The time at which the nurse should call the doctor is the subject of considerable discussion. Doctors never want to be called too late, neither do they wish to be called unnecessarily early, though they prefer to have the nurse err on that side, if at all. On general principles the doctor should be notified as soon as the patient goes into labor, in order that he may make his various plans with the pending delivery in mind. But if the nurse remembers that in primiparæ the first stage of labor usually lasts about sixteen hours and in multiparæ about eleven hours, she will realize that if the pains begin between the hours of eleven p.m. and seven a.m., and are of average character, mild and infrequent, she is not warranted in disturbing the doctor’s much needed sleep, unless he has explicitly requested her to do so. But under average conditions he should be notified by seven o’clock in the morning that the patient is in labor; at what hour the pains began; their character and frequency at the time of the report; the patient’s temperature, pulse and respirations and general condition and the fetal heart rate.
During the early hours of the first stage the nurse should begin to arrange the room and bed for delivery. She will need two, or preferably, three tables, though the top of a bureau may be used in place of one table. A washstand or the bathroom should be equipped for the doctor with soap; two sterile brushes; nail scissors or clippers and file or orange stick; hot water; alcohol and a solution of bichlorid 1–1000, biniodid 1–5000, lysol 2 per cent. or any solution that he may wish; sterile gloves and sterile vaseline or albolene to lubricate his hands. In short, an equipment which will enable him to prepare his hands exactly as he would for performing a major operation.
A large receptacle of water may be boiled, covered and set aside to cool; a boiler or large kettle placed in readiness for boiling instruments or other appliances that the doctor may bring; the room may be given a final cleaning: floor wiped up, furniture and all small articles wiped with a damp cloth; the unopened packages of dressings, sterile douche pan, irrigation-bag and basins may be placed on the tables, ready to be opened when needed, together with the other articles which have been prepared.
In preparing the bed in a patient’s home, it is practically always advisable to make it firm by slipping a board, or the leaves from a dining-table, between the mattress and springs. The bed should be made up with three freshly laundered sheets, the entire mattress being protected by means of a rubber placed under the lower sheet; next a rubber draw sheet, covered by one of muslin, while the top sheet, light blanket and counterpane should be left free at the foot. A flat hair pillow is better than one of feathers.
If the doctor wishes to make a vaginal examination, it devolves upon the nurse to prepare the patient with the most scrupulous care, as it is by means of vaginal examinations, made without careful preparation, that so many parturient women are infected. In fact, even the most conscientious preparation sometimes seems to be an inadequate safeguard, for infection has been known to follow in its wake. For this reason, some obstetricians prefer to make no vaginal examination during labor, when previous inspection has indicated that the case is normal, depending rather upon rectal examinations for guiding information.
The patient should be placed in bed, on a douche pan, with knees flexed and well separated; gown tucked up under her arms; draped with a sheet or the bedding folded down to her knees according to the extent of the area to be prepared; and the articles needed for the preparation arranged on a table at the bedside. The nurse should trim her nails, scrub her hands with soap and hot water; shave the vulva, supra-pubic region and inner surface of the thighs and rinse with sterile water. In shaving the vulva, the strokes should be from above downward, greatest care being taken not to allow hair, soap or water to enter the vaginal opening. She should then scrub her hands vigorously for three minutes, scrubbing about the nails with especial thoroughness. Some obstetricians have the entire area from the umbilicus to the knees prepared as for an operation, while others prepare only the supra-pubic region, inner surface of the thighs and the vulva. The number and kind of solutions which are used in this preparation also vary greatly, but in general the shaving is followed by a thorough scrubbing, by clean hands, with green soap and sterile water, then iodin, lysol or alcohol and bichlorid or biniodid solution, according to the custom of the doctor. (Fig. [74].)
But the kind and number of the solutions are probably not so important as the nurse’s technique. Throughout the entire course of the preparation she must apply the principles of what she was taught about the technique of preparing the skin for an operation and regard the perineal region in the same light as she would the field which was being prepared for a major operation; scrubbing from the centre toward the periphery, always, in order not to carry infective material from an unclean to a clean area, which in this case is the vaginal outlet.
Fig. 74.—Bathing the vulva preparatory to vaginal examination or delivery. (From photograph taken at Johns Hopkins Hospital.)
The supra-pubic region and abdomen are scrubbed across, back and forth, working up from the symphysis; the strokes on the thighs are up and down; in the groin, down toward the rectum, and away from the vagina, never toward it, and fluids poured upon the vulval region must never run into the vagina from over surrounding skin. A sponge or scrub ball must be discarded after approaching the rectum, or stroking away from the vagina in any direction. Some obstetricians instruct the nurse to place a firm, sterile cotton pad or scrub ball between the labia, against the vaginal opening while scrubbing and flushing the adjacent areas, to preclude the possibility of introducing fluids. But with a painstaking nurse this is scarcely necessary.