holder.

2 retractors.

Suture material and sponges as usual.

The hips are strapped in circumference with zinc adhesive plaster to support the bones.

The danger of infection of the wound from the lochia is always present. The main difficulty is in moving the patient, who is more than usually helpless. The bony ring of the pelvis is broken and she can not raise her leg. The repair is cartilaginous at first, but solidifies in a few months so that locomotion is not impaired. Especial pains must be taken to avoid bed sores.

CHAPTER XIII
MINOR OPERATIONS

Aseptic Care.—Place patient on a clean bed pan. It need not be sterile. Drape with a sheet and arrange it so the fold may be easily raised by nurse’s elbow. Have sterile basin with cotton pledgets to be filled with solution of lysol 1 per cent. Lysol must be put in basin first and the water added. Take to bedside. Nurse scrubs her hands ten minutes with a sterile brush, hot water, and green soap. Use no towel, no gloves. Keep hands wet and clean. Cleanse vulva with wet pledgets from above downward. Apply sterile pad.

Sterile Specimen.—To get a sterile specimen of urine without catheter, give aseptic care, tampon vagina with large pledget of sterile cotton. Have patient urinate in a sterile basin. Remove tampon.

Sterile Specimen from Child.—Take a glass test tube and thrust its round end through a hole in a square piece of adhesive plaster. Push it down until the plaster is caught and stopped by the enlarged rim at the mouth of the tube, with adhesive side of plaster on same side as opening of tube. Fasten the tube over the male penis or female vulva by applying the plaster to the surrounding skin. Leave until full.

Aseptic Douche.—Boil douche point and basin. Leave point in sterile basin. Fill douche can with sterile water, temperature 104° to 110° F. Put clean bedpan under patient who is draped with a sheet. Have at hand a sterile basin containing solution of lysol 0.5 per cent, or boric acid 5 per cent in which cotton pledgets are immersed. Scrub the hands as for aseptic care. Cleanse the vulva with cotton pledgets, washing always toward the anus, and use each pledget but once. Adjust the douche point and introduce it just inside the labia. The douche can should be only a trifle higher than the pelvis. When can is empty, apply a sterile pad.

Fig. 86.—Apparatus for getting a sterile specimen of urine from an infant.

If the douche is to be used as a deodorant after the fifth day of the puerperium, either of the following solutions may be employed: Potassium permanganate, 1:5000; formaldehyde 1 dram to quart, or chinosol 1:1000.

The vaginal douche may be used in cases of gonorrhœal infection in pregnancy during the last weeks, in the hope of avoiding infection of the child’s eyes.

It is given like the aseptic douche (q. v.) with potassium permanganate 1:5000, or chinosol 1:1000. It should be hot (112° to 120° F.), and be begun not long before term, so that in case labor comes on, the danger to the child will be minimized. The reservoir must not be too high, nor the douche point inserted much beyond the labia. The woman should be on her back and the douche point should be rubber or glass.

Removal of Sutures.—On, or about, the tenth day the removal of sutures is required.

The nurse will sterilize by boiling, 1 pair of long-handled, sharp-pointed scissors, 1 pair of tissue forceps, and if the sutures extend far into the vagina, a vaginal retractor.

A basin of lysol solution (1 per cent) with cotton sponges, a sterile towel to lay the instruments on, a dish to receive the soiled dressings, sutures and discarded sponges, completes the arrangement.

The patient is now draped with sheets as for examination. The doctor prepares his hands as for operation. The nurse holds the limbs of the patient in lithotomy position and the operation is begun.

Uterine Tampon.—Packing the uterus is mostly employed for hæmorrhage after labor. The patient, therefore, has been prepared and only fresh sponging with lysol solution is required.

The instruments are, 1 vaginal retractor, 1 pair of dressing forceps, 1 vulsellum forceps and a jar of gauze, four to six inches wide and ten or twelve feet long. Always use a single continuous strip. A very large quantity is necessary to fill the uterine cavity. Any sterile gauze may be used, but weak iodoform is satisfactory.

Fig. 87.—Tampon of the uterus. (Hammerschlag.)

The vagina is held open with retractors, the cervix seized with a tenaculum and pulled down, the end of the gauze strip is then carried into the uterus as far as the fundus, the dressing forceps withdrawn and a new length carried in until the cavity is packed tightly from the fundus clear to the os.

Care must be taken that the strip of gauze is not contaminated by vaginal contact during the introduction. A pad and binder are now applied. If no instruments are at hand, or there is not time to sterilize, then the nurse can grasp the fundus through the abdominal wall with her hand and push the cervix down to the vulva where the gauze can be pushed in by the doctor’s fingers, if necessary.

The tampon acts as a hæmostatic through its direct mechanical pressure, and dynamically by stimulating the uterus to contract. It should be removed in from twelve to twenty-four hours.

Fig. 88.—Tampon of vagina. (American Text Book.)

To tampon the vagina the woman lies on her back across the bed, with her feet on the knees of the doctor, who sits facing her. A sterile retractor holds back the posterior wall of the vagina.

With a pair of dressing forceps the doctor seizes the pledgets of cotton or gauze out of the lysol solution and carries them one by one as far as they will go, in various directions around the cervix. One is pushed forwards toward the bladder, the next back toward the rectum, the next in the middle, and so on until no more can be introduced. A pad and binder are applied tightly.

The uterine douche is sometimes employed for hæmorrhage. The field of operation and the doctor’s hands are prepared as usual. The nurse cools the boiled douche water down to 120° F. and if ordered, adds 2 drams of sterile salt to each quart.

The instruments are a vaginal retractor, a long uterine douche point, and one vulsellum forceps.

The cervix is seized and brought down, the long douche point connected with the tube from the reservoir is carried to the fundus and the water started. Care must be used that the return flow is free and unobstructed.

This method is most satisfactory in uterine hæmorrhage after the uterus has been entirely emptied. It stimulates a prolonged and profound uterine contraction.

Intravenous Injections.—The vein in the front of the elbow is usually chosen. (Median basilic or median cephalic.) A rubber bandage or tourniquet is wound tightly about the middle of the upper arm to make the veins stand out prominently. The surface of the skin should be sterilized for operation by scrubbing with green soap and hot water and rinsing with 50 per cent alcohol, followed by 1:2000 solution of bichloride, or by the application of tincture of iodine.

The hypodermic needle is then introduced after expulsion of all the contained air and the piston is drawn up until the blood enters. This assures the operator that the needle has entered the vein. The bandage is now loosened and the solution of the drug is introduced very slowly.

Intravenous infusion or transfusion is given in the same way. The fluid (normal saline?) must be running from the needle as it is introduced.

Hypodermoclysis is the introduction of normal saline solution, under the skin, or under the breasts. The solution may be transfused also into a vein.

By this operation, the quantity of fluid in the vessels is greatly increased and a circulatory stimulant is provided. Normal saline also promotes diuresis and aids in the removal of wastage.

The principal dangers arise from too great rapidity or too large a quantity of the flow.

The skin should be sterilized at the point of attack by a coating of tincture of iodine.

The instruments required are, a bath thermometer, a douche can (fountain syringe) with long tubes and an aspirating needle. A hypodermic needle will do, but the reservoir must be well elevated since the caliber is so small. Ordinarily the reservoir need be held only two or three feet above the point of discharge. The water should be flowing through the needle when it enters the tissues. If the fluid is to be introduced under the skin, the best place is in the loose region between the hips and the ribs in front. If under the mammary gland, the needle must go below and under the gland from the outside edge, not into the gland. If into a vein, such additional instruments will be needed as a rat-toothed tissue forceps, a pair of sharp-pointed scissors, a knife and some fine catgut. From four to sixteen ounces of fluid may be used at a temperature varying from 105° to 110° F.

The openings where the needles entered are closed by cotton and collodion.

Curettage of uterus is done for abortion or puerperal sepsis when foreign fragments are left in the uterus. The room is prepared as for delivery.

The instruments are:

1 vaginal retractor.

1 vulsellum forceps.

1 long uterine douche point.

2 dull curettes.

2 sharp curettes of different sizes, together with gauze for packing the uterus.

Rubber gloves should be worn both by nurse and physician as much for personal protection as for the patient’s safety. In many cases of incomplete abortion or of puerperal sepsis the endometrium is more satisfactorily curetted with the gloved fingers.

Abortion may be indicated in many of the early complications of pregnancy, such as hyperemesis, nephritis, uncompensated heart lesions, tuberculosis, insanity, hydramnios, incarcerated retroversions of the uterus and the presence of hæmorrhage. These cases require the operation to be undertaken and finished by the doctor, but other conditions develop wherein, without volition on the part of the patient or doctor, the abortion begins. Some may be saved, but at times the attempt is futile.

If the emptying of the uterus seems inevitable, the function of the physician is to see that the process is finished as quickly and cleanly as possible.

This may be done in the early stages by packing the cervix and vagina with iodoform gauze and administering ergot in twenty-five drop doses thrice daily.

In case of dangerous hæmorrhage from spontaneous abortion, the vagina can be tamponed with cotton pledgets or gauze by a clean nurse while awaiting the arrival of the doctor.

When the uterus has partially emptied itself and the retained fragments prevent the complete contraction and allow of serious bleeding, or if the fragments are septic, then their removal is required. This is done by the finger or curette.

The preparation of rooms, patient and doctor are the same whether the operation is for therapeutic or incomplete abortion. These have been described.

The instruments are:

1 pair dressing forceps.

2 vaginal retractors.

artery forceps.

2 curettes of different sizes.

2 vulsellum forceps.

1 long uterine douche point.

1 pair Goodell dilators.

1 douche can.

Fig. 89.—Pean forceps.

The induction of labor at or near term is done for pelvic contraction, maternal disease, for danger threatening mother or child, or to avoid the birth of a post-mature child. A variety of methods may be employed, but the Vorhees bag is best.

Technic.—Assemble, and sterilize by boiling twenty minutes, a Vorhees bag No. 3 or 4, Simon speculum or vaginal retractor, 1 pair long Pean forceps, 2 pairs vulsellum forceps, 1 dressing forceps, 2 pairs compression forceps, 1 Goodell dilator, 1 tenaculum forceps, Davidson hand bulb syringe with glass tubes and rubber connections for the bag.

Patient, prepared as for delivery, is placed upon the table in exaggerated lithotomy position. Stirrups will serve.

The vagina is retracted, a smear made from cervix, and the mucous membrane wiped clean with pledgets of gauze on forceps.

Anæsthesia is only occasionally necessary even in primiparas.

Fig. 90.—A, Hand bulb syringe; B and C, Vorhees bags; D, Bag rolled and grasped by Pean forceps ready for introduction.

Before using, the apparatus must be tested by forcibly filling the bag with sterile solution.

One lip and sometimes both are seized by vulsellum forceps and brought down. Usually, even in primiparas, the os is sufficiently patulous to admit the bag—if not, dilate.

Fig. 91.—Vorhees bag in place.

The bag, emptied of residual air and fluid, is rolled up into a compact mass like a cigarette, seized with Pean forceps so that the tips extend just to the end of the bag. Turn the concavity of forceps toward patient’s left leg and introduce. As the bag enters turn the mass to the left—a quarter turn—so that when operation is completed the forceps curve faces upward. Release the lock on forceps. Connect the tube of the bag with syringe tube and force the solution slowly into bag. Pean forceps may be removed as bag fills. Remove vulsellum. Tie tube of bag with tape when bag is full—disconnect syringe. Put sterile pad on either side of tube.

If pains do not start within an hour, or if compression is desired as in placenta prævia or a more rapid dilatation, then a weight of one or two pounds is attached by a tape to the protruding tube and passed over the foot of the bed.

Digital dilatation of cervix may be indicated in cases of rigid os or where prolonged labor or some danger to mother or child requires the hastening of the delivery.

No instruments are needed, but a complete anæsthetic is necessary.

Thorough asepsis must be observed. The patient’s genitals and the doctor’s hands are prepared as described for labor, and rubber gloves are imperative.

The gloved hands and the vagina and vulva are well rinsed with lysol solution 1 per cent. The operation must be done carefully, patiently and gently, lest the cervix be lacerated.

The hand is introduced into the vagina, and first the thumb and index finger are introduced into the os and separated as widely as possible, then the second finger and so on, until the dilatation is complete. (Hirst’s method.)

Another method is the introduction of the tips of both index fingers, back to back. Force exerted will dilate the canal so second fingers may also be inserted. Then patiently and gently the rigid ring of the os is overcome. (Edgar’s method.)

Episiotomy.—This is a clean incision of the vulva, which is done to avoid an apparently inevitable and ragged tear of the perineum.

The instruments required are either a blunt tipped knife or a pair of blunt scissors.

The operation may be done on one or both sides depending on the amount of room required. The incision begins at a point just above the lower third of the vulvar outlet when distended by the head, and passes obliquely downward and outward. This severs unimportant tissues only, instead of allowing the valuable perineal body to suffer. It makes a clean wound that heals readily, instead of a ragged tear through bruised tissue. The cut is high enough to be free from the constant bath in infectious lochia, which troubles the healing of the usual perineal laceration.

Fig. 92.—Episiotomy. (Hammerschlag.)

Rectal Infusion (Drop Method).—A douche bag containing normal saline solution is hung near the bed and kept warm with an electric pad, a hot flatiron, or by a hot water bag on either side. The tube ends in a catheter which is inserted into the rectum. The tube is clamped so that only a drop of solution can escape each second.

Wet packs are both sedative and antipyretic and may be employed for a local or a general effect.

For bronchitis the pack may be applied to the chest only as follows: The child (or adult) is stripped in a warm room (75° F.) and the chest swathed front and back with a thick towel wrung out of hot water (temperature 105° to 110° F.) Over this a woolen shirt may be drawn or a blanket wrapped, and the patient put to bed. After six or eight hours, the dressing is removed in a warm room, a hot bath administered, and the body well rubbed with alcohol, and dried. The treatment may be repeated if necessary. Do not burn the patient by applications too hot.

The general pack is most serviceable in reducing temperature and producing a diaphoresis to relieve the kidney and cleanse the system, as in eclampsia. For this purpose the entire body, naked, is rolled in a sheet wrung out of hot water and then put between heavy blankets in bed. The pulse should be taken frequently and the temperature recorded at intervals. A cool application to the head is very soothing.

The patient sweats profusely and hot drinks may be given to promote a more abundant diaphoresis. Usually the patient drops off to sleep as the fever subsides. Twenty to forty minutes is the average duration of such a treatment.

When the pack is removed, the patient is wrapped at once, without drying, in warm blankets, and left for an hour or so.

CHAPTER XIV
COMPLICATIONS IN LABOR

Pelvic contraction is not infrequently the cause of difficult or prolonged labor. The deformity is most commonly due to rickets in childhood.

There are many forms of pelvic contraction, but in this country only two are at all common; the generally contracted, and the flat pelvis.

The generally contracted pelvis is, in the main, a well shaped pelvis, only its measurements are smaller than normal.

The flat pelvis is marked by a shortening of the anteroposterior diameter of the inlet. It looks as if it had been pressed together from before backward while in a soft condition.

These and other deformities will be recognized in advance of labor by the routine application of the pelvimeter.

The value of this instrument is so great, that no competent man does obstetrical work at the present time without using the pelvimeter as a routine.

