Copyright N° COPYRIGHT DKPOSm A HANDBOOK OF OBSTETRIC NURSING FOR NURSES, STUDENTS AND MOTHERS COMPRISING THE COURSE OF INSTRUCTION IN OBSTETRIC NURSING GIVEN TO THE PUPILS OF THE TRAINING SCHOOL FOR 3 CONNECTED WITH THE W( HOSPITAL OF PHILADELPHIA BY ANNA M. FULLERTON, M. D. FORMERLY OBSTETRICIAN, GYNAECOLOGIST, AND SURGEON TO THE WOMAN'S HOSPITAL OF PHILADELPHIA, PHYSICIAN-IN-CHARGE AND SUPERINTENDENT Of ITS NURSE SCHOOL: AND CLINICAL PROFESSOR OF GYNAECOLOGY IN THE WOMAN'S MEDICAL COLLEGE OF PENNSYLVANIA; LATE LEC- TURER ON SURGERY AND* OPERATIVE MIDWIFERY IN THE NORTH INDIA SCHOOL OF MEDICINE FOR WOMEN SEVENTH REVISED EDITION. ILLUSTRATED PHILADELPHIA P. BLAKISTON'S SON & CO 1012 WALNUT STREET 1911 ^v Copyright, 191 i, by Anna M. Fullerton, M. D. Printed by The Maple Press York, Pa. ©CI.A283442 THIS LITTLE BOOK IS DEDICATED TO DR. ANNA E. BROOMALL PROFESSOR OF OBSTETRICS IN THE WOMAN'S MEDICAL COLLEGE OF PENNSYLVANIA IN APPRECIATION OF HER ABLE AND FAITHFUL WORK AS A TEACHER PREFACE TO THE SEVENTH EDITION In preparing the seventh edition of this work, the previous edition has been carefully revised. A new chapter has been added on "The Examintion Dur- ing Pregnancy'' and one on "Obstetric Operations." Other additions to the text will be found under eclampsia, ophthalmia neonatorum, and the care of premature in- fants. In the chapter on "Care of the New-born In- fant," the modified milk formulae used in the Mater- nity of the Woman's Hospital have been substituted for certain formulae of the former edition and the di- rections for dressing the umbilical cord have been changed to conform with the present usage. In the treatment of breast abscess, Bier's method of suction hyperemia is described. Several of the old illustrations have been withdrawn and twenty-one new ones have been inserted. The typographical work is entirely new. Catharine Macfarlane. 132 South i8th Street, Philadelphia, 1911. Vll PREFACE TO THE SIXTH EDITION. The methods of procedure advocated in this book are those observed in the Maternity of the Woman's Hospital of Philadelphia. The results attained by an adherence to them have well proved their value. In this, as in former editions, I have made an effort to bring the teachings of the book up to the requirements of modern obstetric practice, and to make the little volume a vade me cum of knowledge on the subject; for the guidance, not only of the nurse, but of patients and physician as well. I have to thank Dr. Anna E. Bromall, Professor of Obstetrics in the Woman's Medical College of Pennsyl- vania, for her kindly aid in the revision of this edition ; and my publishers for their efficient help in the manage- ment of business details. Anna M. Fullerton. Fategarh, United Provinces, India, IX CONTENTS PAGE CHAPTER I. The Pelvis i CHAPTER II. The Pelvic Organs it CHAPTER III. The Development of the Ovum 19 CHAPTER IV. Signs of Pregnancy 27 CHAPTER V. Management of Pregnancy 38 CHAPTER VI. The Examination During Pregnancy 56 CHAPTER VII. Accidents of Pregnancy 61 CHAPTER VIII. The Anatomy of the Foetal Head and the Mechanism of Labor 71 xi Xll CONTENTS. PAGB CHAPTER IX. Preparations for the Labor 88 CHAPTER X. Signs of Approaching Labor — The Process of Labor . . 98 CHAPTER XL Duties of the Nurse During Labor 104 CHAPTER XII. Accidents and Emergencies of Labor 121 CHAPTER XIII. Obstetric Operations 137 CHAPTER XIV. Management of the Lying-in 145 CHAPTER XV. Care of the New-Born Infant . 180 CHAPTER XVI. Characteristics of Infancy in Health and Disease . . . 213 CHAPTER XVII. The Ailments of Early Infancy 224 Index 269 LIST OF ILLUSTRATIONS. PAGE Female Pelvis Showing the Diameters of Pelvic Brim . . 4 Rachitic Flat Pelvis with Asymmetry and Double Prom- ontory (Winckel) 7 Oblique Pelvis of Naegele 9 External Genitalia 12 Cavity of the Uterus and Fallopian Tubes 14 Breast Showing Enlarged Milk Ducts During Lacta- tion (Morris) 16 Uterus and Ovum at Seventh or Eighth Day 19 Ovum Cut Open Showing Embryo, Amnion and Chor- ion (Edgar) 21 Placenta and Unruptured Membranes at the Thirty- eighth Week (Edgar) 22 Fcetal Surface of Placenta at Term (Minot) 24 Human Embryo at End of Second Month (Edgar) . . . 25 Pregnancy at the Thirty-eighth Week Showing Striae (Edgar) 29 Height of the Fundus and Position of the Cervix in the Several Weeks of Gestation (Edgar) 33 Frozen Section of Uterus from a Primipara at the For- tieth Week (Edgar) 35 Abdominal Belt 41 Spiral Reverse Bandage of Lower Extremity 46 Nipple Protector 50 Measuring the Interspinal Diameter with the Baude- locque Pelvimeter 58 Digital Method of Measuring the Diagonal Conjugate of the Pelvic Inlet (Edgar) 60 xiii XIV LIST OF ILLUSTRATIONS. PAGE 20. The Foetal Skull (Diameters) 73 21. Left Occipitoanterior Postion 75 22. Right Occipito-anterior Position 75 23. Right Occipito-posterior Position 76 24. Left Occipito-posterior Position 76 25. Presentation of the Face in the Second Facial Position . . 79 26. Breech Presentation, the Legs Extended 81 27. Presentation of Right Shoulder 85 28. Breast Bandage 89 29. Occlusion Dressing (Garrigues) 90 30. Suspension of the Asphyxiated Newly Born Child by the Feet to Assist Gravity in Freeing the Air-passages of Foreign Matter (Edgar) 124 3 1 . Suspension of the Asphyxiated Newly Born Child by the Feet and Cleaning the Posterior Pharynx of Foreign Matter (Edgar) 125 32. Byrd's Method of Artificial Respiration. Position for Inspiration (Edgar) 126 ^^. Byrd's Method of Artificial Respiration. Position be- tween Inspiration and Expiration (Edgar) 126 34. Byrd's Method of Artificial Respiration. Position for Expiration (Edgar) 127 35. Prochownik's Method of Resuscitation 128 36. Prochownik's Method of Resuscitation 128 37. Position of Patient in Hemorrhage after Labor . . . . 134 38. Elliott's Modification of Simpson's Forceps (Edgar) . . 140 39. Tarnier's Axis-traction Forceps (Edgar) 141 40. Smellie's Scissors Perforator (Edgar) 143 41. Braun's Cranioclast (Edgar) 143 42. Nipple Shield 157 43. Shapes of Nipples 159 44. Breast-pump 161 45. Worcester's Y-bandage 163 46. Obstetrical Breast Support, with Knitted Bosoms . .164 47. Bier's Hyperemia Apparatus for Mastitis 167 48. Home-made Bath-tub and Crib 188 LIST OF ILLUSTRATIONS. XV PAGE 49. Lactometer 194 50. Sterilizer (Dr. Louis Starr) 208 51. Graduated Nursing Bottle (Dr. Louis Starr) 210 52. Rubber Nipple (Starr) 211 53. Diagram Showing Eruption of Milk Teeth 223 54. Tarnier's Couveuse 225 55. Auvard's Couveuse (Interior View) 226 56. Auvard's Couveuse (Exterior View) 227 57. Incubator for Premature-born Children (Kny-Scheerer Co.) 228 58. Swaddled Baby 231 59. Feeder for Premature Infants (Cooke) 235 60. Single-bulb Syringe (Starr) 245 61. Arrangement for Irrigation of the Eyes (Dr. Lee) . . . .256 OBSTETRIC NURSING CHAPTER I, THE PELVIS. The Pelvis is that part of the skeleton found be- tween the lower end of the spinal column and the thigh bones. It consists of four bones — the sacrum, the coccyx, and the right and left innominate or hip bones. These bones form a canal through which the child passes during labor. A knowledge of the anatomy of the pelvis is neces- sary to a proper study of midwifery. The Sacrum is a triangular or wedge-shaped bone, composed of five vertebrae joined firmly together. This bone forms a large part of the posterior wall of the pelvic canal. It is wedged in between the tw T o innomi- nate bones, the base of the wedge being directed upwards, and forming by its union with the spinal column a pro- jection which is known as the sacro-vertebral angle or promontory. The effect of this projection is to decrease the measurement antero-posteriorly of the pelvic brim, making it smaller than any other measurement of the brim. Some of the most serious complications of 2 OBSTETRIC NURSING. labor are caused by this narrowing, hence the promon- tory is of. great importance obstetrically considered. The progress of the child is arrested in its attempt to pass through the pelvic canal at this point when the contraction is too great. Below the promontory the sacrum is curved or hollowed out. This is called the concavity of the sacrum and it provides for the proper rotation of the child's head during labor. The two innominate bones — ossa innominata, or hip bones, bound the pelvis in front and on each side. They are very irregular in shape and consist of three parts which in childhood are indicated by the presence of car- tilage which joins the various portions together. The upper flaring portions of these bones are called the ilia, or haunch bones; the lower portions, the ischia, or seat bones; the rami in front, which form the anterior wall of the pelvis and the pubic arch, constitute the pubes or share bones. The pubic bones are united by a joint in front called the symphysis pubis. The union of the in- nominate bones with the base and sides of the sacrum gives us the two joints called the sacro-iliac articulations, the largest and strongest articulations in the whole body. The Coccyx consists of four rudimentary vertebras which are united to the end of the sacrum by a movable joint, called the sacro-coccygeal joint. This joint ceases to be movable late in life, that is from forty-five to fifty years of age. The cartilage in the joint becomes bony and thus the joint becomes fixed. This causes a diffi- THE PELVIS. 3 culty in the birth of the child at the outlet of the pelvis, as it narrows the antero-posterior measurement f the outlet. The pelvis is divided by a ridge, called the He o- pec- tineal line, into two parts, the true and the false pelvis. The false pelvis is that portion which is above the ileo- pectineal line, and the true pelvis is below it. The con- stricted portion between the two, forming the superior circumference of the pelvic canal, is known as the inlet or superior strait. The inlet in a normal pelvis is some- what heart-shaped. The lower circumference of the pelvis is called the outlet and is very irregular in shape. The cavity of the pelvis which lies between the inlet and the outlet constitutes the pelvic canal. When lined by the muscles and soft tissues which cover its bony walls it is called the parturient canal, or birth canal. The cavity is bounded by the sacrum and coccyx, and in front by the symphysis pubis. Its sides are formed by the lower portions of the innominate bones and the soft tissues which fill in the spaces. The depth of the pelvic cavity and curvature of the sacrum influence the character of the labor. If the cavity is shallow and the sacrum only moderately hol- lowed out, the labor is likely to be easy and natural ; but if the cavity is deep and the curve of the sacrum great, the labor may be tedious and difficult. In a normal pelvis, the cavity in front measures an inch and a half (the depth of the symphysis pubis) ; be- 4 OBSTETRIC NURSING. hind it measures 4 1/2 or 5 inches (the length of the sacrum and coccyx) . Measurements or Diameters are taken from certain parts of the pelvis to determine the capacity of the pelvic canal. It is important that every pregnant woman should consult a physician in time to have a proper estimate made of the size of her pelvis. The measure- ments should be taken not later than the seventh month Fig. 1. — Female Pelvis showing the Diameters of Pelvic Brim. of pregnancy, as it may be desirable for the sake of both mother and child that premature labor should be induced, or at least some decision made as to the proper management of the labor. The most important measure- ments to be considered are those of the inlet and outlet. The inlet has (1) an antero- posterior diameter called also sacro-pubic or true conjugate. This extends from the upper border of the pubis in front to the middle of THE PELVIS. 