CHAPTER XIII
OBSTETRICAL OPERATIONS AND COMPLICATED LABORS
Unhappily, not all labors run the smooth and uncomplicated course which was described in the last chapter. Certain abnormalities sometimes arise to complicate delivery, occasionally necessitating operative interference or relief.
There is little that a nurse can do alone, in the presence of complicated labor, but her preparations and assistance will be more effective if she understands the purpose of the operations, and she will better appreciate the gravity of certain symptoms, which she is required to watch for and report, if she realizes the extreme seriousness of their import.
The principal conditions which give rise to, or follow complications, prevent spontaneous delivery or necessitate operations at the time of labor are perineal lacerations; contracted or malformed pelves; marked disproportion between the diameters of the child’s head and mother’s pelvis; ruptured uterus; exhaustion of the mother; poor muscle tone or certain chronic and acute diseases of the mother; death of the fetus; prolapsed cord; certain presentations of the fetus in which spontaneous delivery is doubtful or impossible.
The preparations for operations in hospitals are all so carefully planned and systematized that in the presence of such emergencies the nurse will merely have to carry out the customary routine, but in a patient’s home she may have to exercise a good deal of originality in attempting to meet the needs of the occasion and imitate hospital provisions.
A satisfactory operating table may be fashioned in any one of a number of ways. If the bed is high enough, it may sometimes be made fairly satisfactory by slipping a board, such as a table leaf, under the mattress to make it firm. The use of a kitchen table is time-honored, but it is an unsafe practice unless the available table is very secure and firm, which is usually not the case with present-day kitchen tables. A flat-topped chest of drawers, with the casters removed, makes an excellent operating table, for it is firm, a good height and about the right size. Or an ordinary bureau may be pressed into service after taking out the casters and removing the mirror by unscrewing its supports. The front and sides of a bureau, or chest of drawers so used should be protected from the damaging effects of fluids and solutions by being covered with a bed-rubber or newspapers. A pad for the top of the improvised operating table may be arranged by folding a blanket or quilt to the proper size and folding over that the rubber draw-sheet and a clean muslin sheet.
If the operation requires that the patient be held in the lithotomy position (on her back with thighs and knees flexed and knees well separated), and the doctor’s equipment does not include a strap to hold the legs, one may be improvised from a sheet. It should be folded diagonally, over and over, into a strip possibly a foot wide, passed over one shoulder and the tapering ends used to tie around the legs, above the knees, to hold them in the desired position. Bandages or tapes are not always satisfactory, for the support is subject to a good deal of strain, and narrow strips sometimes cut painfully into the legs and shoulders. Certainly if tapes or bandages are used, cotton pads or folded towels should be interposed between them and the patient’s skin.
In general, the nurse will prepare as for a normal delivery, in each instance adding such details of equipment, or preparation as the contemplated operation requires. Rigid asepsis must be observed throughout the preparations and the operations. When large instruments or appliances are to be used, a wash boiler is probably the safest thing in which to boil them, for it is scarcely possible entirely to cover them with water in a smaller receptacle; and they must be well covered while boiling, or they will not be sterile.
Perineal Lacerations. A large proportion of women during the birth of the first baby sustain some degree of perineal laceration, which may amount to nothing more than a nick in the mucous membrane, or it may extend entirely across the perineal body and tear through the rectal sphincter. The causes of these tears are generally conceded to be rigidity of the perineal muscles; disproportion between the size of the child’s head and the vulval opening; a sudden expulsion of the child’s head, before the perineum is fully distended, and certain abnormalities in the mechanism of labor. Lacerations may, therefore, be prevented, or limited, in many cases by holding back the baby’s head and allowing it to dilate the perineum slowly. But in spite of the most skillful and careful efforts, tears of some degree occur in most primiparæ, and probably in half of all multiparæ. These injuries are usually described as being of the first, second or third degree, according to their extent.
A first degree tear is one that extends only through the mucous membrane, usually at the margin of the perineum, without involving any of the muscles.