The average diameters in normal pelves may be tabulated as follows:

Interspinous—between the anterior superior iliac spines—25 cm.

Intercristal—between the iliac crests—28 cm.

External conjugate—taken from the upper border of the symphysis to the depression below the last lumbar vertebra—20.5 cm. Take 9.5 cm. from this to get the true conjugate.

Fig. 93.—Various forms of pelvic deformity compared with the normal inlet. (Bumm.)

The circumference of the hips just below the iliac crests and above the trochanters—90 cm. It is taken with a tape line. These are the usual external measurements.

The internal measurements are made with the fingers.

Fig. 94.—The pelvimeter.

Fig. 95.—The various diameters of the inlet with the lengths given in cubic centimeters. (Williams.)

Fig. 96.—Measuring the distance between the anterior superior spines of the pelvis. (Williams.)

The diagonal conjugate is the distance from the lower border of the symphysis to the promontory of the sacrum. It should measure 12.5 cm. The first and second fingers are passed into the vagina and pushed up until the tip of the second finger touches the promontory of the sacrum. The finger of the other hand marks the depth of the examining fingers just below the symphysis. The distance is measured when the finger is withdrawn, and 1.5 cm. is subtracted. The result is the true conjugate. These measurements carefully made and the deduction judicially estimated, give one a fairly approximate idea of size and shape of the pelvic inlet. The aim of nearly all the pelvic measurements is to get not only the size and shape of the inlet, but so far as possible, a working estimate of the anteroposterior diameter of the brim, which is the most important of all the diameters. In normal cases this should be 11 cm.

Fig. 97.—Measuring the external conjugate. (Williams.)

Thus, taking 9.5 cm. from the external conjugate (20.5 cm.) gives 11 cm.

Subtracting 1.5 cm. from the diagonal conjugate as obtained with the fingers as above described, (12.5 cm.) gives 11 cm. The subtraction is made to compensate for the thickness of the pubic bone and its inclination outwards.

Fig. 98.—Measuring the diagonal conjugate with the finger. (Eden.)

A circumference of 90 cm. corresponds to an inlet of 11 cm. in its anteroposterior diameter, and every variation of 5 cm. in this circumference makes a difference of 1 cm. (either larger or smaller) in the anteroposterior diameter.

Thus, 95 cm. in circumference=12 cm. in the diameter; and 85 cm. in circumference=10 cm.

Complications increase in proportion to the degree of contraction in the pelvis.

The most frequent difficulties superinduced by the small pelvis are prolapse of the cord, malpresentation and malpositions of the head, prolonged labor, and a large increase in the number of assisted deliveries.

All the possibilities and probabilities in a given case will be carefully worked out before labor by the conscientious obstetrician, and Cæsarean section, induction of premature labor, pubiotomy, forceps, or version and extraction, will be done with a sure foreknowledge.

Prolapse of the cord complicates labor once in about two hundred cases. It is most likely to occur when the presenting part does not enter or does not entirely fill the opening, as in transverse or shoulder presentations, or vertex presentations with small inlets.

The mother is not endangered by this mishap, but the babe is lost in from 35 to 60 per cent of the cases.

The diagnosis is easily made when a loop of cord protrudes from cervix or vulva, and the pulsation will differentiate it from everything else.

If the cord does not pulsate, the family should be informed that the child is dead and the case may be allowed to terminate normally.

If it still pulsates, the woman should be placed in the knee-chest position for ten or fifteen minutes, then upon the side, opposite to that on which the cord has prolapsed, and back again as soon as possible to the knee-chest position. A chair may be used to produce a Trendelenburg position by placing it so that the edge of seat and top of back rest on the bed. Then the patient puts her legs over the lower rungs and lies with her back against the chair back and her head on the bed.

If the cervix is effaced and the os partly dilated, reposition may be attempted either with the finger or a male catheter.

The operation will, of course, succeed most easily if done in the knee-chest position, with gravity to aid.

If the cord can be pushed back, a Vorhees bag may be inserted to keep it from coming down again. This holds back the cord, dilates the canal and stimulates the pains.

When the bag comes out, version and extraction can and should be done at once.

In general, the following summary may be useful:

Prolapse of Cord

Causes.—

Contracted pelves.

Breech and transverse presentations.

Malposition of head, or face and forehead presentation.

Hydramnios.

Accident.

Low insertion of placenta.

Diagnosis.—

Before rupture of membranes careful examination will show pulsating cord in advance of head.

After rupture the cord may be felt in vagina.

Dangers.—

To mother:—None but those due to causative condition.

To child:—Compression of the cord and asphyxiation.

Contraction of exposed vessels of cord.

Patient may lie on cord.

Twenty-five per cent die as a rule under best conditions.

Fifty per cent when left to nature.

Treatment of Cephalic Presentation.—

Extraction of child or reposition of cord, depending upon the degree of dilatation.

If cervix is small, replace and fill cervix with Vorhees bag.

When cervix admits hand, either replace or do version and extraction.

With head engaged, reposition or version is not possible.

Child living:—Rapid delivery with forceps.

Child dead:—Craniotomy or leave to nature.

Prolapse of one or both hands may take place. If the head is engaged, no interference should be attempted. If not, replacement or version may be done.

The soft parts may also complicate the labor process.

No time need be spent here on the rarer forms of obstruction due to uterine or ovarian tumors.

Rigidity of the cervix, or os is not uncommon.

This may be due to a dense, almost cartilaginous consistence of that tissue, to premature rupture of the bag of waters, to weak, inefficient contractions in the first stage, or to a steel-spring-like contraction of the muscular fibers of the os.

In all cases the first stage of labor is greatly prolonged, but so long as the membranes are intact, the child is in no danger.

Two kinds of cases are met with, those in which the pains are violent, and those in which they are weak and shallow. In the first class, as soon as the condition is recognized, a dose of morphine sulphate, ⅙ gr. and scopolamine hydrobromide 1/150 gr. should be given, hypodermically. The rigid ring relaxes under the influence of the narcotic, and labor proceeds rapidly and almost painlessly. Chloroform may be substituted if the morphine and scopolamine are not at hand. If the cervix is effaced and only the rigid ring of the os prevents the completion of the labor, or if the above methods fail, then the patient may be anæsthetized and the rigidity overcome by the fingers. This is an emergency that should not be attempted until all else has failed and some danger arises that makes it necessary to hasten the delivery. (See Minor Operations, p. [211]).

Where the constriction is due to unusual density of the cervix or to cicatricial tissue, it is sometimes necessary to make incisions under aseptic precautions so that the rigid ring may expand.

Weak and inefficient contractions can sometimes be stimulated satisfactorily by the introduction of a Vorhees bag.

Rigidity of the pelvic floor may be due to inadequate elasticity of the tissues as in old primiparas or in young women who have ridden horseback for many years in the cross-saddle position.

The head may come down to the pelvic floor but will not advance further. If the tissues of the vulva do not, or can not yield sufficiently after appropriate time has been allowed, episiotomy may be done. (See Minor Operations, p. [211].)

The uterus itself may functionate abnormally.

Precipitate labor is an over rapid advance of the child wherein the stages of labor are merged into one another and the child expelled in two or three pains.

It may be due to unusual capacity of the pelvis, or to strong contractions which the patient is not aware of, or both. These cases predispose to post partum hæmorrhage and to serious lacerations of cervix and perineum.

The child is usually delivered in an undesirable place, such as a toilet basin or a street car, and perishes from the fall, from cold, from umbilical hæmorrhage, or lack of facilities for revival.

The nurse who is watching a case is responsible for the prevention of a precipitate. If the event impends, the woman must be placed upon her side with legs straight, and she should be instructed to cry out with every pain. Chloroform may be given and the head forcibly held back.

Uterine Inertia.—A sluggish state of the uterus may characterize the labor and the contractions will be slow, shallow and inefficient. The intervals may be prolonged, although the patient complains bitterly of pain.

The condition is seen most frequently in multiparas and is due to defective innervation of the uterus or to imperfect reflexes, and in primiparas also it may be due to the newness of the function that is suddenly called into play, or to contracted pelvis. Many times the trouble results from overfatigue and want of sleep. If this is the case, the remedy may be found in the administration of morphine sulphate ⅙ gr. and scopolamine 1/150 gr. The pains are diminished or abrogated while the contractions continue. The scopolamine may be repeated if necessary. Under proper indications and conditions this treatment is harmless, both to mother and child, but requires supervision on the part of the nurse or physician.

If the patient is not overly fatigued, the introduction of a Vorhees bag, as described under the head of Induction of Labor (p. [208]) will dynamically increase the strength and frequency of the contractions, mechanically aid the effacement of the cervix and the dilatation of the os, and shorten the first stage anywhere from six to twelve hours.

As soon as the os is dilated, pituitrin may be given under due precautions, as hereafter indicated. Pituitrin has but little influence on the nonfunctionating organ, but acts well on a uterus which is definitely contracting. It should not be given during the first stage, since when the uterus contracts, there must be an adequate opening for the advance of the child. Five to seven minims is the usual dose, injected into the deltoid muscle. The injection may be repeated in an hour, if required, since the effects, which begin about five minutes after the injections, will pass off in fifty-five minutes.

By the use of pituitin many operative procedures are altered or avoided. A high forceps case may be converted into a case for the low instruments, and the latter in many instances avoided altogether.

The use of pituitin may be briefly summarized as follows:

Pituitrin

(Use no alcohol to cleanse syringe or skin before injection.)

Indications.—

1. Inertia uteri or weak, shallow pains in second stage.

2. Multiparity.

3. Post partum hæmorrhage.

4. To avoid use of forceps or to reduce a high forceps case to a low one.

5. Cæsarean section.

If the patient is a multipara, sterile linen should be on and attendants ready for the delivery before an injection is given.

Conditions.—

1. Cervix effaced.

2. Os admits three fingers. (Better if membranes have ruptured.)

3. Head should be engaged.

4. No mechanical obstacle to delivery such as tumors or markedly contracted pelvis, etc.

Dangers of Long Labors.—

Compression of cord.

{Vesicovaginal fistulæ.

Necrosis of maternal tissues. {

{Rectovaginal fistulæ.

Infection—peritonitis.

Necrosis of skin over skull.

Necrosis of cranium.

Fracture of skull.

Death of child.

Maternal exhaustion and prolonged convalescence.

Premature rupture of the membranes not infrequently occurs from over-distention, when twins or hydramnios is present, or at any stage of the pregnancy when the membranes are weak. The liquor amnii flows off, not all at once, but after the first gush by intermittent discharges, depending on the painless uterine contractions and the accuracy with which the head fits the pelvis. Labor usually comes on in from twelve to forty-eight hours, but it may be postponed for a month.

The labor is sometimes more painful and prolonged on account of the absence of the fluid wedge and the generous lubrication of the channel which is supplied by the liquor amnii.

The danger of infection of the amniotic cavity with consequent death of the child is always to be apprehended after the escape of the liquor amnii. Also the fœtal parts may prolapse and complicate the labor; or if the cord comes down, the child may be imperiled by its compression.

If near term, the rupture of the membranes is not of great importance though the case must be watched attentively. Daily observation must be made of the fœtal heart tones, the amount of liquor amnii flowing away, and the presence or absence of infection. If labor does not determine in a few days or if the heart tones rise above 160 or go below 120, labor must be inaugurated. (See Induction of Labor, p. [208].)

Rupture of the uterus is the most serious accident that occurs in labor. It happens about once in three thousand confinements. The tear is usually in the lower part of the uterus and follows a prolonged period of labor, where the child is in a transverse presentation, and, therefore, impossible to deliver, or the pelvis is too small or the child too large. It may also follow ill-advised or unskillful efforts to change the presentation by the introduction of the hand into the uterus. Occasionally rupture is produced by external violence, such as blows or kicks upon the abdomen.

It is imperative to be able to recognize the symptoms when rupture impends or actually occurs.

Signs of Threatened Rupture of Uterus.—

1. High position of the contracting ring—especially its obliquity. The contracting ring is a ridge-like formation that may be found running across the anterior and lower portion of the uterus. 2. High position of fundus. 3. Tension of round ligaments. 4. Rotation of uterus about its long axis. 5. Tenderness to pressure of lower uterine segment. 6. Contractions persistent with no pain-free interval.

Signs of Actual Rupture of Uterus.—

1. Hæmorrhage is one of the earliest and most significant signs, and may be either external or internal. 2. Cessation of uterine contractions either abruptly or gradually. 3. Extreme pain felt by patient. 4. Recession of presenting part.

The patient gives a sharp cry and has the feeling that something has given way. Signs of shock rapidly supervene. A predisposition to rupture may be present from the scars of a Cæsarean section, uterine tumors, and degeneration of the muscle.

The treatment depends upon the degree of the injury, and if investigation shows that the uterus has opened into the abdominal cavity, immediate laparotomy is done. In other cases, the morcellation and removal of the child by the natural passage may permit the use of a uterine pack and avert the necessity for an abdominal operation. The child is usually dead and need not be considered.

CHAPTER XV
COMPLICATIONS IN LABOR (Cont’d)

Vomiting in labor frequently occurs near the end of the first stage. It is due to the sympathetic excitement of the nerves of the stomach as the last fibers of the os uteri give way. It requires no treatment.

Hyperemesis in labor is very rare, but when it does occur, the delivery should be expedited.

Hæmorrhages may occur either before, during, or after labor. Hæmorrhage is always serious.

Hæmorrhage before labor arises either from a premature detachment of a normally implanted placenta or from placenta prævia. The first is sometimes called “accidental hæmorrhage” to distinguish it from the latter, or “unavoidable hæmorrhage.”

Accidental hæmorrhage may be the result of an injury or a blow, but in many cases, there is no such history. The hæmorrhage is most frequent in the later months of pregnancy, and may be without any apparent cause. The hæmorrhage may be entirely inside the uterus (concealed hæmorrhage) or it may appear externally.

The hæmorrhage, when concealed, takes place back of the placenta or between the membranes and the uterine wall. If the hæmorrhage is concealed, it is usually followed by an attempt to expel the child. If the hæmorrhage is pronounced, systems of shock appear.

The diagnosis is made by the symptoms which are summarized in differentiating this condition from placenta prævia (p. [231]).

From this affection, nearly all the children and half the mothers die.

Fig. 99.—Various forms of placenta prævia compared with normal attachment of the placenta. (American Text Book—Williams.)

When the hæmorrhage is external and slight, the treatment may possibly be expectant for twelve hours, if carefully watched, but usually the symptoms become so serious that immediate emptying of the uterus is required either by the Vorhees bag, digital dilatation, version and extraction, or Cæsarean section, the method chosen being dependent upon the amount of the hæmorrhage, the vigor of the mother and the condition of the cervix, os, pelvis, and child.

Placenta prævia is the name given to a placenta that is attached low down in the uterus so that its margin or a large part of its mass overlies the os. This happens through the action of the egg which embeds itself too far down on the endometrium—too close to the cervix.

Three different kinds are known and named from their manner of encroaching on the os, as marginal, partial, or central implantation of the placenta.

The hæmorrhage is from a loosening of the placental attachment owing to the stretching and growth of the uterus.