5 the promontory of the sacrum behind. It should measure normally about 4 1/2 inches; (2) the trans- verse diameter, which gives us the longest measure- ment at the inlet, is taken from the middle of the brim on one side to the middle of the brim on the other side. Its average measurement is from 5 to 5 1/4 inches; (3) two oblique diameters. The right oblique diameter extends from the right sacro-iliac articulation to the left ileo-pectineal eminence ; the left oblique diameter extends from the left sacro-iliac articulation to the right ileo-pectineal eminence. Each diameter usually measures about 5 inches. The pelvic canal, or cavity, in the living subject is lined with muscles, bound together and covered by connective tissue. Blood-vessels and nerves are dis- tributed throughout the pelvic cavity, supplying the organs and tissues contained in it. The pelvic canal forms a curbed tube, its planes at different points not being parallel to one another. A plane is an imaginary flat surface extending across a tube or canal at any point ; and may be represented by placing a sheet of paper across the tube at that point. The chief planes of the pelvis are: the plane of the brim, or inlet, and the plane of the outlet. A rod meeting the center of each plane perpendicu- larly represents the axis or direction of that plane. The axis of the pelvic canal is formed by uniting the axes of a series of planes which may be imagined to ex- tend across the pelvic canal at various points from the 6 OBSTETRIC NURSING. inlet to the outlet. The curbed line which is thus formed represents approximately the direction followed by the child's head in its passage through the pelvic cavity. The plane of the inlet is much more tilted or inclined than the plane of the outlet. When this inclination is exaggerated, the effect is to make the abdomen very pendulous, thus causing, in pregnancy, the head of the child to be carried so far beyond the pubes as to make it difficult for it to pass through the inlet or to enter it in the normal direction. In this way malpresentations often atise. The female pelvis differs from the male pelvis in the following particulars : in the female the bones are lighter, the ilia more expanded, the hips thus being made broader. The inlet and outlet are larger, the cavity larger, the promontory less projecting, the coccyx movable, and the arch of the pubes wider. The rela- tive width of the transverse diameter is much greater in the female pelvis. Deformities and Contractions of the Pelvis. — The diseases which most commonly cause deformities or con- tractions of the pelvis are rickets, or rachitis, and osteo- malacia. Diseases of the spine, such as may be caused by tuberculous bone abscesses, may cause the vertebrae or spine bones to become distorted or dislocated and thus affect the shape and capacity of the pelvis. Rickets, or rachitis, is the most common cause of pelvic abnormalities. It is a disease of childhood and is apt THE PELVIS. 7 not only to distort the pelvis, but to arrest its growth so that a rickety pelvis is generally undersized. It is usu- ally also flattened, the symphysis pubis being pressed back towards the sacrum and the promontory of the sacrum bulging forward into the cavity of the pelvis. The effect of this is to shorten the antero-posterior diameter and to cause a relative lengthening of the Fig. 2 . — Rachitic Flat Pelvis with Asymmetry and Double Promontory. (Winckel.) transverse diameter of the inlet. The cavity of the pelvis and the outlet may not be diminished, but, on the other hand, expanded in a rickety pelvis. The labor in such a pelvis is apt to be affected, as follows: If the conjugate diameter is only slightly decreased, the presenting part will remain longer than ordinary above the brim, and because the head does not fill the brim as it should do, the cord may slip down in front 8 OBSTETRIC NURSING. of it or to one side. The os uteri for the same reason dilates more slowly. Thus the first stage of labor is pro- longed. After the presenting part is sufficiently moulded to clear the inlet, the labor progresses normally. Sometimes the contraction at the brim is so marked that the head may not enter at all and it becomes neces- sary to deliver by some operation, as version, delivery by forceps, symphysiotomy, craniotomy, etc. The osteomalacic pelvis is a deformity caused by the softening of the bones in adult life. This leads them to yield under pressure and causes great distortion of the shape of the pelvis. The pubes assume a peculiar beak- like form, and the pelvic canal is very greatly narrowed. The disease which causes such deformity occurs most frequently in countries where the people are underfed. In most cases delivery can only be accomplished by means of Caesarean section. The kyphotic pelvis is one form of contracted pelvis caused by the pulling back- ward of the base of the sacrum. This may result from the form of spinal curvature which is commonly known as "humpback." The result is that the diameters of the inlet are reversed, the conjugate or antero-posterior being the longest, and the transverse being the shortest. This causes an irregularity in the way in which the head of the child enters the inlet , causing the long axis of the child's head to enter the conjugate diameter instead of an oblique diameter. In the funnel-shaped pelvis the outlet is contracted, the tuberosities of the ischia being brought nearer to THE PELVIS. each other and the lower end of the sacrum being pushed forward. The pubic arch is diminished, an angle being produced. All these conditions tend to delay the ex- pulsion of the presenting part at the outlet. The oblique pelvis may be the result of lateral curva- ture of the spine, or of disease either in the hip- joint or Fig. 3. — Oblique Pelvis of Naegele. sacro-iliac articulation. Lameness occurring in child- hood from any cause may also produce it. The pelvis is distorted to one side and thus receives its name. Irreg- ularities in the mechanism of labor are caused by this deformity and, according to the degree of distortion, any of the obstetric operations may be called for, as ver- sion, forceps-delivery, craniotomy, etc. The spondylolisthetic pelvis results from disease in the lumbar vertebrae, at the small of the back. The bones IO OBSTETRIC NURSING. becoming softened, slip forward into the pelvis and this shortens the antero-posterior diameter. This deformity is very rare. A cleft pelvis is one in which the rami of the pubic bones fail to come closely together, the articulation being imperfect. This also is very rare and is apt to be accompanied by ectropion of the bladder. The pelvis ceqitabilites justo minor is smaller in all its measurements than a normal pelvis. The labor in this case is apt to be tardy because of the contraction. The pelvis .cequabilites justo major, or giant pelvis, is one which is larger in all its diameters than a normal pelvis. This is apt to cause a rapid or precipitate labor. Bony tumors and excrescences, and fractures and other injuries to the bones of the pelvis may also dim- minish the size of the pelvic canal and affect the charac- ter of the labor. Sufficient has perhaps been said to show the necessity for the thorough examination of the pelvis in any case of expected labor. The muscles and other soft tissues lining the pelvic canal form a soft covering for the bones and to some extent slightly decrease some of the diameters of the pelvis. As they are not otherwise of obstetrical impor- tance, the student is referred for their study in detail to works on anatomy. The same may be said of the blood-vessels and nerves supplying these structures. CHAPTER II. THE PELVIC ORGANS. The Internal organs of generation are the uterus, Fal- lopian tubes, and ovaries. These are contained within the true pelvis. The bladder and the rectum are also found in the true pelvis. The External Organs are called the " pudenda/' or "vulva." Immediately above the pubic bone, or anterior border of the pelvis, is a cushion of fat, usually covered with hair. This is called the "mons veneris." On each side of the opening of the vulva are the " labia majora," or large lips. Lying beneath these and concealed by them, in young women, are two thin folds of flesh, named the " labia minora," or "nymphae." They join together above, and at their junction is a small projecting body called the " clitoris." The small triangular space be- tween the clitoris and the nymphae is the " vestibule." The opening of the urethra (the "meatus urinarius) , ' ' through which the urine escapes from the bladder, is in the middle of the lower border of the vestibule. It is very important that the nurse should know the exact position of the meatus urinarius, as she will frequently be called upon to pass the catheter. ii 12 OBSTETRIC NURSING. Below the vestibule is the orifice of the " vagina," the canal leading to the uterus, or womb. In virgins a deli- cate membrane, usually crescentic in shape, blocks the entrance to the vagina. This is the " hymen." Fig. 4. — External Genitalia. 1. The right labium majorum. 2. The fourchette. 3. Right nympha. 4. Clitoris. 5. Urethral orifice. 6. Vestibule. 7. Orifice of vagina. 8, 8. Hymen. 9. Orifice of duct of vulvo-vaginal gland. 10. Mons veneris. 11. Anal orifice. The hymen is usually ruptured at marriage, but a woman may be a virgin yet have no hymen; in some cases it persists e^en after marriage, and offers an ob- struction at childbirth. A woman who has borne chil- THE PELVIC ORGANS. 1 3 dren has a few fleshy projections at the orifice of the vagina, the only remains of the hymen, called the "car- unculae myrtiformes." Between the vulva and the anus is a mass of flesh, the space on the surface measuring one and one-half inches in length. During the birth of the child this becomes greatly distended, and thins like rub- ber. This is the "perineum." It may be torn during labor to a greater or less extent; sometimes it is com- pletely torn into the bowel. That part of the perineum in the virgin which forms the posterior border of the vulva is called the "fourchette." It is merely a fold of skin, and is almost always torn in a first labor. Behind the perineum is the " anus," or orifice of the rectum, the lower part of the bowel. The Vagina is a canal connecting the external with the internal organs of generation. The uterus is at the top of the vagina. In front of the uterus is the bladder, and behind and to the left the rectum. A secretion of mucus keeps the vagina moist. There should,. however, be no discharge in a perfectly healthy woman. During pregnancy, and as a result of ill health or local inflammation, the natural secretion may be greatly increased, and the patient is then said to have "the whites." In labor the discharge is very greatly increased, so as to aid the birth of the child. The Uterus is a pear-shaped organ, three inches in length, one and one-half inches in breadth, and about one inch in thickness. It weighs a little over an ounce in its normal condition in a virgin. After child-bearing 14 OBSTETRIC NURSING. it remains larger and heaver than before. That por- tion of the uterus which communicates with the vagina is called the "neck, or cervix.' ' The chief portion of the organ above this is called the body, and the rounded upper surface the fundus. The opening in the cervix which communicates with the vagina is called the "os uteri." That portion of the cervix in front of the os uteri is the anterior lip, while that part which lies behind is the posterior lip. Fig. 5. — Cavity of the Uterus and Fallopian Tubes. A. Superior border or fundus of the womb. B. Cavity of the womb. C. Cavity of the neck of the womb. D, D. Canal of the Fallopian tube. E, E. The fimbriated extremities. F, F. The ovaries. G. The cavity of the vagina. H, H. The ovarian ligments. I, I. The round ligaments. The Fallopian Tubes are two canals which pass from each side of the upper portion of the uterus. They are from three to four and one-half inches long, and will admit the passage of a bristle. Each ends in a trumpet- shaped opening surrounded by a fringe of small projec- tions called ''fimbriae." This is called the fimbriated extremity. When the ovum (or egg) escapes from the THE PELVIC ORGANS. 