There is only one symptom of placenta prævia—sudden, painless, causeless hæmorrhage. The bleeding seldom appears before the twenty-eighth week, and no suspicion of a placenta prævia may arise before the appearance of hæmorrhage, which, as a rule, is soon repeated.

Labor frequently comes on prematurely and malpresentations naturally result from the inability of the presenting part to fit itself into the pelvis.

There is no bag of waters, hence the first stage is longer and bloodier and fraught with much danger.

Interference is regularly indicated to save the life of the mother, while the child also has a high mortality. Puerperal infection is not uncommon.

Placenta prævia is always an emergency. If the patient can be kept under observation in a good hospital, one may temporize, but under other conditions the uterus must be emptied at once, even if only a single hæmorrhage has developed. The indications are, (a) to control the bleeding, and (b) to empty the uterus. The life of the child must be disregarded and the mother alone considered.

If the contractions have not begun, they should be stimulated by the introduction of a Vorhees bag, which, at the same time, dilates the canal and mechanically shuts off the bleeding vessels by compression. In introducing the bag, the membranes may be ruptured so the bag will pass into the uterine cavity. When the implantation is central, the finger must tear a hole through the placenta, and through this opening pass the bag inside the uterus.

If the os is partially dilated, version may be done, and a foot brought down. The leg may then be pulled upon until it compresses the bleeding area and the traction maintained with a slowly developing pressure sufficient to check the hæmorrhage, until dilatation is advanced enough for delivery. Occasionally good results are obtained by tightly packing the cervix and vagina with gauze or cotton. (See Vaginal Tampon, p. [204].)

Cæsarean section may be done in the interests of the child, as well as the mother.

The fœtal mortality in placenta prævia is said to be 60 per cent and the maternal 10 per cent.

Differential diagnosis between
Accidental hæmorrhage and	Placenta prævia
Usually occurs in later months.	Any time after the twenty-eighth week.
May be concealed or open.	Always open and external.
Soon followed by labor pains.	Labor need not occur.
Uterus becomes larger if bleeding is concealed.	Uterus remains same size.
Uterus hard and woodeny.	Uterus, normal consistency.
In severe cases, signs of shock whether hæmorrhage is external or internal.	In severe cases, signs of shock follow the invariable external hæmorrhage.
No placenta can be felt.	Placenta can be felt through the os.
Hæmorrhage continues.	Hæmorrhage intermittent.
No history of previous attack.	Possibly history of previous attack.
No contractions after labor begins in serious cases.	Contractions as usual.
No bogginess of cervix.	Cervix boggy.

Hæmorrhages may occur during labor from retention of the major part of the placenta while a portion is detached. This may be due to pre-existent disease, such as endometritis, or from uterine inertia.

Normally the placenta will separate and be discharged within an hour after labor and in the absence of hæmorrhage it may go even longer than this with safety. The occurrence of severe hæmorrhage, however, requires the immediate cleaning out of the uterus by inserting the hand and peeling the placenta from its attachments.

Post partum hæmorrhage includes all hæmorrhages that occur after the delivery of the placenta.

The “flooding” as it is called by the laity, is most apt to come on either immediately or within an hour or so after labor. If it comes on after the first twenty-four hours, it is called secondary hæmorrhage. Such predisposing causes as over-distention from twins may be present, but the hæmorrhage may follow a perfectly easy and apparently normal labor so suddenly and so profusely that the woman may die in half an hour.

There are four causes for post partum hæmorrhage: namely, (a) uterine exhaustion (atonia uteri); (b) mechanical obstacles to retraction, such as clots or retention of pieces of placenta or membrane; (c) and lacerations of some part of genital passage, such as the vulva, vagina, cervix, or lower uterine segment; and (d) the systemic condition known as hæmophilia.

“Bleeders” (hæmophilias) are women whose blood lacks coagulability, owing to the absence of fibrin-producing elements.

Post partum hæmorrhage is usually an external hæmorrhage, but the woman may bleed to death into her own uterus.

Besides the external signs, the patient may show the symptoms of acute anæmia, such as the rapid pulse, hurried, shallow respiration, pallor, cold sweat, yawning, dizziness, etc.

Nearly all these cases can be saved by prompt recognition and efficient treatment.

The first step is to grasp the uterus. If the hæmorrhage is due to a tear low down, the uterus may be hard, but generally it is relaxed and requires vigorous massage with both hands before it shows any signs of contraction. In the absence of the doctor, the nurse must know how to undertake this maneuver. The uterus, after labor and especially when relaxed, is sometimes difficult to identify and the nurse can only make deep massage in the pelvis until the organ responds and its hard globular mass can be appreciated. As soon as the uterus contracts, clots and contained blood are expelled, and in many cases its bleeding ceases at once. (See Conduct of Third Stage, p. [149].)

It may be necessary to keep the uterus contracted by manual massage in this way for several hours. As soon as possible, the nurse, or someone whom she directs, prepares a hypodermic of pituitrin—10 to 15 ♏︎. An injection of ergot may follow because its effect is more lasting than pituitrin. Next, a hot douche is made ready and the materials for packing the uterus are assembled.

When the doctor arrives, he sterilizes his hands, puts on gloves and introduces two fingers or the whole hand into the uterus to remove clots or any retained fragments of placenta.

The hot intrauterine douche may follow, and if the contraction is not firm and the hæmorrhage checked, the uterus must be packed with gauze. If hæmorrhage comes from cervix, it should be grasped with long forceps, pulled down, and sutured. If from perineum, pack first, and afterward sutures may be introduced.

If the patient is exsanguinated, the foot of the bed is raised, coffee given by mouth, camphorated oil hypodermically, and normal saline transfused under the breasts.

Pituitrin may be continued in larger doses. 1 c.c. will raise the blood pressure very definitely. Adrenalin also may be employed for this purpose.

The following summary may be found convenient:

Post Partum Hæmorrhage

Etiology, Functional.—

Atony of the uterus, especially after rapid artificial or natural emptying of the organ.

More common after uterus has previously been greatly distended.

Premature version and extraction.

Hydramnios and twins.

Imperfect development of uterine musculature.

Precipitate labors.

Haste or improper management of third stage.

Etiology, Mechanical.—

Retention of placenta—partial, total or solitary cotyledons.

Inversion of the uterus.

Placenta succenturiata.

Inflammation of decidua serotina.

Conduct of third stage, i.e., wait until placenta separates.

Etiology, Systemic, Hæmophilia.—

Kind of hæmorrhage.

Hæmorrhage before expulsion of placenta due to laceration of the soft parts, or

Partial release of placenta and failure of uterus to contract, or

Placenta may be attached to periphery or to one side.

Attempts to expel placenta without waiting for uterine contraction are sometimes productive of hæmorrhage.

Hæmorrhage after expulsion of placenta.

Hæmorrhage in interval between pains—comes from placental site.

Hæmorrhage in stream not checked by uterine contraction is due to laceration of the canal.

Hæmorrhage in abnormal quantities at beginning of pains.

Pure atony—comes early.

Hæmophilia again.

Diagnosis.—

Palpation of uterus through abdomen.

Placental site excluded from contraction (paralysis).

View of vulva.

Injuries. Flow continuous, fluid and bright red, shows arterial origin, probably from cervix. Examine.

Atony—bleeding at intervals, clotted and dark.

Hæmorrhage from a tear begins at once.

Uterus contracted and hæmorrhage continues. Look for tear.

If hæmorrhage does not begin within ten or fifteen minutes after labor it is not from a tear.

Always have hæmophilia in mind.

Management.—

Third stage must be conducted properly.

Before expulsion of placenta—early expression.

Credé or manual removal—then secure contraction by massage.

Pituitrin, Ergot, or both.

After Third Stage.—

Restore an inverted uterus. Repair lacerations. See that cavity is clear and clean.

Massage, intrauterine hot water douche, hand in uterus and hand outside and rub, ergot.

Pituitrin hypodermically. Pack uterus with sterile gauze or weak iodoform gauze. Strict asepsis for all intrauterine maneuvers.

Treat anæmia with transfusion, elevation of foot of bed, coffee, external heat, hot rectal enemas, stimulation, bandaging of legs.

Strychnine sulphate, adrenalin, or camphorated oil may be required in usual dosage.

Hypodermoclysis. (See Minor Operations, p. [206].)

After the bleeding stops, the food must be most nutritious—milk, eggnog, rich soups, chicken and mutton broths, oyster stew, and beef steak as soon as she can take it. A diet of fluids and stimulating foods that raise the blood pressure will most quickly relieve the symptoms.

Fig. 100.—The knee-elbow posture. (Bumm.)

Fig. 101.—The knee-chest posture.

Eclampsia occurs in the last three months of pregnancy as a rule, and most frequently just before or during labor.

In about one sixth of the cases only, the attack may follow labor. The attack is characterized by violent convulsions, which come on with little or no warning unless the urine has been carefully watched.

Fig. 102.—The exaggerated lithotomy position obtained with a sheet sling. (American Text Book.)

Fig. 103.—The improvised Trendelenburg position. (American Text Book.)

The prodromal symptoms have already been described under albuminuria in pregnancy (p. [77]). The marked features may be repeated for emphasis: persistent headaches, disorders of vision, spots before the eyes, blindness, edema of cheeks, eyelids, feet and hands, pain at the pit of the stomach, dizziness, nausea and vomiting and ringing in the ears. Suddenly the convulsion occurs, the facial muscles twitch, then the limbs and body are shaken by violent muscular spasms. The body becomes rigid, the tongue protrudes and the face is livid and cyanotic. The spasm usually lasts from one to five minutes and is succeeded by coma that lasts an hour or more. In some instances there is no return to consciousness before the next attack, which comes on every hour or half hour, though occasionally only one seizure is noted.

Fig. 104.—The dorsal position with stirrups. (Dorland’s Dictionary.)

The blood pressure is greatly increased and the urine is diminished, the temperature rises to 101° or 102° F. When death ensues, it is most frequently due to edema of the lungs or cerebral hæmorrhage.

The greater the number of convulsions, the more serious the outlook as to life, and it is said that after twenty seizures fifty per cent of the mothers die. Under the best treatment approximately fifty per cent of the babies die.

Fig. 105.—Dorsal position across the bed. (Bumm.)

There is no routine treatment for eclampsia.

The principles of management for the attack are (1) to empty the uterus, on the theory that the disease is a toxæmia of gestational origin, (2) to eliminate the poison, and (3) to control the convulsions.

The albumin in the urine and other eclamptic symptoms demand urgent attention in prophylaxis.

For the pre-eclamptic period (see Albuminuria of Pregnancy, p. [77]) a rigid milk diet is indicated. The bowels, kidneys, skin and blood vessels must all be brought into service.

In the full blooded patient, venesection may be done and after drawing off ten or twelve ounces of blood, an equal amount of normal saline may be poured into the same vein.

Fig. 106.—Flexed dorsal position with feet on the table. (American Text Book.)

Subcutaneous transfusion or the submammary introduction of saline solution may be done. The skin is stimulated by hot wet packs and the bowels by saline cathartics and frequent irrigation of the colon.

During the attack, the patient must be kept from injuring herself. A spoon wrapped in gauze or a small, long roller bandage should be slipped between the teeth to keep the tongue from injury. The clothing must be loosened or removed. No food, but only water is given by mouth, until the patient is conscious.

The convulsions are controlled by morphine, chloral, or both.

Morphine sulphate, ¼ gr. is given hypodermically, followed in an hour by 30 gr. of chloral by mouth. Two hours later the morphine is repeated and six hours after the first dose of chloral, it is repeated. In this method (Stroganoff’s), four doses of chloral and six of morphine are given in twenty-four hours. That is all. When the stomach will not retain the chloral it may be given by rectum in milk. If a general anæsthetic is used, it should not be chloroform, but ether.

Fig. 107.—The Sims position. (Kelly.)

The labor, if begun, should be expedited by forceps, or version and extraction. Bleeding during delivery should be looked upon as desirable. If more rapid measures of delivery seem demanded and obstacles exist, such as pelvic contraction, imperfect dilatation, or the prospect of a prolonged first stage, Cæsarean section or forcible delivery (accouchment forcé) may be attempted.

If the labor has not begun, when the convulsion occurs and a quick delivery by the normal passage does not seem feasible, then the Cæsarean operation may be the best treatment.

CHAPTER XVI
THE ABNORMAL PUERPERIUM

The practice of obstetrics has many features that are very gratifying to the nurse and physician.

Instead of a surgical operation, which has come unexpectedly and undesired; a disaster in which some part of the body is removed or altered by means of a procedure associated with extreme pain, mental tribulation and large expense, a much-wished for addition is brought to the family, with pain, to be sure, but a pain that is soon forgotten in the general joy. This is the normal condition that causes the nurse and the doctor to rejoice that such a delightful specialty has been chosen.

Then comes a case in which the labor may be complicated by some dreadful anomaly, or the puerperium burdened or disordered by some unwelcome invasion that tortures the souls of the family and may cost the life of the mother, or child, or both.

At such a time the nurse and the doctor feel the full weight of their responsibility, and after a series of anxious days and sleepless nights, they wonder why they did not choose gardening or a clerical position for their life work.

The disorders of the puerperium are many and various, but naturally the breasts and the pelvic organs are most frequently affected.

The breasts of the human female are not reservoirs of milk like the cow’s, but a pair of highly sensitive organs that functionate and produce only as the demand is made. It follows that when the milk comes in, the breasts become engorged and all the neighboring structures are involved in the new process. However, it is not milk that is overfilling the breasts, but serum, lymph and venous blood, which congest the tissues surrounding the glands and produce a hard painful mass.

The breasts become heavy, hot, and painful; supernumerary glands in the axillæ enlarge, but there is no fever. There is but little more reason for a fever when the mammary gland begins to functionate than when the lungs fill for the first time except in the case of nervous patients who bear discomfort badly.

If fever appears simultaneously with the milk, the cause must be sought in some atrium of infection, possibly in the breasts, but usually elsewhere. There is no such thing as “milk fever.” The enlarged glands, the tense mottled skin on which blue veins run visibly here and there, the nipple, flattened and drawn into the swelling, so that the child can not grasp it with the mouth, all produce a sense of disorder that ought to be associated with fever—but is not. This is the “caked breast” of the laity, and if let alone, the hyperæmia subsides and the function remains. The temperature in possibly two cases out of five may rise to 100° F. for twenty-four hours, but it promptly subsides. These temperatures generally occur in neurotic women.

If the breasts are irritated by binders, breast pumps, or massage,—like the blacksmith’s arm, with exercise—the trouble, if not increased, is at least much slower in disappearing.

It is reported that the young virgins of some African tribes nurse the babies in the family, the breasts being stimulated to produce milk largely by massage.

If the condition of the breasts becomes too painful, the liquids by mouth are reduced to the last degree, saline cathartics are given until frequent watery stools result, one or more ice bags are applied to each breast and codeine sulphate may be given at night. The child nurses every four hours only. Williams was the first to show that no tight binder is necessary, but only a supporting bandage. The tight binder is a cruel and useless barbarism that has been abandoned by progressive physicians. No massage is allowed; no pumps; no irritation whatever, and in twenty-four hours the trouble has disappeared. Hot dressings to the breast are equally archaic. They should never be applied to any breast unless it is desired to hasten suppuration.

If the child dies, or for any reason can not nurse (inverted nipple, cleft palate, harelip) and it becomes necessary to dry up the milk, the treatment for “caked breast” is continued. After twenty-four hours the breasts are comfortable and rarely give trouble again.

Cracks, Fissures and Abrasions of the Nipple.—The care of the nipples should be inaugurated about six weeks before labor, as elsewhere described:

The nipple must be inspected and its possibilities determined, early in pregnancy, if possible, for many varieties of badly shaped and ill-developed nipples exist which may make nursing difficult or impossible.

Imperfect nipples especially are predisposed to fissure and crack, and will require extreme care on the part of the nurse. She should inspect them before and after each nursing and sedulously use cleanliness and asepsis in her management. In normal and tranquil as well as in neurotic women, the nipple may become so sore as absolutely to preclude nursing, and this entails much additional work on the nurse and mother, as well as considerable peril for the child. The condition usually begins as a fissure or crack, and is accompanied by much pain. It is serious, furthermore, in another aspect since all breaks in the surface of the nipple are avenues of infection that may result in mastitis. The child may produce fissures or abrasions by rubbing the nipple with his mouth, by pulling too hard, or by the habit of holding it in his mouth and macerating it with his gums when he has finished nursing.

Fig. 108.—Examples of imperfect nipples. (American Text Book.)

The child must not be left at the breast after he has nursed, but the nipple should be gently removed from the child’s mouth by passing one finger in beside the nipple. Fissures and abrasions usually occur within ten days if at all. Abrasions or erosions are due to the wearing away of the epithelial covering of the nipple in patches more or less extensive.

Thin-skinned blonde women suffer more than those with dark, dense oily skins.

A fissure is a distinct separation of tissue that goes deeply into the underlying substance.

A crack is a long abrasion which may deepen into a fissure.

Both fissure and crack may affect the top, the side of the apex, or the base of the nipple. They may be either longitudinal or circular. The entire nipple must be kept under observation and the instant a raw surface is detected, treatment must begin.

Fig. 109.—A standard nipple shield. (American Text Book.)

Compound tincture of benzoin, liberally applied, is a favorite and successful remedy. Our routine is to apply a paste made of equal parts of castor oil and subnitrate of bismuth. This is put on after the child nurses, and must be removed carefully before the next nursing. Sometimes the child’s stools become black and constipated and the trouble may be traced to imperfect removal of the bismuth preparation.

Whatever medication is used, the nipple must be protected from injurious friction by the clothing. This is best done by the hat-shaped lead nipple shield, which is placed over the nipple and held in place by a light binder. The shield should be boiled before use.

To protect the nipple during nursing, a glass shield may be used for a day or so, but not long enough for the babe to get accustomed to it, else he will form a habit hard to break. This shield must be taken apart after use, washed and kept in saturated solution of boric acid until the next nursing.

If all these measures fail, the fissure must be touched with a nitrate of silver stick once, or have a 2 per cent solution of nitrate of silver applied night and morning. It may be necessary to take the child from the breast for a day or so, in which case he nurses the other breast and the side with the bad nipple is pumped.

The care of the nipple is highly important since the apprehension and the actual pain of each nursing may prevent sleep, destroy the appetite, and diminish the milk. If begun early, most fissures will heal in twenty-four to forty-eight hours.

Mastitis.—From three to five per cent of lying-in women have mastitis in the European clinics, but the records in America show a much smaller number.

The disease occurs most frequently in blondes and in primiparas. It is most apt to appear during the first two weeks, when the congestion accompanying the new mammary function produces a stasis that favors the growth of germs, which may enter through the abrasion or fissures of the nipple produced by zealous activity of the child’s gums. But it may also occur when the child’s first teeth come and the nipple is again exposed to injury. At times it is impossible to find a plausible excuse for its occurrence.

Mastitis is usually described in three forms: The (a) parenchymatous or glandular type, which affects the substance of the gland or the enveloping connective tissue; in (b) subcutaneous mastitis the connective tissue beneath the skin is attacked; and in (c) the sub-glandular variety, the infection finds a lodging between the gland and the chest wall.

Mastitis is always due to the presence of microorganisms which in many cases gain access to the gland through fissures or abrasions by means of the lymphatics. In other instances the germs may be in the blood and a local stasis may encourage the infection. Still again, they seem to enter through the normal nipple openings.

Symptoms.—The parenchymatous inflammation begins with a chill, and the temperature promptly rises to 102° to 105° F. The pulse is high. The patient complains of headache and thirst. Examination reveals hard, tender nodules in some part of the gland. The skin may or may not be reddened.

If the trouble has begun in the connective tissue, the skin will be diffusely reddened, the nodule ill-defined, the temperature will rise gradually and the chill may be absent.

Treatment.—The breast is put at rest. No tight binder is applied, no breast pump, no massage. No heat is allowable.

Ice bags surround the gland night and day. The liquids by mouth are restricted and saline cathartics given. Codeine may be administered for pain. Usually the symptoms subside without suppuration in from one to two days.

Should the inflammation persist for more than two or three days, in most cases the tissue will break down and form a mammary abscess. When it is evident that suppuration has begun, heat may be applied to the gland and the process accelerated. The abscess may be superficial or deep and will be diagnosed by a bogginess in a circumscribed area or by fluctuation. The abscess must be opened as soon as possible.

The nurse sterilizes a bistoury and a pair of long artery forceps. Lysol solution and cotton sponges are made and sterile gauze for packing. The hands are surgically prepared and rubber gloves worn. If an anæsthetic is required, gas may be used, or chloroform. The incision is made radially from the nipple so as to minimize the injury to the milk ducts. A gauze drain may be required for a few days.

In the after-care, the nurse must be scrupulously clean and not convey contagion from the breast to the woman’s genitals, to the child’s eyes, navel or vagina, nor to her own person.

Excess of milk is rare, but may be observed for a short time after the glands fill. It seldom requires treatment, but saline cathartics, restriction of fluids, and putting the child on a four-hour schedule will reduce it. Pads may be worn if it runs away freely.

Scarcity of milk is only too common. There may be enough at first and the quantity gradually diminish, or it may be deficient from the very beginning.

The faulty secretion may be due to the age of the mother, to disease (anæmia), to bad nutrition, or to overwork. It may follow a premature child. Compression of the breasts by corsets or tight dresses may prevent development. The amount of gland tissue is very important. Many women have large, fat breasts, but a small glandular development. Mental conditions, such as fright, worry, and anxiety, will diminish the flow of milk or stop it altogether.

Symptoms.—The child is fretful, goes to sleep after nursing but soon wakes up, or may nurse awhile, and then finding it useless, will cry and refuse the nipple. He loses weight and when weighed before and after feeding, the scales scarcely vary. No secretion or very little can be squeezed from the breasts. The child may be given a bottle after which he goes to sleep.

Treatment.—When the gland tissue is defective, no treatment can succeed.

The appetite must be improved by bitter tonics and the mind relieved of its anxieties, if possible. Change of scenery may help. The fluids must be increased, milk, cocoa, chocolate and gruel must be pushed, and such vegetables added as corn and beets. Oyster stews, clams, lobsters, and crabs will help. The diet must be full and nutritious with especial stress on those foods that raise the blood pressure. Malt drinks or champagne may avail in some cases. Exercise in moderation is desirable.

Artificial stimulation of the breast sometimes succeeds. Massage will irritate the glands, increase the congestion, and promote functional activity; or a Bier vacuum apparatus may be put over the gland several times a day and the air pumped out. The breast should be kept distended for fifteen to twenty minutes. There is difficulty in this country in getting glass bells of sufficient size.

Galactorrhœa is the name applied to an abundant secretion of milk poor in quality toward the end of a long lactation or after the child is weaned. The symptoms are an almost constant flow of milk with resultant anæmia.

Treatment.—Elix. of iron, quinine and strychnine with compression of the gland. A dry diet and the avoidance of all irritation of the breasts will aid.

To “dry up the milk,” follow the treatment for “caked breast.”

Fig. 110.—A standard breast pump. (American Text Book.)

Quality of the milk may be such that the child will not take it or, if taken, it fails to nourish. In some cases this is due to overlong, or to irregular, periods between feedings; for when the nursing interval is too short, the milk becomes too rich, when too long, it becomes thinner and less nutritious.

Fright, anxiety or anger may change the character of the milk so that colic, vomiting, and diarrhœa and indigestion are produced in the child. A wet nurse becomes homesick and the milk dries up. It may become extremely indigestible, as shown in cases where a wet nurse quarrels with her husband and her foster child develops green stools. If the mother’s milk does not agree, the child may be put on feedings for twenty-four or forty-eight hours, while the milk, pumped from the breast, is sent to a laboratory for analysis. If a return to the breast is unsatisfactory, artificial feedings or a wet nurse must be supplied.

Removal of the child from the breast may be required for a variety of reasons. Thus, the mother’s addiction to alcohol or opium is good ground for taking away the child. Arsenic, bromides and iodides of potassium, saline cathartics, salicylates, alcohol, opium and belladonna must be given to the mother with great caution during lactation, for they pass over into the milk.

Acute diseases, such as erysipelas, pneumonia, diphtheria, typhoid, malaria, pronounced puerperal sepsis or persistently high fever from any cause, usually dries up the milk; while cardiac lesions, unless well compensated, chronic anæmia and tuberculosis, obviously demand the removal of the child for the sake of both. Sometimes a new conception, especially when the milk becomes poor in the last half of gestation, compels the mother to wean her babe.

A syphilitic woman may nurse her own child, provided her condition is good and the child also is syphilitic.

Theoretically, the return of menstruation in no way affects the nursing child, unless the blood is lost to the point of anæmia. Yet cases do occur in which the child has indigestion, colic and bad stools, as well as loses weight, when the mother is menstruating.

The quality of the milk is sometimes altered, but only for a day or so, and the child should continue at the breast unless some definite indication for removal arises.

Weaning ordinarily is completed by the ninth month, but the child should never be carried beyond the twelfth month on account of changes in the character of the milk.

When a child is weaned, the substitution of an artificial food may be made gradually,—a bottle a day, two bottles a day, etc., until, in a couple of weeks, the breasts are at rest.

The excessive prolongation of lactation is shown upon the mother by impairment of the health. The patient is pale, weak, anæmic, fretful, and thin. Headaches, dizziness, loss of appetite, and constant fatigue will be complained of.

The treatment is to remove the child at once and put the mother on stimulating drugs and foods. A change of air and scenery, if possible, will be highly beneficial.

The wet nurse is always a tribulation, which must be endured until the child can be put on artificial food. She should have a Wassermann test before entering upon her duties. Syphilis, tuberculosis, and gonorrhœa must be guarded against. She must be kept like the family cow, in a placid frame of mind, fed on nutritious food that is not too rich, and exercised enough to keep the blood circulating.

Light housework and duties that take her out of doors part of the time are advisable. Her moral character can only be assured through those who have known her. If she brings her own child with her, she will need watching to provide for an equable distribution of the milk. The first few days is never a criterion of a wet nurse’s effectiveness. Change of food and surroundings may interfere with her usefulness.

Gas may complicate the puerperium after Cæsarean section, and even after normal labor. A rectal tube of soft rubber may be passed as high as possible into the bowel and left for some time, or enemas of S. S., turpentine, asafœtida, or milk and molasses may be given. By mouth calomel or mag. cit. is valuable.

Headache in the puerperium should be watched carefully, and the cause discovered. Pain in the head may be a habit with the patient, or it may be a symptom of some complication either present or developing, such as toxæmia, eclampsia, or acute yellow atrophy of the liver. In general, it is due to milder conditions like exhaustion, too many visitors, excitement, nerves, or insomnia.

After-pains.—Sometimes patients are greatly annoyed by after-pains. The pain may be due to a clot retained in the uterus or possibly a stimulation of the uterus when the child goes to breast. Gentle massage of uterus, or ergot, quinine, or codeine may be required to bring about the expulsion of the clot or to control the pain. A reasonable degree of after-pain is of favorable significance. (See p. [154].)

CHAPTER XVII
INFECTION

Puerperal fever is a wound infection.

The conditions of the pelvic organs during labor and post partum, are well adapted to receive and develop microorganisms, for the healthy antimicrobic power of the vaginal secretion is absent or diminished.

A long and exhausting labor, possibly accompanied by hæmorrhage, or terminated by an operation, has diminished the immunity and broken the resistance of the tissues to a dangerous degree.

The mucous membrane of vulva and vagina are torn and bruised, the vitality lowered, and the surface covered with bloody lochia, which is an excellent nutritive medium for microbic development. The uterus is a vast, open wound, filled with fibrin, blood clot, and decomposing tissue, while the whole pelvis is maintained at exactly the proper temperature for germ propagation.

Through these wounds, toxins are carried into the circulation, and germs, nourished upon the abundant and favorable culture media, pass through the uterine walls or by way of the lymph channels first into the adjacent tissues and thence to all parts of the body.

Certain definite organisms reach the disintegrating tissues and produce a putrefaction. They do not, however, once their work is done, pass into the body. But in producing putrefaction, they also produce injurious poisons, called toxins, which do enter the body and cause an absorptive fever known as sapræmia.

Fig. 111.—Germs most frequently found in cases of puerperal fever. (Kelly’s Gynecology.) 1, streptococci (in chains); 2, gonococci; 3, tubercle bacilli (not a source of puerperal infection); 4, bacillus coli communis; 5, staphylococcus pyogenes aureus; 6, bacillus aerogenes capsulatus.

Other organisms are the pus microbes, which begin their growth in any favorable location and continue to spread and flourish onward and inward by blood vessel, tissue or lymphatic, until overpowered by the resistances of the body, or until by general sepsis, they have killed the patient. These are the streptococcus, staphylococcus, bacillus coli and bacillus pyocyaneus. These are the germs that the nurse or the doctor may bring to the patient on hands, clothing, or hair. These are the organisms against which our scrupulous asepsis and antisepsis is directed. It is against them and their activities that the doctor and nurse prepare by the long and painful scrubbing of the hands and elbows, the rubber gloves, by the shaving and scrubbing of the patient, and by all the paraphernalia and equipment that go to furnish the modern lying-in-chamber or delivery room. It is on account of these germs that the conscientious doctor or nurse lies awake nights and painfully reviews his technic when his patient has a temperature, and it is on their account that he shudders at the callous disregard of human life that is shown by those who do not observe the known laws of asepsis.

It is true that many women escape when the attendant is unclean, but this is due to a splendid immunity, and in no way absolves the man or woman who neglects his asepsis and has patient after patient running temperatures, some of whom are bound to die or be crippled for life. It is for this reason that a surgeon should do surgery and not general practice; it is for this reason that an obstetrician should limit himself to the care of women in childbirth and not endanger them by taking cases of scarlet fever, erysipelas, and unclean surgery.

In country practice, all kinds of work must be done since there are not enough men to specialize, but it is inexcusable in the city where a man can always be clean and keep clean, if he is willing to forego the income derived from attendance upon septic and infectious cases. Any article not surgically clean may contaminate the patient by contact; but ulcers, suppurating wounds, abscesses, and hands improperly or insufficiently cleaned are the deadliest causes of post partum temperature.

Infections are said to be either self-produced or brought to the patient from without.