1 5 ovary, it is received by the Fallopian tube and reaches the cavity of the uterus in this way. The Ovaries are two small flattened bodies about an inch long and half an inch thick containing many thou- sand germ cells or ovules. They lie about an inch from the fundus of the uterus on each side, in the folds of the broad ligament. The broad ligaments are folds of peritoneum, a thin glistening membrane which covers the uterus and all the pelvic organs, and by means of which the uterus is suspended in the pelvis. The blad- der and rectum being covered with the same tissue, there is an intimate connection between the three, so that if one is deranged the others are also likely to be involved. The Breasts are considered as belonging to the ex- ternal organs of generation. They are two glands situ- ated on the front of the chest, one on each side of the breast-bone. They vary in size and shape in different women, and during pregnancy they enlarge greatly. They secrete milk for the nourishment of the child. The nipple at the apex of the gland is a conical-shaped projection. The milk ducts all come toward it from the different parts of the breast and open on its surface. The areola is a pink or brown circle which surrounds the nipple. There is an intimate connection between the breasts and the uterus. Pain in the breast may be the result of disease of the uterus. The secretion of milk is called ''lactation." i6 OBSTETRIC NURSING. Menstruation is a bloody discharge from the uterus every month. It begins usually about the age of four- teen and recurs every month, except during pregnancy or while a woman is nursing. There are occasional ex- ceptions to this rule. It ceases at the change of life, or menopause (usually between forty-five and fifty) . Areola Milk ducts Nipple or Mamilla Fig. 6. — Showing enlarged milk ducts during lactation. (Morris.) At puberty — that is, when this function first appears — the girl becomes a woman, the breasts enlarge, and the pelvi's increases in size. The organs of generation become ready to perform the functions of reproduction. The menstrual flow recurs every twenty-eight days and THE PELVIC ORGANS. 1 7 lasts about four days. The quantity of blood lost at a period is from four to eight ounces. Different women vary much in this respect. The discharge is blood mixed with mucus. Its color is dark red. Any pecu- liarity in color, or the appearance of any clots in the discharge, will need to be noticed by the nurse and the discharge kept for the doctor's inspection. There is usually a feeling of discomfort at the menstrual period, with headache, pains in the back, breasts, etc. These symptoms are more severe in some women than in others. The periodic congestion of the uterus, which results in the production of the menstrual flow, is prob- ably associated with the ripening of the ova or eggs in the ovaries called ovulation. It has been found, how- ever, that the ova may escape from the ovaries and be carried into the uterus through the Fallopian tubes independently of menstruation. The ova that do not become impregnated are simply carried away by the natural discharge. Conception most usually takes place immediately or very soon after a period. This is not an invariable rule, as women have become pregnant before menstruation has been established, or even after the menopause. They may also become pregnant while nursing. The principal disorders of menstruation are : Dysmenorrhea, or painful menstruation ; Menorrhagia, or excessive flow at the period ; Amenorrhea, or suppression of the menstrual flow; and 1 8 OBSTETRIC NURSING. Metrorrhagia, the occurrence of hemorrhage between the menstrual periods. The causes of these disorders are very numerous and must be determined by a physician. CHAPTER III. THE DEVELOPMENT OF THE OVUM. Ovulation is the process whereby ovules mature in the ovary and are projected from its surface into the Fallopian tubes where impregnation usually takes place. When an ovule becomes impregnated the mucous lining Fig. 7. — Uterus and Ovum at Seventh or Eighth Day, Showing Decidua Vera. {Edgar.) of the uterus becomes thickened and vascular. The fertilized ovule is called an ovum. On reaching the uterus it becomes imbedded in the thickened mucous membrane which grows around it and forms a covering 19 20 OBSTETRIC NURSING. known as the decidua reflexa. The remainder of the mucous lining of the uterus, with the exception of that which lies beneath the attached ovum, is called the decidua vera. The portion to which the ovum is attached is the decidua serotina. The latter with blood-vessels and nerves supplied from the walls of the uterus develops into the placenta, or after-birth. After the third month of pregnancy the decidua vera and the decidua reflexa come in contact with each other and unite to form one membrane, shreds of which are often seen, after a birth, clinging to the outer surface of the chorion, or outer layer of the bag of membrane enclosing the foetus. The chorion in the early stage of its development is covered with tufts called villi. Later on many of these villi shrink and disappear. Those, however, which are next the decidua serotina greatly increase in size and number and are penetrated by blood-vessels, running from the foetus, thus forming the foetal portion of the placenta. The amnion is the internal layer of the sac which con- tains the foetus. It contains within it the amniotic liquid in which the child floats during the time it is carried in the uterus. The amniotic liquid, or liquor amnii, consists of water holding in solution a small quantity of albumen and some salts. It is supposed to be secreted by the amnion. The amniotic liquid protects the foetus during its life THE DEVELOPMENT OF THE OVUM. 21 within the uterus from shock and jolting, as well as from the contractions of the uterus during labor. In labor it helps to dilate the uterine os, for being contained in the amnion, a pouch is formed which presses down into the mouth of the womb, causing it gradually to open. Fig. 8. — Ovum Cut Open Showing Embryo, Amnion and Chorion. {Edgar.) The chorion and amnion lie in very close contact with each other by the end of gestation. The amnion, a very thin, shining membrane, may be peeled off the shaggy chorion. It lies also over the foetal surface of the placenta and forms a covering for the umbilical cord. For the purposes of description the placenta is divided into a maternal and fatal portion, but there is no marked line of division between them. 22 OBSTETRIC NURSING. The blood-vessels, both arteries and veins, in the part of the uterus immediately connected with the placenta become enlarged. The veins are developed into large channels or sinuses. The arteries running between the Fig. 9. — Placenta and Unruptured Membranes at the Thirty- eighth Week. (Edgar.) uterus and placenta become corkscrew-like as they de- velop and are called curling arteries. The arteries which come from the foetus through the umbilical cord divide and subdivide, so that finally a capillary or hair- THE DEVELOPMENT OF THE OVUM. 23 like vessel runs into a villus. At the extremity of each villus the vessel turns back and becomes a vein. The little veins from the villi are afterwards gathered to- gether into large trunks which unite into the large vein of the umbilical cord. The circulation of the blood in the foetus is entirely separate and distinct from that in the blood-vessels of the mother. In the placenta the blood-vessels of the foetus, in the chorial villi, lie in close contact with the large blood-vessels of the mother. In this way an interchange of gases takes place between the maternal and the foetal blood. Oxygen and other supplies are given to the foetal blood-vessels, and the blood is thus purified and replenished. Carbon dioxide and other impurities are carried off through the maternal circulation. The placenta has two surfaces, the fatal and the maternal. The internal or foetal surface is smooth, be- ing covered by amnion through which the branches of the two umbilical arteries and one umbilical vein are seen branching out and dividing before they enter the substance of the placenta. The umbilical cord is usually attached to the placenta near the middle of the foetal surface ; but sometimes it is attached to the edge, when it is called a battledore pla- centa. Very occasionally the cord is attached to the membranes, when it is called placenta vellamentosa. The placenta is usually about eighteen inches in cir- cumference and one or two inches thick. 24 OBSTETRIC NURSING. In twin births each child has usually its own placenta and bag of membranes. Sometimes the placentae are attached to the uterine wall at quite separate points. Again they are close together and seem fused into one. More rarely there is only one placenta for both children with a single bag of membranes. When twins are found in one amniotic sac they are generally of one sex. Fig. io. — Foetal Surface or Placenta at Term. (Minot.) The umbilical cord, funis, or navel string is the means of communication between the placenta and the foetus. The cord varies in length at full term. It may be only one foot. Usually it is about two feet. In some cases it may be considerably longer. Two umbilical arteries and one umbilical vein are found in the cord. These are surrounded by a gelatinous mat- ter, called Wharton's jelly, which supports the blood- THE DEVELOPMENT OF THE OVUM. 25 vessels. The arteries are twisted around the vein. During labor if the cord becomes prolapsed it may be seized between the fingers and the foetal pulse — the beating of the arteries in the cord — may be felt. Some- times knots are found in the cord, which are formed by the child passing through a loop in the cord while it still floats in the amniotic liquid. These are called true knots, to distinguish them from false knots, which are simply thickened places in the cord caused by accumulations of Wharton's jelly. Sometimes true knots in the cord are drawn so tight that the foetus is killed either before or during the delivery by FlG - n.— Human . _., Embryo at End of the Obstruction OI its Circulation. lhe Second Month. term foetus is applied to the product ( Ed z ar -) of conception at the end of the third month of pregnancy. During the first three months it is called an embryo. It is desirable that a nurse should understand a few facts as to the development of the embryo and foetus dur- ing the different months of pregnancy. In the second month the head and extremities are visible and the em- bryo weighs about 60 grains. In the third month the head is out of proportion in size to the rest of the body and the embryo weighs about 200 grains. Sex may be distinguished in the fourth month. The foetus measures about 6 inches and weighs from 4 to 6 ounces. At the fifth month the measurement is about 10 inches and the 26 OBSTETRIC NURSING. weight 10 ounces. The nails are beginning to form. At the sixth month the foetus is about 12 inches in length and weighs one pound. The eyelashes are formed. In the male child the testicles are still in the ab- domen. By the seventh month the length is about 1 4 inches and the weight three or four pounds. The eye- lids are open and the testicles have descended into the scrotum. The skin is wrinkled and very red, and there is considerable wooly hair, called lanugo, over the body. During the eighth month the foetus measures about 1 9 inches and weighs from four to five pounds. At the end of the ninth month it usually weighs from six and a half to 7 pounds, and measures about 20 inches. In some cases the child may weigh from eight to ten pounds. It is covered at birth with a greasy, whitish material called vernix caseosa. CHAPTER IV. SIGNS OF PREGNANCY. The Signs of Pregnancy may be divided into three classes: the suspicious, the probable, and the certain. Under the head of suspicious signs may be classed the many nervous sensations which are apt to accompany early pregnancy ; as, general discomfort, sudden changes of temperature, headache, toothache, giddiness, faint- ness, changes in disposition, perverted appetite, etc. Of the probable signs one of the earliest and most con- stant is the stoppage of the monthly flow in a person who has been regular. This may be, however, caused by other conditions than pregnancy. Thus, change in one's mode of living, a new climate, or general ill health may produce the same result. In the early months of mar- riage we may also have an irregularity in menstruation where there is no pregnancy. On the other hand, in rare instances,, we may have the monthly flow persist- ing for some months or throughout the entire pregnancy. It is then generally scanty and short in duration. A deepening in the color of the vagina and vulva, by which they take on a purplish hue, is another sign, and is caused by the enlargement of the blood-vessels and a stoppage of the circulation, due to pressure from the 27 28 OBSTETRIC NURSING. enlargement of the uterus. This coloration may be caused to some extent by tumors. Increase in the size of the breasts occurs in the early months of pregnancy with a deposit of coloring matter in the areola, or ring which surrounds the nipple. Some of this coloring matter seems to extend irregularly over the outer margin of the ring, and is called the * ' secondary areola ' ' or " areola of Montgomery. ' ' With this distention of the breasts there is also a secretion found in them — a watery fluid, sometimes yellowish in color, known as " colostrum," which appears about the third month. Temporary distention of the breasts, with the accumu- lation of this secretion, may occur in a slighter degree as an accompaniment of menstruation, or it may per- sist for a long time after a woman has stopped nursing her infant. Enlargement of the abdomen, which begins about the end of the third month of pregnancy, is another impor- tant sign. Yet this may also be caused by tumors, or by flatulence, or by the deposit of fat in the abdominal walls. Marks upon the abdomen, due to the rapid stretching of the skin, sometimes occur in great numbers, and are called " stria" owing to the fact of their resemblance to the marks left by whip-lashes. These marks sometimes extend down upon the thighs. This, too, may be caused by tumors. The " brown line" of pregnancy is the deposit of pigment in the median line of the abdomen. SIGNS OF PREGNANCY, 2 9 This may exist when there is no pregnancy, as also may the peculiar browning of the skin found in irregular patches over the face, particularly on the forehead, and called the "mask of pregnancy." 3° OBSTETRIC NURSING. " Morning Sickness," another sign, begins early in the second month or at the time of the first missed i e ts pr Q lower portion of the posterior wall of the uterus^ancra[e increase of the antero-posterior diameter of that organ, as discovered by what is known as bi-manual palpa- SIGNS OF PREGNANCY. 3 1 tion — one finger of the examiner resting over the pos- terior wall of the uterus through the rectum, while the other hand makes pressure over the lower part of the abdomen. Another sign is that afforded by the thermometer, when its bulb is carried within the cervical canal. If pregnancy exist, the temperature is said to be from a half to one degree higher than in the vagina. The pulse of a pregnant woman is said also to show less variation from change .in position than that which occurs in the non-pregnant state. Thus, the change from lying to sitting or standing does not cause a quick- ening, such as is usually observed in the non-pregnant state. The uterine souffle is a blowing sound which is sup- posed to occur in consequence of the enlargement of the blood-vessels of the uterus, and which, therefore, cor- responds in its rhythm with the radial pulse of the patient. This must not be confounded with the funic souffle, a blowing sound which sometimes occurs in the vessels of the cord, and which is synchronous with the foetal pulse, therefore about twice as rapid as the mother's pulse. When the uterus is large enough to be felt through the abdominal walls, palpation over it is apt to cause a contraction, which is indicated by a temporary harden- ing. This is another indication of pregnancy. The positive signs of pregnancy as agreed upon by most obstetricians are but two : the direct appreciation 32 OBSTETRIC NURSING. of the parts of the child by touch, and the " foetal pulse, ' ' or heart sounds of the child. The " foetal pulse ' ' is, as a rule, twice as fast as the pulse of the mother. It is hardly strong enough to be heard, even by experienced ears, much before the fifth month — or end of the twen- tieth week; rarely heard well before the twenty-fourth week. Methods of Determining Date of Confinement. — The ordinary method of reckoning the probable date of confinement is as follows : Learn on what day the last monthly flow began, then count three months back- ward (or nine months forward) and add seven days. For example, say that a woman was unwell last on March 15: counting three months back gives December 15; add seven days, and we have December 22 as the prob- able date of her confinement. All methods of reckon- ing are only approximate. It is best to consider the date calculated as the middle of a period of two weeks, within which labor may occur at any time. When, for any reason, it is impossible to make the calculation by this method, it may be computed by adding four and a half months to the date of quickening in the case of a woman pregnant for the first time, and five months in the case of one who has previously borne children. The third method, that of adding forty weeks, or ten lunar months, to the date of conception, is too uncer- tain to be of much practical use. Examination of the patient by an intelligent physician who knows and appreciates the distinctive signs of the several months SIGNS OF PREGNANCY, 33 offers a fourth method of computing the date of pregnancy. Some of the more important of these distinctive signs may be mentioned, as determined both by external and Fig. 13. — Height of the Fundus and Position of the Cervix in the Several Weeks of Gestation. (Edgar.) internal examination. During the first month of preg- nancy the uterus, because of its weight, sinks lower than before, so that the abdomen is flattened, the navel being depressed. It is not until the end of the fourth 3 34 OBSTETRIC NURSING. lunar month that the uterus rises above the brim of the pelvis. About the middle of the fifth month the fundus of the uterus may be felt about midway between the umbilicus and the pubes. By the end of the sixth month it reaches to the height of the umbilicus. By the end of the seventh month it is three fingers' breadth above the umbilicus. By the ninth month it has reached almost to the lower end of the breast-bone, and dur- ing the tenth lunar month it sinks to a point about mid- way between the umbilicus and lower end of the breast bone. This is caused by the head of the child pressing down into the pelvic canal, thus the abdomen is made to look smaller than it did just before the descent. By making an internal examination, — that is, carrying a finger up into the vagina, the head of the child may be felt through the tissues of the neck of the uterus and will be found to lie quite low. In the earlier months before the presenting part has engaged, it will be diffi- cult to reach by the examining finger and the neck of the uterus will not be found to be obliterated. During the latter part of the last month of pregnancy, there is a gradual stretching of the lower segment of the uterus, the cavity of the body of the uterus and the cer- vical canal are made to communicate by the widening of the internal os uteri, until finally the two are made to form but one cavity and the external uterine os is felt as a small opening lying directly in contact with the pre- senting part. The settling of the child, causing the descent of the SIGNS OF PREGNANCY. 35 uterus, produces a relaxation of the abdominal walls and a pouting of the umbilicus during the last month of pregnancy. During the last weeks of pregnancy the position of the foetus in the uterus may be determined by palpation over the abdomen. The patient should lie on her back Fig. 14. — Frozen Section of Uterus From a Primipara at the Fortieth Week. (Edgar.) with her lower limbs drawn up and the abdomen un- covered. The body of the child may then be felt by passing the hands over the abdomen, and the position in which it lies thus determined. In multiple pregnancy more than one child exists. Twin pregnancy occurs once in about 90 cases. Trip- lets are very rare, — occurring once in about 8,000 labors. . Larger numbers at one birth are still less fre- 36 OBSTETRIC NURSING. quent. In multiple pregnancies the shape of the abdo- men differs from that seen in single pregnancies. The abdomen is broader across and more irregular in shape. Sometimes in twins pregnancy, if the abdominal walls are thin, a furrow or depression may be seen between the two foetuses. On palpation, also, two separate foetal heads and foetal trunks may be made out. On auscul- tation two distinct foetal hearts may be made out. Extra-uterine or ectopic pregnancy occurs outside the uterus. When it takes place in the peritoneal cavity it is called abdominal pregnancy ; when in the ovary, it is known as ovarian pregnancy; when in the Fallopian tubes, it is called tubal pregnancy. Tubal pregnancy is the most common of these forms. The gestation sac usually bursts about the third or fourth month, and the patient may lose her life unless she receives the prompt attention of a good surgeon. All extra-uterine preg- nancies are abnormal conditions and when suspected should receive prompt medical attention. The signs of early pregnancy exist but the uterus fails to enlarge regularly, and severe cramp-like pains with blood discharges are apt to recur at intervals. Numerous tables for a rapid computation of the date of confinement have been made. The accompanying table is one much used. By taking the upper figure in each pair of horizontal lines as representing the date of the first day of the last menstrual period, the figure im- mediately beneath it will represent the probable date of confinement. SIGNS OF PREGNANCY. 37 CO t^ o ■re so OS cm IQ 00 CM ^ CM CO CO CM CM o CM r-H CM t-H CO CO CM o CO CM CM OS CM CM 00 CM O CM CM OS CO CM 00 CM r^ CM S S3 T-H OO o t- 00 lO CM CM CO CO CM S -*J< T-H CM CO O CM CO CM OS CM CM T-H CO CM CM O t>- CM CM OO lO t-h CM t-h 00 T-H T-H O i>- CO T-H CM CO S3 °° CM CM CM t~- CM CM T-H so CM CM £ *° CM CM OS -*f< t-h CM %% *>• CM t-h CM t-i CM »o O t-h CM ■* OS »— 1 T-H CO 00 t-H T-H CM I>- t-H t-H t-H CO -t-H t-H o io OS CO CM ^*H OS CM CM T-l CO CM CM 23 TJH OS T-H T-H CO oo t-H T-H CM !>■ i-H t-H r-H CO T-H t-H o »o co I s - CM CM CM CO CM CM O ^ CM CM os co t-h CM O0 CM t-h CM CO o t=! CM iO OS ^ 00 co «>- 1-H T-H CM 55 T-H T-H T-H O O "* OS CO 00 CM *" 3 CO o »o OS T* 00 CO t* CM CD i-H iC CM CO CO O CM CO CM OS CM CM t-H O0 CM CM O t^ CM CM CM OS T-H T-H t-H 00 o t- CO CM CO CM O T-H LO CM 00 <* CM *> CO CM CO CM CM t-H 1^- O CO OS *C CM t^ CO CM CO CM CM CO o CM CO CM OS CM CM CM CM 00 IO t-H CM iO CM t-h CM T-H 00 T-H T-H O t>- CM OS T-H CO T-H T-H o c^ 00 to t-h CM H 00 T-H T-H O t^ 00 -<* CM r>. co CO O CM CO CM OS CM CM T-H 00 CM CM O t^ CM CM OS CO t-h CM CO to t-h CM CO CO T-i CM iO CM t-h CM 00 S t-h CM CM OS T-l 00 o 1^ OS CO T-H 00 »o t-H CO CO T-H iO CM T-H T* T-H T-H CO o T-H CM OS T-i CO CO O CO CO OS id CM 00 -* CM t- CO CM CO CM CM »0 T-H CM T* © CM CO CO OS CM CM CM 00 CM CM O CO CM CM t* o t-h CM CO OS T-H T-H 1— I l>- O CO OS CO '■ OS co 00 to r- -* CO CO IO CM 00 tO |>. T^ T-H CO CO *0 CM «0 "^ t— I rji CO O ' CO o CM OS t-h OO CM OS t-H CO OS "* 00 co T-H I>- CM T-H CO tH tO o •<* OS co 00 CM t^ T-H CO OS CO T-H CO to T-H t- T*l T-H CO CO iO CM T* T-H CO O CM OS t-h 00 OS CO 00 iO T-H t-H CO CO iO CM T-H -<* T-H T-H CO O T-H CM OS T-l CO OS CO T-H 00 iO t>- ^ CO CO iO CM -^ T-l CO o CM OS t-i CO OS CO T-H 00 »o T-H r>- •* T-H CO CO T-H tO CM T— I tH t-i CO O CM OS t-H 00 t£ CO Ca < ^ TH Q ►=>^ CD S 03 •*•> o ^ > CIO o- § OS to CO "<* t^ co CO CM tO T-H -T*l O co os CM 00 T-l t>. «t\ o CHAPTER V. MANAGEMENT OF PREGNANCY. The management of pregnancy consists, for the most part, in greater attention to the laws of health. The increased activity of all the organs of the body, together with the disturbances caused by pressure, necessitates this. Constipation is an almost invariable accompaniment of pregnancy. In the early months it is a sympathetic condition; later, the effect of direct pressure upon the bowels. It is also, undoubtedly, in part due to the want of exercise. The treatment of constipation is the same as in other conditions, except that only mild laxatives are used. Regularity in attention to the bowels, a glass of hot water at night and again in the morning, liquids (either milk or water), not taken with the meals, but in the in- tervals, a teaspoonful of common salt in the water occa- sionally, the use of uncooked fruit and coarse bread, the avoidance of starches and fine flour — all these are help- ful in overcoming this condition. There is an objection to the use of sugared fruits, as confection of fruit, senna leaves, etc., because of their liability to disturb the stomach. Prunes are, perhaps, the least objection- able; licorice powder, because of the senna which it 38 MANAGEMENT OF PREGNANCY. 