The only organism that is demonstrably self-infectious is the gonococcus, which may be present in the vagina before labor and may infect the puerperal woman; but it is wiser, safer, and more nearly accords with the facts, to regard all infections as alien borne, as brought to the patient and introduced by the unclean hands or instruments of her medical attendants.

Prevention.—A conscientious and capable nurse or doctor will not go from an infected case to a confinement. Both will keep their bodies clean, the teeth filled, and pyorrhœas scraped and treated. The occurrence of pus anywhere on the body is sufficient reason for the doctor to give up his confinements for a time, and the nurse to report off duty.

No raw, and but few mucous surfaces should be touched by the fingers of the attendants, where a sterile instrument can be used.

The nurse should never make vaginal examinations unless an emergency exists, and then only when her instruction has been thorough and her experience great. Every examination is a possible source of danger, no matter how carefully the hands and patient are prepared. The nurse is not to change the pads without washing her hands, and she must wash her hands always after changing the pads, before dressing the navel of the child.

The navel or eyes of the child may be infected easily by the hands of nurse, doctor, or patient. The breasts of the mother may be infected by the hands of nurse, doctor or patient. The vulva and vagina of the puerperal woman is highly susceptible to infection from the hands of nurse, doctor or patient.

Rule.—All temperatures arising in the puerperium are due to infection, unless satisfactorily explained by finding the source. The possibility of a slightly elevated temperature from insignificant causes may be kept in mind, but such temperatures are transient and yield quickly to appropriate treatment or to none at all.

Puerperal infection is most apt to appear during the first week of the lying-in period, and it generally develops about the third or fourth day post partum. If the symptoms come on later than this, there is always a hope that the infection has taken its origin in something else than the labor.

Symptoms.—In mild cases, a rapid pulse, headache, and a temperature of 101° or 102° F. may be the only symptoms. Severe cases begin with a chill, followed by a marked rise of temperature. The temperature is always irregular and generally remittent.

The pulse rises to 120 or 130 beats a minute, headache and prostration appear, occasionally associated with vomiting.

The flow of lochia may be either increased or diminished and either offensive or free from odor. Foul-smelling lochia is a sign of putrefaction but not necessarily of sepsis.

At the same time there is some tenderness in the lower part of the abdomen, usually most marked at the sides of the uterus. The uterus is larger than it should be, and not hard, but doughy and sensitive to touch.

The involution is arrested, except in cases of pure septicæmia. This is an important reason for the daily observation and recording of the regular descent of the organ.

The disease runs a variable and more or less prolonged course and the prognosis is always doubtful until the event. Signs of grave import are: repeated chills, insomnia, pulse above 120, persistent vomiting and meteorism, with dry, brown tongue.

Treatment.—Mild cases without chill when the uterus is large and the lochia sometimes offensive, are usually sapræmic. Free catharsis, ergot in full doses, and a half-sitting position to aid drainage will cause the symptoms to subside in two or three days.

In the severe type, the treatment is mostly a case for careful nursing. The more energetically the doctor acts, the more liable he is to do harm. The patient needs all her strength to fight the disease, and should not be required to fight the consequences of injudicious interference.

There is still some discussion about the advisability of assuring oneself that the uterus contains no remnants of the labor. Some feel that this should be determined by curetting the uterus with finger or instrument and following the operation with an intrauterine douche. If this is the view of the attending man, the nurse must aid, for the responsibility is his and not hers.

On the other hand, the weight of authority at present seems inclined to the view that any remnant of the labor will drain out naturally or be expelled by ergotdriven contractions without the necessity of opening up new raw surfaces by interference and thus spreading the infection.

The main idea is to promote drainage in every way possible. No curette, no douche, no uterine packing. Nevertheless, the vulva may be cleansed and the vagina carefully retracted and by appropriate means a culture obtained from the uterus. If this shows streptococci, all local treatment is to be abandoned at once.

In general, the food must be fluid, and as nutritious as possible. This means milk, beef and mutton broths, oyster stew, etc. The nourishment must be pushed artfully and ingeniously. Alcohol is not indicated. The bowels are kept open.

Normal saline, drop method, by rectum, will promote diuresis, skin action, and supply the body with the much needed fluid. Subinvolution is controlled by ergot in full doses. The room must be light and as many windows opened as the weather will permit. Frequent change of posture, from side to side, from dorsal to prone and especially to the half-sitting position, will give the patient comfort and prevent decubitus (bed sores). The daily bath with an alcohol rub, keeps the skin in good condition and eases the mind.

The child should be taken from the breast, because the milk is poor in quality and quantity and it may be infectious. Besides, the mother needs all her strength. Nature usually solves the problem by drying up the milk.

All pads soiled by the patient should be collected in paper bags or rolled in newspapers and burned. Sheets, towels, and pillow slips must be boiled in the house and not sent to the laundry. They should be soaked for half a day in a 2 per cent solution of lysol before being washed, and exposed to the hot sun for a day or so afterward, if possible. No comforts should be used on the bed, and the blankets must be left suspended in the room when it is fumigated at the conclusion of the case. All dishes and utensils can be boiled. Plenty of air and sunshine are essential for the cure of the patient and to prevent the spread of the disease.

The nurse must use every precaution to avoid carrying the infection to herself or others. Rubber gloves should be worn while changing the dressing. It is better to have the child cared for by another nurse. The nurse must get her rest and some exercise out of doors every day. It rejuvenates her and reacts to inspire the patient.

When she leaves the case the nurse should boil her linen and wash her hair with soapsuds and hot water, and bathe frequently.

Milk Leg.—This is an infection characterized by swelling of one, or rarely, both, limbs, from the foot to the groin. The leg is white from the edema, and as the condition is associated with fever and since the milk diminishes or disappears about the same time, it was thought in former days that the milk went to the leg.

The cause of the swelling is a phlebitis of the external iliac or femoral vein which becomes thrombosed or so filled with clots that the return circulation is impeded.

Symptoms.—The attack is signalized by a rise of temperature to 102° to 104° F. There is headache, pain in the affected limb, and general prostration. It is a true sepsis.

The disease appears usually in the latter part of the second week of puerperium, when the patient has begun to congratulate herself that all danger is over. In many cases the doctor has yielded to importunity and let the patient get up before involution was sufficiently advanced and the patient will report that she got up too early.

The limb must be immobilized and kept warm. The immobility should be maintained for at least ten days after the fever has subsided and the pain gone.

The convalescence may be protracted over weeks and months.

Bed sores may complicate a long convalescence. Bathing with alcohol or alcohol and alum, and the frequent change of the patient’s position will usually prevent them. Rubber rings and sheeting should not be used if it can be avoided. Ointments containing zinc are of great value in the cure of this affection.

Phlebitis, in minor degree or in localized sections, may occur in the veins of the leg and the site of the invasion will be outlined as red lines or as irregular nodules. Some fever may attend the condition. Rest of the affected member, with ice bags for the pain, constitute the treatment. Bed sores must be guarded against.

Sudden death in the puerperium is a shocking disaster. Rapid death may follow the complications of labor accompanied by hæmorrhage, such as placenta prævia, rupture of the uterus, etc.; but death may be sudden, without warning, from pulmonary embolism, acute myocarditis, fatty degeneration of the heart, or the entrance of air into the uterine veins. This may happen several days after labor in a woman who is passing through a convalescence apparently normal in every respect. Such an event is probably due to a thrombus which may form in any of the veins of the body, but more frequently in those of the pelvis and legs. In the latter it may be recognized by hard lumps that form somewhere along the course of the veins in consequence of a phlebitis. There is always the menace that some fragment of this mass, which is merely a hard clot of blood, may become detached and float off in the circulation to other parts of the body, such as heart, lungs, or brain (embolism), and by interference with those structures, produce paralysis or instant death. When a thrombus is diagnosed, the affected part must be kept as quiet as possible. No massage is permissible. Tincture of iodine or 20 per cent ichthyol may be applied. The woman should remain quiet for at least ten days after the apparent disappearance of the symptoms.

CHAPTER XVIII
THE CARE OF THE CHILD

Hitherto the mother and the complications and changes peculiar to her condition have been selectively considered, to the neglect of the child; but the labor being over, and the nurse having assured herself that the uterus is hard, that there is no hæmorrhage, and that the mother is resting, now turns to the child lying in its blanket. A hot water bag, carefully tested, should lie at its feet wrapped in toweling or napkins.

The eyes have already received the Credé treatment, 1 per cent solution of silver nitrate or possibly a 15 per cent solution of argyrol for prevention of ophthalmia, and a thorough cleansing comes next.

In a warm room, away from drafts, the nurse takes the child in her lap, or on a table, with a blanket underneath. She first anoints the child all over, either with benzoated lard, liquid albolene, sterile vaseline, or olive oil. This softens the vernix caseosa that covers the child and aids its removal.

The skin is wiped carefully with cotton or a soft cloth, paying particular attention to the folds of the groin, the arm pits, and the genitals. The nostrils are gently wiped out with applicators dipped in oil.

The child must be covered as much as possible during the operation and the work finished quickly. The whole period should not exceed twenty minutes.

During the cleansing process the nurse should look closely for anomalies or anatomical imperfections, like an imperforate anus or urethra, supernumerary digits, etc.

The Bath.—Daily, until the cord comes off, the baby is sponged with oiled pledgets, followed by a spray bath, or a sponging with lukewarm water and castile soap. The child must not be put into a full bath tub on account of danger of infecting the umbilicus. The bath water in a tub or basin quickly becomes filled with bacteria from the surface of the child’s body and may be conveyed quite easily to a raw wound.

Fig. 112.—Rubber bath tub.

All discharges must be wiped away, and the buttocks cleansed with oil. If the skin becomes irritated by urine or otherwise, the child should be well covered with talcum powder, especially in the folds of the groin and in the genital crease. All infants are benefited by a little mild massage after the bath.

If other babies are handled, a child with infected eyes, or skin eruptions, must be quarantined and cared for separately by a special nurse. The color of the skin should be pink, changing under manipulation to red. If there is mucus in the mouth, it may be wiped out with an applicator, if in the throat, the child may be held up by the feet and the head drawn back for a few minutes so that gravity will aid the discharge of the obstruction.

After cleansing the skin, the nurse sterilizes her hands and dresses the cord. The gauze which was temporarily wrapped around the stump is removed, the cord and adjacent skin washed with alcohol and dried. The stump is powdered above and at the sides with a mixture of equal parts of boric acid and subnitrate of bismuth, and then wrapped in gauze. The band is put on, the temperature taken, and the baby dressed. Some physicians prefer to have the cord dressed in 95 per cent alcohol, which is frequently renewed. The normal separation of the cord takes place through a kind of dry gangrene, which should be favored by dry rather than wet dressings. The 95 per cent alcohol does not remain at 95 per cent after it is exposed to air, hence it does not absorb moisture from the cord as absolute alcohol would. However, the attending man is responsible, and his orders must be followed.

The Umbilicus.—The cord may be severed as soon as the child has cried lustily or the cessation of pulsation may be awaited, in either case the child secures a little more blood, which gives him a better start in life.

Two tapes are tied about the cord, one close to the skin margin of the child and the cord is cut between them. A kind of mummification or dry gangrene normally develops and the stump falls off, as a rule, about the fifth day, leaving a moist, granulating area, which forms the umbilicus.

A metal clamp may be used in place of a tape to compress the cord. The advantage of the clamp is that on account of its greater width and rigidity it does not cut through the cord when applied. Furthermore, it can be made and kept more nearly aseptic. It does not soak up the juices from the cord and form a culture medium for germs. It can be removed on second day. The cord usually comes off a day or so sooner than when the tape is used.

Fig. 113.—The Pettit cord clamp.

The care of the cord is extremely important, as many infections can be transmitted through it to the child. At each dressing the cord is inspected, and whether it is dry or moist, offensive or inodorous, should be noted. These facts, with the falling off of the cord, are put down on the history sheet as they are observed. The binder, after each removal, is not pinned, but sewed on. The sewing should begin below and go up in order to have the tightness low down.

Eyes.—After the first instillation of silver nitrate solution, a reaction appears with redness, swelling, and discharge, which passes off without treatment in two or three days. During the bath, care must be used not to get anything into the eyes nor anything from the eyes or nose upon the navel.

At each dressing the nurse should irrigate the edges of the lids gently with boric acid solution. If the eyes become red, swollen, and have a purulent discharge after the second day, the case is possibly ophthalmia and they must be watched with extreme vigilance. A smear should be taken for the microscope and preparations made for energetic treatment.

The following summary may be of service in memorizing the routine of nursery procedure.

Nursery Rules

1. Keep temperature of nursery 68° to 72° F. 2. During bath, keep temperature of nursery 75° to 80° F. 3. Temperature of bath water 98° to 99° F. 4. Never use a diaper that has not been laundered. 5. Tie case number on child’s arm before leaving delivery room. 6. Watch cord for hæmorrhage. 7. Record temperature, stools and urine. 8. Give water freely between feedings. 9. Put to breast twelve hours after birth, and every three hours thereafter until the child begins to gain, then one and possibly (?) two night feedings may be omitted. 10. Change binder daily. 11. Oil bath first, then shower bath on subsequent days. 12. Dress cord with alcohol 95 per cent, dry and apply bismuth subnitrate and boric acid powder (equal parts) into crevices beneath clamp or tape and under edges of the crust. Change dressing daily. Cord should fall off fifth day. Report failure to do so. 13. Clamp may be removed on second day.

Routine for the Child.—

1. Temperature. 2. Undress. 3. Weight. 4. Shower bath. 5. Dress cord—record condition. 6. Binder daily until discharged. 7. Diaper and dress. 8. Sponge eyes with boric solution. 9. Cleanse nostrils with albolene. 10. Brush hair. 11. Drink of warm water. 12. Observe case number daily.

Clothing.—(See Infant’s Outfit, p. [101].) The clothing must be light, loose, warm, and not irritating to the skin. The outside garment should have wing sleeves which permit free motion of the hands, but do not permit them to reach the eyes.

The band of plain outing flannel should always be worn for the first few weeks.

Birds-eye linen makes the best diapers on account of its superior absorbent qualities.

The feet must be kept warm by stockings, and artificial heat, if necessary. On hot days much of the clothing may be removed and the shirt, band and diaper may be all that are needed.

The care of the shirts and bands is part of the daily duty of the nurse. They must be washed daily, either by the nurse herself or under her supervision, as they are easily injured. After washing, in soft water, if possible, and with wool soap, they must be dried on a stretcher. Diapers must be put directly into cold water. Fæces may be brushed off with a whisk broom, and the napkin rinsed, boiled and again rinsed. No diaper should be used a second time until this has been done. No bluing may be used on the diapers and the soap must be mild, otherwise chafing and intertrigo will follow.

The infant’s toilet basket must contain:

4 soft bath towels.

1 pound of absorbent cotton.

1 dozen wash cloths of soft material.

1 small hair brush.

1 pair nail scissors.

Talcum powder.

Bath thermometer.

Hot water bottle.

Albolene.

Castile soap.

8 oz. boric acid solution.

8 oz. benzoated lard.

Paper bags for waste.

Pitchers and basins.

Fig. 114.—A, standard breast pump; B, standard nursing bottle; C, the breast tray; D, the Wansbrough lead nipple shield; E, the Brophy nipple for harelip and cleft palate.