39 contains, is apt to cause griping pains. Rhubarb is, perhaps, the best of the mild laxatives. A small piece of rhubarb root, the size of a pea, may be taken at night, followed by a glass of water. If there is an objec- tion to its taste, it may be taken in pill form. Fluid extract of cascara sagrada with an equal amount of glycerine is useful. Cream of tartar, a half teaspoonful being taken at night in a cup of cold water, is often efficient. In some cases it may be necessary to repeat the dose in the morning. Massage of the abdomen, so efficient in the manage- ment of constipation, should never be resorted to in the pregnant state, as it is apt to excite uterine contractions and may lead to miscarriage. There is an objection to the too frequent use of enemata on the same ground; also, the habit is thus acquired of depending upon this stimulus, and overdistention of the bowel is the result. It may be necessary, however, occasionally to alternate an enema with a laxative, especially when the patient suffers from piles. Diarrhea is rather a rare disturbance of pregnancy, but it sometimes occurs as a direct result of constipa- tion — small, hardened masses forming in the bowel, known as " scybala," which produce an irritation of the mucous lining. The use of rhubarb night and morning, in the manner described above, until all the masses are removed from the bowels, will serve to check the diarrhea. Should the condition be due to other causes, 40 OBSTETRIC NURSING. as indigestion, etc., appropriate remedies will have to be prescribed by a physician. Changes in the Urinary Organs are mainly due to direct pressure. In the first three months of pregnancy there is direct pressure on the bladder, hence great irri- tation, due to interference with the distention of the bladder, producing a constant desire to pass water. For this the recumbent position is the only help. The uterus rises in the abdomen at the end of the third month, and the bladder being thus relieved from pres- sure, this symptom passes away. The tendency from the fourth to the ninth month is to the accumulation of urine, because there is less than the proper irritability of the bladder, the organ being flat- tened between the uterus and the abdominal walls, and its walls thereby suffering a partial paralysis. In the last month there is incontinence of urine, be- cause the pressure is so great that there is no room for the accumulation of urine. During labor there is pressure upon the neck of the bladder and urethra, leading to retention. This may exist for the last two weeks of pregnancy. Necessity for the use of the catheter is confined, as a rule, to this period. The distention of the bladder may impede labor. With the drawing up of the uterus the bladder is drawn up and the urethra elongated, hence a long catheter will be necessary. Some use the English rub- ber catheter, Nos. 8 and 9. The glass catheter care- fully used is best. MANAGEMENT OF PREGNANCY. 41 Fig. 15. — Abdominal Belt. Sometimes irritability of the bladder is due to exces- sive acidity of the urine. A physician will generally prescribe some alkali to overcome this condition, as a drop of liquor potassa in a tablespoonful of milk once in three or four hours, or the use of mucilaginous drinks, as flax- seed tea, barley water, milk, etc. , may relieve the distress. When the abdominal walls are much stretched and the uterus falls upon the bladder, this may be remedied by the use of the binder or an abdominal supporter. Incontinence of Urine leads to the excoriation and reddening of the parts about the vulva. Frequent washing with warm water and borax or pure Castile soap relieves the irritation. Diachylon or zinc oint- ment is best when an ointment is needed. Incontinence is sometimes the result of overdisten- tion of the bladder. Here the use of the catheter is indicated. A nurse, unless thoroughly experienced, should never attempt to pass the catheter in the case of a pregnant woman, as serious injury may be done to the soft parts in a bungling attempt. In all cases she should have the sanction of the physician before doing so. The Kidneys are especially subjected to pressure from the seventh to the ninth month of pregnancy. A passive congestion is thus produced, which may lead to 42 OBSTETRIC NURSING. the occurrence of albuminuria, or albumin in the urine. This is an evidence of a drain upon the blood which the physician heeds to watch very carefully. It is cus- tomary, therefore, for physicians to examine the urine of patients whom they expect to attend at least once a week, from the seventh month on to the termination of pregnancy. Scanty urine, headache and impairment or vision may be symptoms of grave kidney disease and should be reported to the physician promptly. Examination of Urine. — The urine obtained on first emptying the bladder in the morning before break- fast, if possible, is the most satisfactory for examin- ation. When a small quantity of albumin is present in urine, it is often increased after a meal. The same is true of sugar. A specimen obtained by the use of the catheter is the best for the purpose, if the patient be troubled by a discharge from the vagina. It is important also to note the amount of urine passed daily during pregnancy. The nurse in attendance upon a patient who is awaiting her delivery should make a daily record of the amount passed, to keep the physician informed as to the work done by the kidneys. The average quantity of urine excreted in twenty- four hours in health during the non-pregnant state is about three pints, or fifty ounces. A clean vessel, set aside for the patient's exclusive use, should be used by her each time that the bladder needs to be emptied during the entire twenty-four hours. The nurse then measures MANAGEMENT OF PREGNANCY. 43 the amount, using for the purpose a graduate set aside for the work, or some other vessel of known capacity. The color of the urine will need to be noted by the nurse, in her record. The natural color is clear, pale yellow, or amber. Substances taken by the patient, as food or medicine, or conditions of disease may cause the color to vary, or render the urine turbid. There is a natural increase in the amount of urine passed by a pregnant woman, but the increase is mainly in the water. Therefore the urine will be lighter col- ored than usual. The reaction of the urine should be acid. Small strips of blue and pink litmus-paper (that is, paper colored by a delicate coloring matter known as litmus) should be kept on hand for the purpose of testing the urine while fresh. When a strip of the blue litmus-paper dipped into the urine turns pink, we know the urine is acid; w T hen the pink paper is made to turn blue, the urine is alkaline; when no impression is made on either, it is neutral. Usually the estimate of the amount passed in twenty- four hours, and a record of the color and reaction cover the requirements of a nurse's observations of the urine. Sometimes, however, a physician requires the nurse to test daily for the presence of albumin. This test is effected as follows: Fill a test-tube one- quarter or one-third full of clear urine (after filter- ing the urine, if cloudy, through filter paper). If the urine is not distinctly acid in reaction, add a few drops 44 OBSTETRIC NURSING. of acetic acid. Boil the fluid over an alcohol lamp, directing the flame to the upper part of the urine. If a cloudiness appears, it is thus at once contrasted with the clear urine of the lower layer, as the tube is held up toward the light. This cloudiness may be due to albumin or earthy phosphates. A few drops of nitric acid, if added, will make the phosphates disappear but not the albumin. Leucorrhea, a discharge from the vagina, commonly known as "the whites," is often considerably increased during pregnancy, and is due to the greater activity in the secretion of all the mucous membranes. If a vaginal discharge be of white, yellow, or green color, it indicates inflammation of the vagina itself. The discharge, on reaching the vulva and coming in contact with the air, decomposes and becomes irritating. Cleanliness is im- portant in overcoming the effects of this. The itching induced by it is sometimes very obstinate, and generally worse at night. A solution of borax and water for bathing the parts, or carbolic acid, 15 to 20 itl to a pint of water, will often give relief. Should vaginal injec- tions be ordered by the physician, they should be given with great caution. A fountain syringe should be used, which produces a continuous stream, and the rubber bag or reservoir containing the water should not be held higher than two feet above the level of the bed or couch on which the patient lies. The interrupted stream should never be employed. In some conditions of ex- cessive discharge the physician may prescribe tannic MANAGEMENT OF PREGNANCY. 45 acid suppositories to be used nightly in the vagina. After a thorough drying of the parts surrounding the vulva, they may be dusted with a powder consisting of one part powdered camphor to four parts starch. This often gives great relief. Calomel powder may be used in the same way. 4 Hemorrhoids, or Piles, are often very troublesome during the latter part of pregnancy. Lying down im- mediately after a movement of the bowels, and remain- ing in the recumbent position for ten to fifteen minutes, will tend to relieve them, also care in obtaining a daily evacution of the bowels, and the use of means to secure as soft a movement as possible. Should the piles come down, they should be fomented by cloths wrung out in hot water, to which a little Pond's Extract or fluid ex- tract of hamamelis may be added, — one tablespoonful, or two, to one pint of water, — and when shrunken, anointed with cold cream or cosmolin, or any ointment prescribed by the physician, and returned into the bowel. Sometimes the case is so aggravated as to necessitate keeping the patient in bed for a time. A physician- should, of course, be consulted about the treatment. Swelling and Pain of the external organs of gene- ration and of the lower limbs, resulting from pressure and the overdistention of the blood-vessels, is best re- lieved by the recumbent posture. Should the veins of the legs be much enlarged or the feet swollen, the patient should have compression made 4 6 OBSTETRIC NURSING. over them by the application of a bandage (the spiral reverse of the lower limb) , or she should wear an elastic stocking, such as may be obtained of any good instru- Fig. 16. — Spiral Reverse Bandage of Lower Extremity. ment maker. For the bandage the best material is flannel cut bias, the width being about three inches. The bias bandage makes more even compression. Great harm may result, from the neglect of enlarged MANAGEMENT OF PREGNANCY. 