Weight.—The weighing of the child should precede, for convenience, the first cleaning of the skin and the daily bath. The child is either put on the scale naked or weighed in a blanket, and the weight of the blanket, ascertained before or after, is subtracted. The daily weight record is just as important as the temperature. A scale that registers ounces and fractions thereof must be used, and the child should be guarded from falling during the performance. Usually the child loses from eight ounces to a pound the first week, but it should gain back to its birth weight, by the end of the second week. If the child does not gain, it may be due to lack of milk from the breast, and the weight may be taken before and after feeding to verify or refute the suspicion.

The mouth should be inspected each morning, but not cleansed with the boric acid solution unless definitely indicated. Spots or any unusual appearance should be reported.

The Genitals.—The vulva of the female infant usually requires but little care besides cleanliness. There is sometimes a whitish discharge which disappears spontaneously in a few days. It is a drainage of vernix, smegma and epithelium from the vagina and labia.

With a male, the prepuce must be inspected when the child is about a week old. If it is long and the orifice small, circumcision may be suggested. Under any circumstances, the foreskin must be retracted, the adhesions broken up, and the smegma removed. This must be repeated daily until the adhesions do not recur. The maneuver should be done the first few times by the physician, for fear of a paraphimosis.

Sleep in the newborn is normally quite deep and almost continuous, probably twenty-two hours a day, for the first week. The rather fast respiration of the child, even when sleeping, is no cause for alarm. A healthy infant breathes about twenty-five times a minute. The child should not be rocked, carried about, exhibited, or handled more than necessary. It should not sleep with the mother, lest it become too hot or too cold, be overwhelmed by bedding, or overlaid by the mother.

Bowels.—The first stools are black and tar-like,—this is meconium. It disappears by the end of the first week. The presence or absence and the character of an evacuation, as well as the number in twenty-four hours, must be daily recorded. For a breast-fed child, there should be three or four a day, for the first ten days and the number should gradually diminish until a routine of two a day is obtained.

The diaper of bird’s-eye linen should be large and thick; two may be used if required. They should be carefully washed after soiling. Bluing must not be used, because where this substance comes in contact with the skin, irritation follows.

Weaning should be brought about by the gradual substitution of other foods, somewhere between the sixth and twelfth months.

Urination should be copious. The child is always wet, and frequent changes are necessary to keep the skin from getting raw and sore.

Both bowels and bladder should be emptied within the first twenty-four hours. Failure to do so should be reported, as an imperforate anus or urethra may exist.

Frequently a piece of ice whittled out like a lead pencil and passed into the rectum will stimulate urination.

Catheterization is practically never necessary. The child may go three days without injury, but the condition of the bladder above the pubes must be attentively watched and its degree of fullness appreciated by percussion.

Nursing.—The child should be put to the breast twelve hours after birth and every three hours thereafter—no more and no less without definite reasons.

If the child is strong and vigorous, only one feeding may be given at night, and even this may be omitted in some cases where the child gets an abundance of food. Six or seven feedings a day are enough. The child should stay at the breast from fifteen to twenty minutes, depending on its activity and the rapidity of the milk flow, and then be removed. It must not be permitted to sleep at the breast.

Fig. 115.—Proper position of mother while nursing child. (Witkowski.)

Care must be used that the child gets the nipple over the tongue and not under it. Many infants have to be taught to nurse. This may be due to a lack of strong animal instinct in many cases. There may be an abundance of milk and a good nipple, but the child will not learn to nurse without a vast expenditure of time, patience, and energy on the part of the nurse. Squeezing a little milk into the mouth or filling a nipple shield with milk will sometimes aid in educating the infant, or even starting the supply with a pump, as many nurses do, is advantageous. Certain drugs, like castor oil and turpentine, taken by the mother, may affect the taste of the milk, and be reason enough for the refusal of the child to take hold. Other drugs like mercury, arsenic, potassium iodide, and alcohol may go over in the milk to the nursing child.

If the child is weak or premature, the milk must be pumped from the breast and fed to it until strength comes. The difficulty about this is the bad habit acquired, but there is no way to avoid it.

A child should get at each feeding half an ounce of milk to each pound of weight. The capacity of the stomach at various months is given by Hirst as, first week, ½ oz.; second week, 2½ oz.; third and fourth week, 3 oz.; third month, 5 oz.; fifth month, 9 oz.; ninth month, 12½ oz. Holt says that the capacity at birth should be one ounce, and increase at the rate of an ounce a month up to the sixth month.

As hunger stimulates the gastric and salivary glands, so the sight of the child arouses some emotional center in the mother, which starts the milk, and the mouth of the child provides an additional stimulus of great power. About fourteen ounces is secreted by the seventh day, and after the second month the daily average rises to three or four pints. Milk secretion is favored by drugs and foods that raise the blood pressure and diminished by substances that lower the blood pressure.

There may be too little milk in the breasts, and if so, the child will lose weight daily; also the child will waken before nursing time, fret, refuse water, but greedily seize the nipple if it is presented. It will continue to nurse long after its time is up and cling and cry when removed. The breast itself may seem flabby and loose, and no milk, or very little, can be pressed from the nipple.

Normally, the breasts feel full and tense, both to patient and nurse, just before feeding time. The real test, however, is in taking the weight of the child before and after feeding. Where the milk is insufficient, the scales will not vary, and after a few repetitions the nurse can be certain. An infant should be handled as little as possible after feeding lest the milk be vomited.

Fig. 116.—Proper method of taking rectal temperature.

Temperature of the newborn child varies from 98° to 99° F. It should be taken morning and evening, or oftener, if complications are suspected.

The temperature often goes up on the third or fourth day, and may stay up for several days. This phenomenon is called by some a starvation or inanition fever. The temperature may go to 106° F. and the rise is generally associated with a hot dry skin, dry lips, weak pulse, restlessness, and great prostration. The fontanelle may be sunken and the cry sinks to a fretful, feeble whine.

It is important that the fever should be recognized and treated, since the condition may terminate fatally. The etiology is obscure. The fever should not be confounded with pyogenic infections, for these rarely begin before the fifth or sixth day.

The treatment is simple. Give water regularly every two hours by mouth, and rectal flushings of normal saline twice daily. The symptoms rapidly subside if the child is properly nourished. Hence the breasts should be inspected and the child weighed before and after feeding. Usually the milk is poor and scanty. If the temperature does not soon fall the child should be put to another breast or artificial feedings should be instituted.

CHAPTER XIX
THE CARE OF THE CHILD (Cont’d)

Heart.—The heart tones while in the uterus may vary between 138 and 150 per minute, but when higher than 160 or lower than 120, danger is near. After delivery, the heart runs from 130 to 140, and during the first year gradually drops to 115, approximately.

Asphyxia neonatorum is a condition, wherein, for some reason, the child fails to breathe after delivery. Out of every one hundred babies born, about six will die at birth or within the first ten days, and a large proportion of them from asphyxia in some form.

Asphyxia is found in two degrees: asphyxia livida (blue) and asphyxia pallida (white).

In the first, the child is deeply cyanosed. This may be due to patency of the foramen ovale, and yet it is a question whether this cyanosis is not really a normal process. The child does not undertake its first respiration because it needs oxygen, but because an excess of carbon dioxide (CO₂) in the blood acts as a stimulant to the respiratory center, which is thus set to work, with the result that oxygen is taken in. The blue asphyxias, therefore, may be only the first step in the physiological process of respiration. In these cases, the pulse is strong and full, and the muscular tone is preserved, as well as the sensibility of the skin.

In the second degree, the condition is quite different. The face is pale though the lips may be blue. The heart is irregular and many times can not be felt. The cord is soft and flaccid, with its vessels nearly empty. The reflexes are abolished, the skin and extremities cold. A few convulsive efforts at breathing may occur, but they soon cease.

Treatment is directed first, to opening up the respiratory passage. The child is held up by the feet so the mucus, blood, and fluids may escape from the mouth. Compression of the chest wall will aid. The tracheal catheter is passed into the trachea and the mucus sucked out. Next, the skin reflexes are stimulated by slapping the back, or buttocks, and by blowing upon the face.

Fig. 117.—Method of passing the tracheal catheter. (Hammerschlag.)

The child at this time may be dipped in a tub of very warm water, (112° F.) and the chest and face sprinkled with cold water. Meanwhile, Laborde’s method of traction on the tongue may be tried. The tongue is seized with tongue forceps (handkerchief, napkin, or piece of gauze will do) and rhythmically drawn out and released about ten times per minute.

Further, the Byrd method of artificial respiration must be employed.

Fig. 118.—Byrd’s method of artificial respiration. Extension and inspiration. (Edgar.)

Fig. 119.—Byrd’s method of artificial respiration. Beginning flexion and expiration. (Edgar.)

The back of the child is held in the right hand, so that the thumb and forefinger grasp the neck loosely, the other hand holds the buttocks from behind and the body is slowly but firmly flexed between them until the thorax is compressed, then the grip is relaxed and the body widely extended to allow the air to rush into the lungs. This maneuver should be repeated about twelve times per minute. When the heart ceases to beat, the child is dead and respiration can not be established.

Fig. 120.—Byrd’s method of artificial respiration. Flexion and compression. Note position of child which aids the escape of fluids from the mouth and nose. (Edgar.)

The same treatment is employed for the apnœic child born in Cæsarean section and the oligopnœic child born under “Twilight Sleep.” The method called “Schultze Swinging” is not to be recommended generally, on account of the chilling which is so necessarily associated with the exposure. The nurse should learn to practice all these methods of resuscitation.

After the child breathes it must be watched carefully for at least forty-eight hours, lest the symptoms recur, and the child die.

Asphyxia Neonatorum—

(a) Livida—body congested—blue.

(b) Pallida—body limp and pale.

Remember possibility of patent foramen ovale.

Etiology.—

Too long compression of cord.

Diminished irritability of medulla.

Compression of brain during extraction.

Shock during version.

Aspiration of mucus.

Treatment.—

Hold child by heels with head pulled back to straighten the trachea, and wipe out mouth and pharynx gently with cotton wound about the finger.

Stimulate skin reflexes by slapping and blowing.

Tracheal catheter, artificial respiration (Byrd) 8 to 10 times per minute.

Hot and cold bath alternately—rub the skin and knead the muscles.

Laborde’s method of traction on tongue 10 to 12 times per minute.

Continue efforts so long as heart beats.

Convulsions occur not infrequently during the first few weeks. They may develop as a result of injuries to the head during labor, or as a symptom of toxæmia. They may arise from constipation, from intestinal indigestion with curds, from fever or from hæmophila. Meningitis and other infections are associated with this symptom, and occasionally atelectasis. They may also be the manifestation of a spasmophilic diathesis. The attack may begin with such premonitory phenomena as restlessness, muscular twitching, and staring of the eyes, but more frequently the onset is without warning. The facial muscles are contracted, the neck thrown back, the hands clenched and the extremities spasmodically cramped and tightened. There may be frothing of the mouth and consciousness is lost. Respiration is feeble, shallow and irregular. The face is discolored and strange rattling noises come from the larynx. The bowels and bladder may move involuntarily. The attack lasts from a few minutes to half an hour.

Convulsions are not serious in all cases.

The responsibility for the management of this complication usually falls upon the nurse. She calls the doctor, to be sure, but the attacks in many cases have ceased and the child may either be dead or out of danger of a recurrence before his arrival.

The hot bath is a universal remedy and quite as efficient as anything. The temperature should be taken and the bowels washed out.

If the fontanelles are tense when the doctor arrives, a spinal puncture may relieve the tension. A specimen of the blood is drawn through a needle and sent to the laboratory for examination.

The cause must be found, if possible, and removed. A change of food may be all that is required. Cod-liver oil may be added to the diet in dram doses, three times a day, and milk curds, suspended in arrow-root water. For the acute condition, chloral hydrate is best. It is given by rectum, one or two grains in an ounce of water, and may be repeated in four hours.

Atelectasis is the name given to a failure of the lungs wholly to expand during the efforts at respiration. The child may live for weeks with this affection, but usually it expires within a few days.

In this condition, the child has a constant tendency to get blue, the color deepens, and death may occur in spite of every aid. The treatment may be permanently efficacious in some cases, but in most, the revival is only temporary. Again, the child may live, but in a weakly, declining state for days, until death comes.

Aside from the physical signs of dullness elicited by percussion over the lungs, the most conspicuous symptoms are the cyanosis and the intermittent but persistent whining cry.

Fig. 121.—Method of giving gavage. (Grulee.)

Treatment is by daily or hourly spanking, and by alternating hot and cold baths, by sprinkling with cold water or by massage to stimulate the skin reflexes. The treatment may have to be repeated every twenty or thirty minutes, and the earlier it is instituted, the more persistently carried out, the more chance of success.

Exercise is just as important to the infant as to the adult. The kicking of the legs, moving of the arms and lusty cry are all means of stimulating the circulation, the muscular development, and the expansion of the lungs. The position should be changed occasionally in the crib from back to side and from side to back. Also the child’s legs and back should be rubbed and massaged until the skin is red every time the bath is given.

Flushings.—The child is laid across the lap, or on a table. A rubber sheet is so arranged that the discharge will drain away.

A soft rubber catheter, No. 18–20 French scale, is attached to a small funnel. The apparatus is boiled and filled with normal saline, or sterile water, at a temperature of 85° F. to 95° F. Half a pint to a pint may be required.

The catheter is oiled and passed into the rectum just beyond the sphincter. It must not go farther. The funnel is then raised and the fluid flows into the bowel. This flushing must not be confused with the administration of an enema for constipation, for which, however, it is often an excellent substitute.

Gavage is forced feeding by means of a tube. A soft rubber catheter or tube, about No. 7, French scale, is lubricated with albolene, vaseline or sweet oil. The upper end is connected with a small tube or glass funnel holding two or three ounces.

The child is laid upon its back in the arms of mother or nurse, the baby’s arms are held and the head steadied.

In case of diphtheria or scarlet fever, the tube may be passed through the nose and down the pharynx and into the œsophagus five or six inches, or even into the stomach. It is more convenient and easier when possible to pass it through the mouth directly into the stomach. The food is then poured into the funnel, which, by elevation, empties itself into the stomach. If regurgitated, more food must be given. When withdrawn, the tube should be pinched to prevent leakage into the trachea.

Fig. 122.—Apparatus for gavage or lavage. (Tuley.)

The great danger in these cases is the ease of overfeeding.

Lavage or washing of the stomach may be performed in the same way with the above apparatus, when necessary. As soon as the stomach is filled, the tube is lowered and the fluid siphoned out.

CHAPTER XX
THE CARE OF THE CHILD (Cont’d)

Tongue-tie is not met with so frequently as in the old days. If the child can suck and nurses energetically, this complication can be excluded. It may, however, occur. In such a case, the frænum is unusually broad and seems to extend clear to the tip of the tongue, which apparently is bound down to the gum and to the floor of the mouth.

The thin membrane may be snipped with the scissors close to the tongue and then torn back with the finger.

Harelip and cleft palate interfere with nursing and require continual attention to keep mucus out of the throat. Brophy has a rubber flap placed over the nipple of the bottle in such a way as to occlude the split tissue and thus enables the child to get nourishment.