47 veins, as they sometimes become so distended as to burst. Prof. T. S. K. Morton has devised a method of putting on a spiral bandage of the lower extremity, which retains its place better than that just described, which is apt to loosen when the patient moves about. Dr. Morton begins the application of his bandage as in the ordinary spiral reverse bandage of the lower limb, but carries oblique turns up and down the limb until its surface is entirely covered, in place of making reverses. When this bandage is further secured in place by carry- ing a running line of stitches up both the inner and outer side of the limb, it keeps its place perfectly and is quite as serviceable as an elastic stocking. Pain caused by the stretching of the walls of the abdomen my be relieved by thorough inunction of the skin. Cotton-seed, olive, or cocoanut oil may be used for the purpose. Severe pains in the back, neuralgic in character and so severe sometimes as to prevent the patient from sleeping, may yield to change of position, relieving pressure. Rubbing with soap liniment, volatile liniment, whisky, or any liniment not too active, is helpful. Warm hip- baths may sometimes be prescribed by a physician. The Salivary Glands are in some cases very active dur- ing pregnancy, inducing so excessive a secretion of saliva as to cause the patient great annoyance. This trouble is generally very intractable, and may refuse to yield to all treatment, ceasing only with parturition. Astringent washes, as of tannic acid, alum, myrrh, etc., 48 OBSTETRIC NURSING. may be tried, as also the use of pieces of ice. Physicians sometimes use atropia in small doses. Its use requires careful watching. Bad Teeth, which occur often during pregnancy, are said to be due to acidity of the saliva. A little baking soda or prepared chalk placed in the mouth at night will counteract the effect of this acidity when it exists, or milk of magnesia may be used as a mouth wash, a teaspoonful being distributed systematically around the teeth after each meal and at bedtime. The question is often asked whether there is any danger in having the teeth filled or attended to during preg- nancy. There is always some danger, because a certain amount of nerve-irritation is the result. If the patient be suffering, however, it is better to have them filled by a temporary rubber filling, which causes little pain or irri- tation, than to lose rest in consequence of toothache. Extraction of the teeth should only be allowed when absolutely necessary. If the pain be simply a neuralgic pain, it is better to wait. Vomiting is, as has been mentioned in the preceding chapter, a most common accompaniment of pregnancy. It more frequently exists, perhaps, with the first preg- nancy than any other. The act is accomplished, as a rule, without much effort. Diet seems to have little effect upon it. Various articles have been recom- mended for it, as rice water, beef -tea, barley-water, the various gruels, the yolk of a hard-boiled egg, scraped beef, in the form of sandwiches, ice-cream, cracked ice, MANAGEMENT OF PREGNANCY. . 49 etc. In some cases one or another of these seems to relieve the irritation. A cup of coffee, weak tea, or milk, taken warm early in the morning before the patient raises her head from the pillow, will often act as a preventive. In extreme cases of vomiting rectal feeding must be resorted to. In obstinate vomiting it is important that the physician should examine for the position of the uterus or the existence of ulcera- tions or erosions. It must not be forgotten that the constant loss of food may be so great a drain upon the patient's strength as to endanger her life. As this symptom is so largely sympathetic, the proper use of bromides or other nerve- sedatives prescribed by a physician may be of great use in checking it. In all cases of excessive vomiting a careful record of the pulse rate should be kept, for a pulse of 100 or above indicates a serious condition. Care of the Breasts in a pregnant woman necessi- tates careful attention to the prevention of compression. Full development should be permitted by the looseness of the - clothing. The importance of the proper dress- ing of growing girls cannot be overestimated in this connection. Did mothers realize the evil — of which the atrophy of the breasts is but one — resulting from tight lacing, there would be fewer unhealthy women and fewer mothers unable to nurse their offspring. The nipples should be prevented from rubbing, and the skin over the nipples should be strengthened by using the nipple-bath — filling a small, wide-mouthed bottle one- 4 50 OBSTETRIC NURSING. third full of cold water and inverting it over the nipples daily, from five to ten minutes at a time. Sometimes a little cologne-water or alcohol is added to the nipple- bath, or, better still, borax in the proportion of one tablespoonful to the pint of water. Keeping off crusts and concretions of various kinds from the surface of the nipples by the daily use of olive oil €~2§p and alcohol, equal parts, is very satis- ^^^^ MJ ~~^^^^ factory. This keeps the skin pliable. ^mmmum^^^^ The use of the nipple protector, which Fig^ 17.— Nipple w {\i b e referred to more fully in the Pp o trot* op chapter on the management of the lying-in, is of great importance where there is a tendency to flattening of the nipple, to remove the pressure of the clothing. Drawing out the nipple gently between the thumb and finger is also helpful in overcoming this tendency. The Clothing of a pregnant woman should be worn loose from the very beginning, both because the breasts begin to enlarge early and because any amount of pres- sure upon the intestines tends to produce uterine dis- placements, which are especially dangerous during pregnancy, as they predispose to abortion. The cloth- ing must be warm but light in weight, it should be supported from the shoulders. Next to the skin the patient should wear a union suit of wool or Deimel mesh. Over this, up to the fifth month, a comfortable straight-front corset may be worn, providing it does not constrict the waist; from the fifth month on the MANAGEMENT OF PREGNANCY. 5 1 enlarging uterus should be supported from below and the ordinary forms of corsets must be abandoned; a maternity corset, such as Berthe May's or Van Orden's, should now be worn or an elastic abdominal belt and separate breast supporter. Over the corset a chemise may be worn and a light weight silk skirt with adjustable band. The gown is preferably a loose one-piece affair made on a princess foundation or a two-piece suit consisting of an adjustable " maternity" skirt and a jacket or blouse to be worn outside of the skirt. For street wear, a long, loose wrap will be required which must not be heavy. It is well for the stockings to be of wool or silk and side, suspender garters should be worn. The shoes or slippers should be comfortable and with broad soles and low heels. Many physicians insist that flannel should be worn — at least during pregnancy — both summer and winter. A lighter flannel can be substituted in summer for that which would be worn in winter. The use of flannel is to prevent chilling of the surface, and this is especially important where — as in pregnancy — the kidneys are overworked. It is important also for the condition of the heart and lungs. Coughs often cause premature labors. Bathing is very necessary for a patient during her pregnancy, as at other times. As regards the character of the bath, she can do as she has been accustomed to, using warm or cold water. A change from warm to $2 OBSTETRIC NURSING. cold water, or vice versa, is, however, not allowable. A sponge-bath, followed by brisk rubbing, is the most de- sirable. The skin is thus kept in good condition. Shower-baths should be avoided, also the shock of sea- bathing. Sea Voyages are injurious, because of the danger of receiving falls or blows in consequence of the motion of the vessel, and also because of the liability to sea-sick- ness induced by them. When it is absolutely neces- sary to take a sea voyage, there is probably least danger in the last three months of pregnancy, because the pla- centa, or afterbirth, is then well developed and its at- tachment to the uterus close. The Regulation of the Diet during pregnancy is of great importance. A patient should eat heartily for break- fast and dinner, but the evening meal should be light, especially from the seventh month on to the close of pregnancy. This meal should consist of stale bread, with butter and cooked fruit, as stewed apples, and a glass of milk or weak tea. Digestion is less active in the latter part of the day, and often a hearty meal may prov^e the direct exciting cause of convulsions. The food should be plain, wholesome, nourishing, well- cooked, and chosen in each case with special reference to the avoidance of digestive disturbances and constipa- tion. Meat in moderate quantity, broths, milk, eggs, and fresh fruit should constitute an important part of the dietary. Pastry and confections should be avoided. There is a mistaken theory prevalent in this day that MANAGEMENT OF PREGNANCY. 53 a mother, by abstaining from certain kinds of food, as meat, eggs, milk, etc., and confining herself chiefly to a fruit diet, may thus, by preventing the hardening of the bones of the child, do away largely with the pains of labor. The truth of the matter is this: that during pregnancy all the functions of the mother's body are especially active in promoting the development of the child, hence an insufficient supply of essentially nourish- ing food will first affect the mother's system and render her unfit for the demands upon her strength at the time of parturition. Should a restriction to the fruit diet effect w T hat it is claimed to do as regards the infant, it would result in the production of sickly, rachitic children, poorly developed mentally and physically. Moderate Exercise is essential during pregnancy. Walking on a level, not riding, is the best form of exer- cise. A daily walk should be taken, not, however, after nightfall. The patient should avoid lifting — in fact, all straining movements — and most particularly should she avoid the use of the sewing-machine. Exercise, judiciously taken by the pregnant woman, serves to pre- vent undue development in the size of the child, and in this way serves to make her labor easier. Maternal Emotions. — There is sufficient proof that the mother's emotions influence the child to render it important that her surroundings during pregnancy should be as pleasant as possible, and that she should avoid fright or any violent emotion. At the same time 54 OBSTETRIC NURSING. there is no ground for the popular belief that when a pregnant woman is thus frightened her child will be " marked.' ' Complications of Pregnancy. — Chorea, or St. Vitus' Dance, Epilepsy, and Insanity are forms of nervous dis- orders which sometimes complicate pregnancy. Such cases require skilled medical treatment. Patients with heart trouble, and those who are con- sumptive, also require constant medical supervision, as pregnancy has a deleterious influence upon them. Con- sumptives sometimes feel better while pregnant, but sink rapidly afterward. Those diseases which are associated with high temper- ature, such as the eruptive fevers and inflammation of the lungs, have a marked tendency to bring on the labor before time. There is also danger of their inducing puerperal septicemia. Syphilis is a constitutional disease and a form of blood-poisoning which also has an injurious effect upon pregnancy. If the pregnancy does not terminate pre- maturely, the child is usually born with the taint of the disease. Jaundice, or icterus, during pregnancy, may be caused by the obstruction due to pressure of the gravid uterus on the liver. It is sometimes the result of acute yellow atrophy, a disease in which the liver wastes away. The patient becomes intensely jaundiced and abortion often takes place. Displacements of the uterus, as prolapse, ante version MANAGEMENT OF PREGNANCY. 55 and retroversion, sometimes complicate pregnancy and require careful management by a physician. For pro- lapse the wearing of a pessary until the uterus rises into the abdomen may be sufficient. The irritability of the bladder caused by anteversion in the later months of pregnancy may be relieved by the use of an abdominal belt, or bandage ; in the earlier months by the recumbent posture. Retroversion of the gravid uterus is most serious, causing retention of urine and threatened abortion. The use of the catheter with replacement of the uterus are indicated. CHAPTER VI. THE EXAMINATION DURING PREGNANCY. After missing several periods, the pregnant patient usually calls upon her physician to arrange for attend- ance in her approaching confinement and is directed to report at regular intervals and to send a specimen of urine for examination every month. At the first visit or subsequently, a complete physical examination is made and the pelvis is measured. Four to six weeks before the expected date of confinement, the abdominal examination is repeated and an internal examination is usually made. Preparation for the Physician. — Provide towels, a basin of hot water, nail brush and soap, a basin of bi- chloride solution 1-4000, sterile rubber gloves. While the examination is in progress renew the hot water in the basin, have ready in a convenient place the pelvi- meter, stethoscope, auscultation towel, pencil and tablet for taking notes and a yard-stick or tape-line. Preparation of the Patient. — The bowels and bladder must be empty. In a private home the patient should be in bed wearing a nightgown, drawers and stockings. In office practice, the patient must re- move her dress, long petticoat and corset and must loosen every band and string about the waist. 56 THE EXAMINATION DURING PREGNANCY. 57 Place the patient on the bed or table in the recum- bent position with a pillow under her head, roll the undervest or nightgown up to the armpits and draw the skirts and drawers down below the hips. Cover the lower extremities with a neatly folded sheet reach- ing to the level of the symphysis. After examining the heart and lungs, the physician notes the size, shape and consistence of the breasts and nipples; then proceeds to palpate the abdomen to determine the height of the uterus, the relative position of the child, and whether the presenting part is engaged in the pelvic brim. After locating the child's back, the physician listens over it using the auscultation towel or stethoscope and counts the rate of the foetal pulse, usually keeping the fingers of one hand on the mother's radial pulse. Pelvimetry. — The following measurements are usually taken : 1. Interspinous. The distance between the anterior superior iliac spines — 9 1/2 to 10 1/2 inches. 2 . Intercristal diameter. The widest interval between the iliac crests — 10 1/2 to 11 1/2 inches. 3. Between the great trochanters. The greatest distance between the external surfaces of the great trochanters of the femurs— 12 1/2 inches. 4. The external conjugate. Baudelocque's diameter, from the depression just below the last lumbar spine to the middle of the anterior surface of the pubic symphysis — 8 inches. 53 OBSTETRIC NURSING. 5. Right external oblique. From the right posterior superior spine of the ilium to the right anterior superior spine — 8 3/4 inches. 6. Left external oblique. ft- - mf Fig. 18. — Measuring the Interspinal Diameter With the Baudelocque Pelvimeter. 7. Transverse diameter of the outlet. Between the tuberosities of the ischia — 4 1/2 inches. The first two measurements are taken with the patient in the dorsal recumbent position ; the next two with the patient in the THE EXAMINATION DURING PREGNANCY. 59 left lateral position; the left oblique is taken with the patient in the right lateral position and the transverse of the outlet with the patient in the dorsal position. These external measurements give an idea of the general shape and symmetry of the pelvis rather than of its exact size. If these measurements are undersize, a careful internal measurement must be taken. Internal Examination. — After taking the external measurements, the physician proceeds to disinfect his hands and puts on sterile gloves in preparation for the internal examination. Meanwhile, the nurse cleanses the patient's vulva, using first sterile water and green soap mixture, then bichloride solution 1-10,000 followed by sterile water. Use absorbent cotton and wipe from above downward. By internal examination the physician determines the height and nature of the presenting part, the con- dition of the soft parts and the comparative roominess of the pelvic canal. Measuring the Internal or Diagonal Conjugate. — This is the most important obstetric measurement and is taken as follows: Two fingers of the right hand are inserted into the vagina, the tips of the middle finger resting against the promontory of the sacrum while the web of the thumb is closely applied to the under surface of the symphysis. The index- finger of the left hand marks the point where the lower border of the symphysis touches the web of the right thumb and the right hand is now withdrawn. The nurse measures 60 OBSTETRIC NURSING. with the pelvimeter the distance thus obtained — nor- mally 51/4 inches. By subtracting 3/4 to 1 inch from this measurement an accurate idea of the anteropos- terior diameter of the pelvic brim is obtained. In con- tracted pelves this measurement is of great importance ; ■;:% Fig. 19. — Digital Method of Measuring the Diagonal Conjugate of the Pelvic Inlet. {Edgar.) indeed, indications for the induction of premature labor or for the performance of Cesarean section may be based on this measurement alone; in some cases it is necessary to etherize the patient in order to determine it exactly. CHAPTER VII. ACCIDENTS OF PREGNANCY. A Discharge of Blood from the womb, known as "uterine hemorrhage," may occur at any time during the pregnancy, and is usually a sign that the patient is threatened with a miscarriage. 1 However slight the flow, the nurse should have the patient lie down until the doctor has 'been told of its occurrence, and decides what the patient should do. A note should be sent to the doctor, telling just what has happened, and clearly making him understand the urgency of the symptoms — that is, the amount and character of the flow — and the condition of the patient. A nurse should not trust to a verbal message, as the physician may fail to respond to the call promptly, not being aware of the urgency of the symptoms. The patient should be required to use the bed-pan, or, at least, a vessel the contents of which can be thoroughly examined, both for the bowels and the passage of urine. All discharges, soiled cloth- ing, clots, etc., should be carefully saved for the in- spection of the physician. Meantime, an effort should be made on the part of the nurse to control the flow. The patient should lie with her head low, and a pillow under her hips; she 1 Such a flow, if excessive, is called an antepartum hemorrhage. 61 62 OBSTETRIC NURSING. should not be warmly cohered, plenty of cool, fresh air should be admitted into the room, and she should be keep exceedingly quiet. Should the symptoms become more urgent, the patient being threatened with fainting, the head may be lowered by raising the foot of the bed, placing bricks or chairs under it in such a wav as to make a decided in- clined plane or bed. The patient should be fanned, given hartshorn to inhale, and her limbs rubbed, to keep them warm, with alcohol or whisky. Small doses of whisky or aromatic spirits of ammonia may be given her in cold water, if able to swallow, or black coffee or tea, not too warm. If there is much blood flowing from the vulva, vaginal injections of hot water, at a temperature of about i io° to 1 1 5 , may be kept up until the flow ceases. The physician when called may think it best to tampon- ade the vagina. For this purpose long strips of steril- ized gauze or sheeting may be needed, which the nurse should have in readiness. Alarming hemorrhages are often the result of acci- dents, falls, or blows, or they may be caused by heavy lifting. Hemorrhage from a Low Attachment of the Pla- centa, or afterbirth, or when the afterbirth occupies an unusual position — that is, at the side of or over the mouth of the womb — occurs without any history of accident. It takes place at any time from the seventh month of pregnancy on to its termination, and without any premonitions of its coming. It may occur at night ACCIDENTS OF PREGNANCY. 63 while a patient is lying in bed. The management of this condition would be the same as that described above, until the doctor comes. 1 Hemorrhage from Varicose Veins. — Women suffering from enlarged, swollen veins, "varicose veins," or " varices,' ' of the lower extermities, if not careful in keeping the limbs bandaged or supported by elastic stockings may have hemorrhage occur by the bursting of one of these overdistended veins. The amount of blood lost may be so great as to imperil the patient's life. Should such a rupture of a vessel occur, compres- sion should be made just below the point of rupture, to control the bleeding, until the physician, who should have been sent for, arrives, when he will resort to the measures necessary for securing against further hemorrhage. Miscarriages are apt to recur, hence a patient who has once suffered from one should be cautioned to take ad- ditional care of herself during any subsequent pregnancy. Any sensation of weight about the hips, with the recur- rence of a "show," or slight discharge of blood, and cramp-like pains should warn her to lie down and send for her physician. Such a patient should also take the precaution to lie down as much as possible (if not in bed, on a lounge) during the time when, under other cir- cumstances, she would have her monthly flow. Any Rupturing the membranes is often the only way to check an antepartum hemorrhage, due to these causes. Sometimes version of the child is per- formed and a limb brought down in such a way as to make pressure against the detached placenta. 64 OBSTETRIC NURSING. patient having had a number of miscarriages should keep herself under the care of her physician from a very early date in the pregnancy, being placed under a reg- ular course of treatment. It is well, in this connection, to speak of the impor- tance of care in the after-treatment of miscarriages. Not uncommonly, patients, especially of the working classes, get up and go about their work a day or two after the occurrence. This is a dangerous proceeding, for, though the ill effects may not be felt for a time, chronic disease of the uterus is apt to result. If the pregnancy terminates before the fourth month it is commonly called an abortion. Between the fourth and seventh months it is a miscarriage, and after the seventh month, if before term, a premature labor. It is really necessary to give more time to the recov- ery from the effects of an abortion than to recovery from a confinement at term, and the patient should be willing to remain in bed at least a week or ten days, or longer, if thought best by her physician. The patient should not leave her bed as long as any discharge of blood continues. The causes of abortion may depend on some disease of the ovum or embryo, or it may depend on the mother. A frequent cause is the pouring out of blood between the two layers of the decidua. When this bleeding occurs low down, near the os uteri and is slight, abortion may not follow. When there is more blood and especi- ally if it occurs nearer to the fundus of the uterus, the ACCIDENTS OF PREGNANCY. . 