These babies must be fed systematically by gavage, if necessary, until the deformity can be repaired.

Hernia at the navel is a common complication of infancy. It is not due to crying, to improper tying of the cord, nor to neglect by the nurse, as frequently charged. It is a congenital fault, wherein the cord opening does not close, and in time, crying and straining will drive the intestines out of the aperture like a pouch. The defect is revealed by the bulging outward of the navel when the child cries. Ordinarily the breach will close of its own accord.

Fig. 123.—Cleft palate nipple. (Brophy.)

Fig. 124.—The device for feeding the child with cleft palate at the breast. (Brophy.)

Treatment consists in folding up the skin of the abdomen so that the groove will be over the umbilicus and include it. Then adhesive tape is put on to hold it. The surfaces of skin thus coming in contact should be dusted with rice powder or stearate of zinc. Another method of treatment is to place a wooden button form, round side down, on cotton, over the opening, and bind it on with a zinc adhesive plaster. The dressing should be changed at least once a week.

Inguinal hernia usually heals spontaneously also, but a truss may be required.

Fig. 125.—Device for assisting the cleft palate child to nurse. (Brophy.)

Hæmorrhage of the newborn is either accidental or spontaneous. Accidental hæmorrhage may arise from an imperfectly tied cord, or it may be an effusion, through compression or rupture, into any of the internal organs, such as the brain, lungs, or abdominal viscera. These latter conditions rarely give rise to symptoms, and are seldom recognized during life. There is no treatment.

The intracranial hæmorrhages are open to diagnosis through the presence of pressure symptoms, but these, too, are impervious to treatment unless a vessel can be tied, like the middle meningeal artery.

Spontaneous hæmorrhages may develop during the first few days of life from sepsis, syphilis, Buhl’s disease, hæmophilia, and true melæna neonatorum. The fragile condition of the blood vessels, the great changes in the blood and circulation after birth, as well as constitutional dyscrasias, are etiological factors of importance. All the causes are not as yet known.

Fig. 126.—Method of strapping an umbilical hernia.

The blood may come from the umbilicus, the mucous membranes of the eyes, nose, mouth, stomach and intestines. It may be effused into the tissues beneath the skin, or into any organ of the body. Marked nosebleed is generally syphilitic in origin.

As a rule hæmorrhages in the newborn are most common in males, and strongly hereditary.

The tendency to bleed lasts only a few weeks, and if recovery takes place, it is permanent. In some cases, however, where hæmorrhage has developed in the brain, clots may form in important centers, and the child be permanently paralyzed in speech, sight, hearing, or intelligence.

Symptoms of hæmorrhage begin during the first week and almost never after the twelfth day. The appearance of blood is the earliest and the most definite sign. The bleeding may come first from the umbilicus, or from the stomach, or from the intestines (melæna neonatorum). The amount lost is small, but the oozing is continuous. The temperature may be high or subnormal, and may or may not be due to the hæmorrhage. The skin is pale, the pulse feeble, prostration marked, and weight is lost rapidly. Convulsions are not infrequent.

The diagnosis of the condition is simple. It is only necessary to be certain that the blood is really effused, and not a temporary or accidental event such as the regurgitation of swallowed blood. Black tarry stools will show blood if placed in water.

The prognosis is not good. About two-thirds of these babies die.

The treatment is to stop the hæmorrhage by ligature, suture, or compression if possible and to alter the character of the blood by adding to its fibrin content. This is brought about, if at all, by the administration of coagulose, coagulen ciba, or by transfusion from an adult—preferably the father.

Paralysis of the face (Bell’s paralysis) may follow the use of forceps. The prognosis is favorable. Paralysis of the nerve in the neck (musculospiral) is sometimes known as Erb’s paralysis. It happens in consequence of difficult breech deliveries or of vertex labors when much force is required to extract the shoulders.

The deltoid, biceps, and other muscles are affected so that the arm can not be raised. The failure to raise one arm will be the symptom that will attract the attention of the nurse. Some cases recover in a month or so, either spontaneously or by the aid of electricity. If not, the injured nerve must be cut down upon and its continuity restored.

Ophthalmia neonatorum is an infection of the eyes of the newborn by the gonococcus. The infection occurs as the child passes through the vagina or vulva, or when an unclean finger is put into the eye.

The reaction is violent. The discharge at first is thin, then thick, pus. If untreated, the eyesight may be lost by ulceration. In the asylums twenty-five per cent of the inmates are blind from this infection; and as late as 1896, seven per cent of the blindness in the state of New York could be traced to this avoidable disease.

The preventive treatment consists in the frequent douching of the vagina before labor with potassium permanganate solution 1:5000, or chinosol 1:1000. After labor, a drop or so, of 1 per cent solution of nitrate of silver is dropped into each eye and not neutralized.

After the infection has occurred, iced compresses are applied to the eye, night and day, and a solution of argyrol 15 to 20 per cent instilled into the outer corner, twice a day. In female infants with ophthalmia, the vagina must be watched for discharge which does not fail to appear in most cases. Argyrol (20 per cent) should be injected with a medicine dropper and left to drain out spontaneously. All dressings used about the child should be destroyed, and the nurse should use the most scrupulous cleanliness and care of her own person.

Separation of the cord may be delayed in puny babies and in cases where the cord is large and thick.

Some of these cases are doubtless due to a patency or fistulous condition of the urachus. Usually the separation may be hastened by touching the constrictured part with silver nitrate. Or, if the cord does not separate before the second week, it may be desirable to cut off the hanging fragment and touch the base with silver nitrate or dust with alum powder.

Granulations may protrude like a mulberry from the stump of the navel (“proud flesh”). These are touched with nitrate of silver stick.

Menstruation may appear occasionally from the vulva of the newborn. It is really a hæmorrhage, a menstrual flow, which is associated with uterine activity, but rarely significant. There is no treatment. It disappears spontaneously.

The breasts of the newborn may fill with milk and become indurated and tender. Nothing should be done to them. Let them alone and the swelling will subside in a few days and the milk (“witches’ milk”) disappear.

Icterus may develop from the third to the sixth day. The child becomes yellow and stays yellow for a week, when the color gradually leaves. It is thought to be due to the liberation of some embryonic residue in the fœtus, but nothing is known certainly. For the simple form no treatment is required. Recovery is prompt and uneventful. However, jaundice is associated with other conditions that prove fatal, hence every icterus should be watched carefully until it disappears.

Child’s Nails.—The nails are frequently rough and ragged at ends and sides. They should be smoothly trimmed lest they become infected at the junction with the skin and give rise to paronychia. If infection does occur, the skin and flesh may be pushed back with a sterile applicator, and the point touched with peroxide of hydrogen. A syphilitic history may be traced in some of the babies.

Thrush is a form of contagious soreness, characterized by white flakes or patches on the mucous membrane of mouth or anus which look like milk, but can not be wiped off.

It is due to a vegetable fungus and occurs most frequently among anæmic or poorly nourished babies or those suffering from harelip. It is associated with symptoms of indigestion.

It may always be prevented by keeping the mouth and nipples clean, as directed on another page, and by keeping the bottles and rubber nipples in a solution of boric acid when not in use. When the disease appears, the mouth must be swabbed three or four times a day with an applicator soaked in saturated solution of boric acid. This is curative.

Aphthæ or stomatitis is the name given to whitish vesicles, followed by superficial ulcers that occur upon the inside of mouth and lips of the infant. It is rare in the newborn child. Boric acid solution is cleansing, and stick alum, frequently applied, will effect a cure.

Wheals, urticaria or “stomach spots” appear as generally distributed small spots about the size of a split pea, with a white center and a red periphery. They appear about the third day and last twenty-four hours.

They may be mistaken for insect bites and they may, or may not, be accompanied by temperature, which is probably only a coincidence.

The wheals disappear spontaneously without treatment.

Bednar’s disease is characterized by the appearance of two ulcers on the hard palate, one on either side and just above the spot where the last tooth will erupt. It is most liable to occur in sickly infants and supposedly arises from the abrading of the mucous membrane by a rubber nipple or through the rough cleansing of the mouth. It is very resistant to treatment. The child must be put in good condition by attention to the nourishment and the spots touched with tincture of iodine on an applicator.

The exudative diathesis is indicated superficially by a definitely bounded red patch on either cheek, which is not relieved, or only temporarily, by the common ointments and powders. The mother says the “face is chapped,” or that the baby has a “milk eczema.” Otherwise the skin is pale.

These children are frequently fat, but the tissue is flabby. The urine is sometimes ammoniacal. There is no marked disturbance of temperature. Fretfulness and constipation are the principal symptoms.

The condition is due to too much fat in the food. A skimmed-milk diet is best for a time. The fat can be added gradually until the limit of tolerance is found.

If chalky masses appear in the stools, the fat must be reduced again. Occasionally the child must be taken off the milk entirely, and a soup or gruel diet substituted.

For local application, the following formula is sometimes beneficial: (Grulee.)

℞	Naphthalene		℥i
	Starch		ʒiv
	Zinc stearate		ʒiv
	M.
Sig. Apply frequently.

The “cradle cap” is a frequent sign of the exudative diathesis in its milder stages.

The term is applied to a yellowish-gray patch over the large fontanelle. The mother calls it “dirt,” which she finds hard to remove and it always recurs. The mass is composed of dry scales, which gradually change into an eczema. Vaseline or sweet oil left on over night makes the removal of the scales quite easy the next day. If a raw surface is left, zinc ointment should be applied. The diet must be changed as previously described.

Erythema, especially of the diaper region, is sometimes a manifestation of congenital syphilis. It is usually limited to the inner side of the thighs, the perineum, scrotum or vulva, and buttocks. It must be associated with other and more characteristic signs, however, such as snuffles, cachexia, etc., before it becomes diagnostic of syphilis. Most erythemas of this area are due to irritation from moist or soiled diapers, but other factors may be important. Bluing in the diaper, gastrointestinal troubles, and circulatory disturbances are contributing causes. The local treatment is the same as for intertrigo. If the child is syphilitic, systemic measures must be instituted.

Intertrigo, or chafing, is a form of eczema due to moisture, bluing in the diapers or uncleanliness. The child should be cleaned with oil instead of water, and well powdered with stearate of zinc or zinc ointment may be used. Talcum powder which contains boric acid is contraindicated.

Pemphigus neonatorum is an eruption of blisters or blebs which seem to follow infection from the maternal passages or to be communicated by other babies who have the disease.

From three to fourteen days after birth, the blebs develop on the abdomen, neck or thighs, and show a tendency to spread to other parts of the body. The vesicles vary in size from one-fourth of an inch to two inches in diameter, and contain a serous, purulent, or bloody fluid. Other signs of general sepsis may appear.

In diagnosis care must be used to exclude syphilis, which also exhibits blebs, but usually on the soles of the feet or the palms of the hands. Besides, a nonsyphilitic child is generally better nourished. The prognosis is unfavorable if the child is weakly, if the blebs spread rapidly over a large area, or if the infection attacks the umbilicus.

Treatment.—A rigid quarantine must be enforced. In the hospital no new cases can be admitted. The alimentation must be increased, the blisters evacuated, and the surfaces cleaned and covered with a 25 per cent ointment of ichthyol, or an ointment of ammoniated mercury 2 per cent.

Strophulus, red gum, or miliaria rubra are names applied to an inflammation of the sweat glands when their secretion is retained. It is a “sweat rash” characterized by an eruption of scattered red papules or small vesicles which commonly appear on the cheeks or neck of young infants, or where skin surfaces come in contact. It is due to excessive clothing or heat. It is really a prickly heat. The treatment consists in the removal of the cause, and a generous use of stearate of zinc powder or rice powder.

CHAPTER XXI
THE CARE OF THE CHILD (Cont’d)

Constipation in the newborn may come from many causes. The amount of food may be so inadequate that no residue is left, and the bowels move only once in forty-eight hours. Over-stimulation of the bowel by castor oil or colonic flushings in the early weeks of life to correct colic may diminish its sensitiveness and produce atonic constipation. In the artificially fed infant too much fat in the food is a very common cause of the trouble.

Treatment.—Correct the amount of fat in the milk. If the child is breast-fed, the mother’s diet should be non-nitrogenous and vegetables should preponderate. Drugs should not be given until all else has been tried. Gluten suppositories will furnish a mild irritation to the rectum. Orange juice and prune juice may be given, or Mellin’s food or oatmeal water added to the milk. Milk of magnesia ½ to 1 teaspoonful, or Husband’s magnesia, in same dosage, may be given daily. Senna is also efficacious.

Diarrhœa is generally significant of an error in diet which is usually a plain indigestion, though there may be too much sugar in the food.

The stools are more frequent and always softer than usual, possibly fluid.

Diarrhœa means increased intestinal action due to irritation from something. It may be due to indigestion, to the presence of hard curds, to acidosis, or it may accompany almost any disease of infancy as a symptom merely. The odor is due to gases formed in the canal by bacterial action. There is but little odor in fermentation, but much in putrefaction. Mucus appears either as balls or strings. The balls come from the small intestine, strings from colon. Blood indicates ulceration at some point in the bowel, or an erosion just above the sphincter.

Fig. 127.—Proper position for introduction of a suppository. (Grulee.)

Fatty curds may be either white, granular, sand-like masses, or small, soft, and yellow. The protein curd is large and smooth, or white and bean-like. Both occur only when the artificially fed infant is given raw milk (Brenneman). If the milk is boiled for two minutes these masses will not form.

The cause must be determined. The frequent stools, however, are exhausting, and may have to be checked with opiates or mechanical astringents.

When due to indigestion, all food by mouth may be stopped for two or three days and only barley water administered.

In a breast-fed child, diarrhœa is sometimes checked by diluting the milk with a little barley water, given just before nursing. With these infants, not much change in the sugar content can be made by alterations of the maternal diet, but where artificial food is used, the amount of sugar is easily reduced to a satisfactory degree.

Colic is a cramp-like pain of the bowels. Previous to the attack the child is restless, expels some gas, and has the “colic smile,” which leads the mother to believe the child is quite well. When the attack comes on, the thighs are flexed on the abdomen, and the legs on the thighs. The child has a sharp cry, that is nearly continuous, but in some way related to the nursing period, for the attack comes on a few minutes, and sometimes an hour, after taking the breast. The belly is rigid, the arms wave aimlessly. Diarrhœa may be present, and the movements are accompanied by much flatus. Distention is nearly always present. When the belly is tapped it gives a drum-like note and the child belches gas, sometimes accompanied by milk, which seems to relieve.

Treatment.—Colonic flushings to relieve the bowel of irritating curds. The child may be laid face down with a bag of hot water under the belly. Mixture of asafœtida gtts. xx to xl, or whiskey and hot water should be given for the attack, followed later by a full dose of castor oil. The diet should be rigorously investigated.

Vomiting may or may not be serious. The child may nurse too rapidly or too much, and the over-distended stomach simply empties itself. Many infants “spit up” their excess of milk, and thus relieve themselves. This is a simple regurgitation, usually of unchanged milk, though it may be acid from admixture with the gastric juice.

Vomiting, in a breast-fed child, may come during an attack of colic when the eructations of gas appear. It may be a symptom of gastrointestinal intoxication, of too much fat in the food, too short intervals between feedings, or too much sugar in the food.

Projectional vomiting awakens suspicion of a pyloric stenosis or meningitis, and must be reported to the physician at once.

Vomiting which occurs within twenty minutes after feedings is not serious ordinarily, even though gas and large curds are expelled, but all vomiting later than this, is significant of a pathology.

Treatment.—Regulation of the hours of feeding is most important, and next, the character of the food. If the child vomits an hour or so after nursing, it may be that the milk is too rich (fat). Try a longer interval, or give an ounce or so of cereal water before putting the child to the breast.

Prematurity exposes the child to three distinct dangers, which arise, respectively, from atmosphere, food, and infection. Very few children born before the seventh month survive. A child born at the eighth month, or with a weight of three pounds, or more, can be saved almost always. The premature child up to the time of birth, has been protected very carefully against temperature variations by the liquor amnii, and when suddenly precipitated into a new environment, which its vitality barely tolerates, the consequences are serious.

These infants have a poor heat production, and the natural warmth of the body must be preserved. This is best done by incubators, which supply air and moisture in stable and appropriate amounts. Chilling of the child for even a few moments may be fatal. A room may be fitted up to produce the necessary conditions of light, air, heat and moisture. The child, wrapped in sheets of cotton, except the face, is then covered with a blanket, and surrounded by a temperature varying from 88° to 95° F., which is gradually lowered to 80° F. as the child gains strength. An occasional whiff of oxygen, as prescribed for an atelectatic child, is sometimes advantageous.

Bathing.—Premature infants must not be bathed, but the skin should be cleansed with cotton and warm sweet oil or albolene. All unnecessary handling is to be avoided.

Food.—Breast milk is the secret of success with these cases. Since most of the infants are too weak to take the nipple, the breasts must be pumped, and the child fed with spoon or pipette.

The interval between the feedings depends a little on the amount taken, but it should not be less than one and one-half hours, nor more than two hours. As the child gains, the interval may be lengthened to three hours. Lack of sufficient nourishment is shown by cyanosis and loss of weight, and overfeeding, by vomiting and diarrhœa.

The child must be fed by hand until strong enough to nurse the breast. In certain cases of prematurity, as well as in diseases like pneumonia, scarlet fever, and diphtheria, the child must be fed by gavage. Nutritive inunctions of benzoated lard or cod-liver oil are also valuable, not only for the passive exercise supplied, but for the absorption of a certain amount of the unguent.

Marasmus means wasting, but the term is applied to infants that steadily lose weight. The bodies of infants are so largely composed of fluid, that loss of weight occurs quite easily and rapidly. Loss of weight may be sudden or gradual. It comes on rapidly after acute diarrhœa, either with or without vomiting, or it may follow persistent vomiting without diarrhœa.

Malnutrition from defective feeding is the most common cause of wasting in infants. This may be from lack of sufficient food or lack of proper ingredients, as well as irregularity of intervals, and disease. Rickets, congenital stenosis of the pylorus, congenital syphilis, and tuberculosis are all possible factors in the etiology.

In any case, no treatment can be instituted until these conditions have been confirmed or excluded.

Pyloric stenosis (the account follows Grulee) may be a thickening of the muscular coat of the outlet of the stomach (pylorus) or a spasmodic contraction. The condition is most frequent in males and in the first born.

Symptoms usually begin before the second week. There is constipation with small ribbon-like stools, and the urine is scanty. The most marked sign, however, when it is present, is the excessive, uncontrollable vomiting, which ordinarily occurs fifteen to thirty minutes after eating, but may be delayed for several hours. The vomiting may be of the common type, but more frequently it is projectile in character, like that seen in meningitis. The contents of the stomach are violently expelled, sometimes several feet. Physical examination may reveal the stomach bulging under the arch of the ribs and peristaltic waves moving back and forth across its surface. The pylorus itself may sometimes be felt as a lump or tumor.

Prognosis.—About fifty per cent die.

Treatment.—Dietetic and surgical. Grulee recommends small amounts of food, poor in fat, be given at short intervals. If this fails, operation is required.

Pneumonia in the newborn most frequently results from the aspiration of mucus out of the maternal passages as the child is born. This may happen when the cord is compressed, or at any time when a partial asphyxiation impels the child to try to breathe.

It may also come on when a feeble child has been chilled by a prolonged first bath.

The disease develops about twenty-four hours after birth in a child apparently well. The temperature rises, respiration becomes rapid, and cough develops. The child is fretful, restless, refuses the nipple, and gasps for breath. It may become cyanotic. The prognosis in newborn infants is very serious.

Treatment is stimulation. A mustard bath will benefit where the respiration is rapid and the child blue. Tincture of digitalis may be administered in drop doses every three or four hours. Carbonate of ammonia, ¼ gr., in mucilage of acacia, half a dram, may be given for cough.

Child must be fed on mother’s milk pumped from breast.

Snuffles may be due to improper clothing, to drafts of air, or to syphilis. If due to cold, camphorated oil may be rubbed on the nose and the passages kept clean with an applicator soaked in albolene. If this fails, a small pellicle of anæsthone may be placed in each nostril, and the child laid upon its back until the ointment melts and runs back into the pharynx.

Furuncles (boils) may be numerous. They come from irritation of the skin by atmosphere, soap, water, and clothing, whereby infection enters. This is especially liable to occur in the hair.

Keep the boils washed with boric acid solution and open them as soon as the focus, or head, appears.

Phimosis is such a close adjustment of the prepuce to the glans penis that it can not be retracted. In some cases there may be obstruction to the outflow of urine, but generally a tiny portion of the glans can be seen. The prepuce may or may not be redundant. This condition makes cleanliness impossible and balanitis may result.

On account of the straining required to urinate, prolapsus ani, hernia, and hydrocele of the cord sometimes develop. Symptoms may arise from preputial adhesions, as well as phimosis. Frequent or difficult micturition, nocturnal incontinence, priapism, pruritus, and masturbation may develop out of the irritation, as well as nervous manifestations, such as insomnia and night terrors.

The condition should be recognized and corrected in infancy. If the adhesions are dense, an incision can be made down the dorsum of the prepuce, the tissue forcibly separated from the glans, and the flaps cut off. Stitches may be required. In other cases circumcision may be necessary.

Paraphimosis.—When a prepuce with a small orifice is forcibly retracted over the glans, it occasionally happens that it cannot be pulled forward again. If allowed to remain this way, the parts will swell, and the penis become strangulated as if with a ligature.

The danger arises from the stoppage of the circulation, which may be followed by ulceration and gangrene.

Reduction must be brought about by manipulation, if possible, but where this fails, the constricting band must be cut through and sedative applications used.

Balanitis is inflammation of the prepuce from the decomposition of smegma, which collects under a tight foreskin. The condition is quickly relieved by cleanliness and a few applications of vaseline or zinc oxide ointment. Circumcision should not be done until the inflammation has subsided.

Circumcision, either as a physical necessity or as a religious rite, is frequently performed.

The nurse prepares a table with sterile linen, a basin with antiseptic solution and sponges, sterile towel, and sterile vaseline, with a roll of gauze bandage an inch wide.

The object of the operation is to remove the prepuce and leave the glans exposed.

The instruments needed are a pair of sharp scissors, a pair of dissecting forceps, two pairs of artery forceps, small, full curved needles, and fine catgut.

The nurse gives the child some gauze to suck, which has been soaked in brandy and sugar-water, brandy one dram to an ounce of water. Then taking her place at the child’s head, she flexes the thighs back upon the abdomen, and widely separates them. The field of operation is thoroughly washed with soap and warm water, the prepuce is then retracted and the smegma wiped away. Then the body and limbs should be covered with clean linen, except the penis, or a sterile towel may be used with a hole in it through which the penis is drawn. The redundant tissue is removed and fine catgut sutures put in.

The operation being completed, the wound is covered with sterile vaseline and wrapped with a sterile gauze bandage, leaving the end of the glans exposed.

Fig. 128.—Hydrocephalus. (Bumm.)

The gauze and vaseline are changed whenever saturated with urine. Healing ought to be complete by the seventh day. The nurse should examine the dressing at frequent intervals during the first twenty-four hours, since serious hæmorrhages may occur from vessels that have not been included in the sutures.

Priapism is a condition of functional fullness and firmness of the penis that is more than ordinarily constant. Its importance lies in the fact that it may be a symptom of spinal irritation, balanitis, worms, or phimosis.

Spina bifida is the most common congenital deformity. It is characterized by a fluid tumor, which protrudes from an opening in the vertebral column. It may appear anywhere along the spine, but is found most frequently in the lumbar or cervical region. The deformity is supposedly due to an arrest of development. It is nearly always fatal inside of two weeks, though cases have been known to reach mature years.

Fig. 129.—Anencephalus. (Williams.)

There is no treatment except protection from injury.

Hydrocephalus is sometimes, but not necessarily, associated with spina bifida.

The ventricles of the head are filled with cerebrospinal fluid, and the fontanelles are widely separated. The cause of the anomaly is unknown.

This condition may render labor difficult or impossible until the diagnosis is made and the skull perforated. Rupture of the uterus may result from the futile efforts to expel the child. If born alive, the child nearly always dies, or if it grows up, the intelligence is imperfect in most cases.

Anencephalus is a monster, having a body, but only a part of a head. The eyes protrude, the tongue may hang from the mouth, and the brain is under-developed.

Sudden death of infants that are apparently healthy comes with a shock to the physician as well as the parents, and in some instances, no plausible reason can be assigned for it. Apoplexy, pneumonia and stoppage of the trachea by milk curds may explain some cases. Suffocation by lying on the face in wet bedding, or overlying by the mother will account for others. Internal hæmorrhage into lungs, pleura, stomach, or brain is also known to be causative.

CHAPTER XXII
INFANT FEEDING

A well fed infant is a happy little animal, who sleeps approximately twenty-two hours a day, and gains from four to six ounces a week. If properly fed at the breast, this condition is easily obtained; but if artificial food is necessary, the resources and skill of the attendants may be tried to the utmost before the welcome result is brought about.

The feeding of infants may be considered under three heads, (1) the breast; (2) breast and bottle combined (mixed feeding); and (3) artificial, which is really modified cow’s milk.

Breast feeding has been taken up elsewhere, but the same care should be taken in feeding from the bottle as in feeding from the breast, so far as concerns the intervals between the feedings and the duration of the same. Since it takes from one to two hours longer for cow’s milk to digest than it does for mother’s milk the longer interval of three or four hours between feedings is better for the artificially fed child. With such an interval there will be less vomiting, less colic, less tendency to overfeed, and a better natured baby.

One feeding should be omitted at night, and if possible, two.

Length of time for taking the bottle depends somewhat on the child, but it should not exceed fifteen minutes, as a rule.

Supplemental Feeding.—A mother who has too little milk may have it supplemented by a modified mixture in one of two ways.

First, the quantity furnished by the breast must be determined by weighing the infant before and after feeding, and then the total amount for twenty-four hours can be deduced. With this information, it is not difficult for the doctor to know how much cow’s milk to prescribe. The supplemental feeding may be given by alternating the bottle and the breast, or by giving the breast and following it immediately with the bottle. In the meantime, the mother must be put on tonics with an abundance of fluids, and a generous diet that will raise the blood pressure, in the hope that the milk will increase sufficiently to enable her to feed the child entirely from the breast.

When it becomes necessary to substitute some other food for the breast milk, it means that the milk of some other mammal must be modified for the purpose. The most convenient and abundant source of supply is the cow.

While in many respects cow’s milk is similar to mother’s milk, it is in reality quite a different product. Mother’s milk is taken, undiluted, directly from the breast, while cow’s milk is given from a bottle, hours after milking, and not only must it be diluted, but certain ingredients must be added to aid its digestibility.

When taken into the stomach in its natural state, mother’s milk is a liquid, while under the same conditions, cow’s milk forms a semisolid gelatinous mass.

It is essential that the milk should be as fresh, clean, and free from bacteria as possible, and this can be approximated only in certified milk. This milk is required by law to have its constituents definitely standardized. Thus, there must be 4 per cent of fat, 4 per cent of protein, and 4 per cent of sugar, and it must be so free from bacteria that not more than 10,000 per cubic centimeter can be found. The cattle also are tuberculin tested. The following comparison is from Holt:

Mother’s Milk		Cow’s Milk
Sp. Gr.	av. 1.031	av. 1.031.
Fat	4.  %	Fat	4.  %
Protein	1.50%	Protein	3.50%
Sugars	7.  %	Sugars	4.50%
Salts	.2 %	Salts	.75%
Water	87.3 %	Water	87.3 %
Reaction	Alkaline	Reaction	Acid
Bacteria	Very few	Bacteria	Many
Both range from 1.026 to 1.06.

Fig. 130.—Elements of human milk. (Eden.)

The fats are substantially the same, but the fat of cow’s milk is less easily digested than the fat of mother’s milk.

The protein of mother’s milk is virtually half lactalbumin and half casein, which is only slightly coagulated into soft flocculent curds by the action of rennin and acids, while the casein of cow’s milk is nearly three times greater in amount than the lactalbumin and is coagulated into coarse, tough curds.

The sugars in both cases are lactose in solution, but mother’s milk contains a much higher percentage.

Cow’s milk contains three times the quantity of salts found in human milk, but the water is the same in both.

So, while the two milks seem in comparison to be much alike, in reality they are quite different; hence it is necessary to modify cow’s milk in such a way as to make it not like mother’s milk chemically, but to make it act like mother’s milk.

It is extremely difficult to bring up an infant on artificial food, and inasmuch as half the infants that die during the first year, perish from intestinal disorders, it is imperative that every resource should be exhausted before the breast feedings are abandoned. It is fallacious to believe that anyone can feed a baby, or that feeding consists merely in trying one food after another until one is found to agree. Only a competent physician should prescribe the food, and he should study his problem and make his modifications just as he would alter his medicines for a particular disease.

However, it is necessary for the nurse to know how to carry out the doctor’s orders intelligently and how to report to him the conditions present.

In prescribing for the child, the doctor usually has some definite outline in his mind, such as

Age and weight.

Example: 3 months old; weight 10 pounds; 7 feedings; 1 every 3 hours.

Interval, three hours.

Amount in each bottle, four ounces.

Formula:

Milk, 12 oz.

Diluent, 16 oz. (Cereal water or plain water.)

Sugar, ½ oz.

Flour ball, if any, ½ oz.

Boil if ordered.

The infant should not take more than two ounces of milk to a pound of weight in each twenty-four hours.

Proprietaries.—Baby foods are not to be recommended nor condemned. They are placed on the market as substitutes for mother’s milk with definite instructions as to preparation. They are also very expensive. They are not to be condemned, because many of them are invaluable when used in connection with cow’s milk. Sometimes a child will not tolerate anything but malted or condensed milk, or Nestle’s food, for example. The malt sugars, such as Horlick’s and Mellin’s, are easily assimilated, fattening, and laxative.

All foods in the modification of milk should be of the best. The standard sugars are Merck’s milk sugar, Mead’s Dextri Maltose, Nährzucker, cane sugar, and Mellin’s and Horlick’s foods. Robinson’s barley flour or Johnson’s are the best known. Imperial granum is a partially dextrinized flour and corresponds to the home-made “flour ball.”