65 blood forms a clot and serves to separate the ovum from its attachment to the uterus, thus causing abortion. When the ovum is expelled with the freshly formed clots around it, it is called a blood mole; when, however, it is retained for some time in the uterus and undergoes a change into a fleshy mass, it is called a flesh mole. Sometimes abortion is caused by degeneration of the chorion into a grape-like mass of small vesicles. This is called hydatidiform degeneration of the chorion, and constitutes a bladder mole. It commences at an early period of the pregnancy and almost always causes the death of the embryo. The enlargement of the uterus does not follow the regular progress that it does in nor- mal pregnancy, and irregular bloody discharge from the uterus, containing some of these little bladders will arouse the suspicion as to the condition which exists. The uterus should then at once be emptied. Fatty degeneration or fibrous degeneration of the placenta, the causes of which are not certainly known, also often result in abortion. Other causes, such as fright, extreme nervousness, excessive coitus, fevers, poisonous conditions of the blood, as in syphilis, lead poisoning, carbonic acid poisoning, etc., are very numerous. When it is impossible to prevent an abortion, the sooner the uterus is emptied the better. If the os uteri is well dilated, this may easily be accomplished by in- troducing the finger, after thorough sterilization of the hands, and detaching the ovum, and drawing it out. 5 66 OBSTETRIC NURSING. It is best always for a physician to assume the respon- sibility of this. When there is not enough dilatation, it can often be aided by plugging the vagina with strips of antiseptic gauze. This is best done through a speculum. One of the most dangerous forms of abortion is when only a portion of the ovum has been expelled. This is called an incomplete abortion. Two dangers arise from this : septicemia, or blood-poisoning from decomposition of the portions of the ovum and placenta retained; and hemorrhage which may occur frequently as long as the uterus remains unemptied. The treatment required is to dilate the uterine os under chloroform or ether, and to carefully remove all that remains of the ovum. Sometimes a small portion of retained placenta forms a kind of polypus and is called a placental polypus, its attachment to the uterine wall being quite firm. It will need removal as any other form of uterine polyp. Certain drugs, such as ergot, cannabis indica, savin, quinine, etc., called oxytocics, have the power to cause the uterus to contract and may cause abortion. They should, therefore, be avoided during pregnancy. Premature Rupture of the Membranes enclosing the child, with a discharge of colorless liquid, commonly known as " breaking of the waters," is another of the accidents of pregnancy, and is invariably followed, within a few days, at least, by the expulsion of the child. The patient will complain of her clothing be- coming wet, either by a sudden discharge of a quantity ACCIDENTS OF PREGNANCY. 67 of liquid, or by a slow but continuous flow. The nurse can assure herself that this liquid is not urine by her sense of smell. The smell of urine is characteristic. With the amniotic liquid surrounding the child, there is almost an entire absence of smell, a peculiar, faint, musty odor alone being recognizable. It is best, in removing this wet clothing from the patient, to set it aside, that the physician may judge for himself of the character of the liquid. The patient should at once lie down, not taking the erect position for any cause, not even for defecation and urination, and the physician should be sent for, with a written state- ment as to what has occurred. It is important that the physician should see the patient as soon after the rupture of the membranes as possible, because the sud- den loss of water may have brought about changes in the position of the child which may endanger its life. The loss of the entire amount of liquid contained in the sac would cause also difficulties in the delivery, or what is known as "a dry labor." Convulsions, or eclampsia, may sometimes occur dur- ing the pregnancy. The symptoms which threaten this trouble are extreme restlessness and uneasiness on the part of the patient ; diminution in quantity of urine passed, severe headache, often confined to one side of the head; disorders of vision, as seeing things double, or seeing but the part of an object, sometimes very im- perfect vision, and occasionally absolute loss of sight; twitchings of the muscles, especially of the face, may 68 OBSTETRIC NURSING. occur. The convulsion is ushered in by this restless- ness and twitchings, beginning first about the eyes and extending rapidly to the mouth, arms, and lower extermities. The movements are not violent, hence the patient is not likely to throw herself out of bed. During the convulsion the tongue may be bitten and the lips covered with blood-stained mucus; spasm of the diaphragm results in arrest of breathing and marked cyanosis. After one or two minutes' duration the muscular spasm relaxes, the convulsion terminates in a long inspiration and the patient passes into a state of coma. She lies unconscious, with flushed face, snoring respiration, full pulse, and elevated temper- ature. This state may last an hour or more, the pa- tient gradually regaining consciousness if treatment has been successful or, if otherwise, repeated convulsions occur during one of which the patient may die or in some cases death results from oedema of the lungs. Upon the first onset of eclamptic symptoms the physician should be sent for meantime, the nurse should see that the patient is kept lying down, that her cloth- ing is well loosened, especially about the head and chest, that plenty of fresh air enters the room, and that the patient is kept from biting her tongue. A folded hand- kerchief or towel slipped in between the teeth pushes back the tongue and prevents the teeth from coming down upon it. False teeth should be removed, the room should be darkened and sudden noises, loud talking and jarring of the floor or bed must be prevented. ACCIDENTS OF PREGNANCY. 69 The patient's feet should be kept warm and head cool. The members of the family must be kept calm and pre- vented from meddlesome interference, for the attempt to make the patient swallow any stimulant while struggling and unconscious may result very disastrously. Should the attending physician live too far away or be delayed in coming, the nearest physician should be sent for. Eclampsia is caused by some organic poison produced during pregnancy and imperfectly eliminated, as a rule because of kidney disease. Treatment is directed toward eliminating the poison and terminating the pregnancy. Three avenues of elimination are available — the skin, intestines, and kidneys. Hot packs stimulate copious elimination by the skin. Method of giving a Hot Pack. — Under the patient place a rubber blanket covered by a wool blanket, arrange four hot-water bottles or four hot bricks wrapped in bath towels on each side of the patient far enough away from her to avoid any possibility of burning , then cover all with a second wool blanket and rubber blanket. Put an ice-bag to her head and watch the pulse and respiration; if the pulse becomes feeble or irregular or the respirations shallow the pack must be discontinued, but if well borne the patient may remain in it for thirty minutes after sweating begins. At the end of this time remove the rubber blankets, bricks or bottles, sponge the patient off with warm alcohol and leave her between dry blankets. Such a pack may be re- 7 attachment of, 62 position for delivery of, 13 operative removal of, 132 After-care of parturient, 133 After-pains, 168 Ailments of infancy, 224 Airing of infant, 212 Amenorrhea, 17 Anesthesia, 137 Aseptic dressings, 90 Antiseptics, 106 during labor, 107 Artificial breathing, 124-129 Attentions after labor, '118 Auvard's couveuse, 226, 227 B. Baby's basket, 97 Baby's clothes, 93 Bag of waters, 100 Bandages, abdominal, 89 for breasts, 90, 162, 164 for varicose veins, 46 Barley water, 240 Bathing during lying-in, 152 pregnancy, 5 1 Bed, confinement, 91 preparation, 109 Bed-sores, 174 Bier's suction hyperemia, 161, 167 Binder for bady, 93 for mother, 89 Birth-marks, 248 Bladder, 40, 153 baby's, 250 Bleeders, 262 Bleeding from cord, 260 Blisters, 249 Boils, 251 Bossi's dilator, 139 Boston bandage, 163 Bowel movements, 237 Breast-pumps, 161 Breasts, anatomy of, 15 caked, 160 care of , during lying-in, 156. pregnancy, 49 gathered, 165 of infants, 258 Breech delivery, 81-83, 133, 140 Bruises, 263 Buhl's disease, 262 Byrd-Drew Method of resuscitation, 125 Caked breasts, 160 Caput succedanum, 80 Catheter, 153 Cereals, 242 Cesarean section, 142 Chafing, 251 Chart, order, 179 Chorea, 54 Cleansing of infant, 185 Cleft palate, 259 Clothing during pregnancy, 50 for puerpera, 88 of infant, 93, 185 of nurse, 104 Coccyx, 2 Cold in head, 257 Colic, 236 Colostrum, 191 Complications of pregnancy, 54 Conception, 17 Confinement, determining date, 36 Constipation of infants, 245 of mother, 38, 155 Convulsions of infant, 263 during labor, 135 pregnancy, 67 Cord, care of, 182 tying, 130 Couveuse, 225 Cow's milk, 196 modified, 198 Cramps during labor, 115 Craniotomy, 144 Cranioclast, 143 Cream, 198 Crib, 187 269 270 INDEX. Cries of infant, Cross-bed, 137 Cyanosis, 265 219 G. D. Deformities of infants, 259 Delivery, position for, 117 Deportment of nurse; 136 Development of infant, 213 Diarrhea of infant, 238 of mother, 39 Diet after labor, 147 during pregnancy, 52 of infants, 189 Dilatation by bags, 138 Disinfection, 106 Dress for mother, 88 for nurse, 104 Drink for baby, 244 Duties of nurse during labor, 104 Dysentery, 239 Dysmenorrhea, 17 Earache, 258 Eclampsia, 67 treatment of, 68, 69, 70 hot pack for, 69 symptoms of, 67 Eczema, 249 Emergencies of labor, 121 of pregnancy, 60 Emotions, maternal, 53 Epilepsy, 54 Erythema, 249 Etherization, 137 Examination during pregnancy, 56 Exercise during pregnancy, 53 Expression of infants, 220 Eyes of new-born, 186, 253 Falling of cord, 260 Fallopian tubes, 14 Farinaceous foods, 244 Feeding in indigestion, 239 of infants, 189 Fever blisters, 252 Fevers, 264 Flour ball, 242 Foetus, head, 71 positions, 75 presentations, 78 Fontanelles, 72 Food after labor, 147 during pregnancy, 52 of infancy, 200 Forceps delivery, 140 Formulae for infant feeling, 204 Fresh air for infants, 213 Galactagogues, 193 Galactorrhea, 168 Gavage, 235 Gelatin, 240 Genitalia, n Gertrude suit, 96 H. Hair, baby's, 186, 215 Hand feeding, 196 Hare-lip, 259 Head, fcetal, 71 shape, 214 Hearing of infants,- 215 Heart trouble, 265 Hematoma of scalp, 256, 259 Hemorrhage during labor, 134 pregnancy, 61 packing the uterus for, 139 Hemorrhoids, 45 Hernia in infants, 246 Human milk, 192 Hydrocephalus, 267 I. Incontinence of urine, 41 Infants' foods, 189, 241 Infectious diseases, 265 Inflammation of bowels, 238 Injections for infants, 245 for mother, 126, 114 Innominate bones, 2 Insanity, 54, 175 Internal examination, Involution, 149 Itch, 25 59 Jaundice, 261 Kidneys, 41 J. K. L. Labor, mechanism, 71 preparations for, 88 signs of, 98 stages of, 100 Laborde's method of resuscitation, 12 Lactation, 191 Lactometer, 194 Leucorrhea, 44 Liebig foods, 244 Lime water, 239 Lion incubator, 228 Lochia, 150 Lying-in, 145 INDEX, 271 M. Manual extraction of breech, 141 Marasmus, 266 Meconium, 184 Mellin's food, 244 Menorrhagia, 17 Menstruation, 16 Methods for calculating date of confine- ment, 32 for resuscitation, 124 Metrorrhagia, 17 Miliaria, 249 Milk, analysis, 192 condensed, 241 crust, 250 foods, 241, 244 leg, 173 modified, 198 Miscarriages, 70, 72 Molding of infant's head, 215 Morning sickness, 30 N. Nervous diseases of pregnancy, 54 Neuralgia, 47 New-born, care of, 180 Nipple protector, 158 shield, 157 Nipples, care of, 156 rubber, 211 Nursing bottle, 209 O. Oatmeal water, 240 Obstetric operations, 137 preparation of patient for, 137 preparation of instruments, 137 preparation for operator, 137 Ophthalmia neonatorum, 253 causes of, 253 prevention of, 254 treatment of, 254 Order-chart, 179 Outfit of baby, 93 of mother, 88 Ovaries, 15 Ovum, development, 19 Pains, false, 99 of labor, 99 true, 99 Paralysis, 267 Pasteurization, 200 Pelvis, anatomy of, 1 contents of, 1, 2, 3 deformities, 6 measurements of, 4, 57 Peptonized food, 203 Perforator, 143 Perineorrhaphy, 138 Phimosis, 251 Piles, 45 Placenta, 61, 65 Positions of fcetal head, 75 Powder, use of, 182 Pregnancy, complications, 61 management of, 38 signs of, 27 Premature rupture of membranes, 66 Prematurity, 224 Preparation of patient for labor, 1 06 of room, 109 of patient for examination, 56 Presentations of fcetus, 78 Prickly heat, 249 Prochownick's method of resuscitation, 128 Prolapse of cord, 136 Pubiotomy, 141 Puerperal fever, 172 mania, 175 ulcers, 173 Pulse in hemorrhage, 134 in infants, 218 in lying-in, 172 in pregnancy, 3 1 Q. Quality food for infants, 197 Quantity food for infants, 202 R. Red gum, 248 Respiration of infant, 217 Resuscitation of infant, 124 Rickets, 266 Ring-worm, 252 Rubber cloth, 91, 92 Rules for feeding infants, 202 for lying-in wards, 67-71 for management couveuse, 227 for premature infants, 232 Running at ears, 257 Rupture in infants, 246 of membranes, 66 of uterus, 136 S. Sacrum, 1 Salivary glands, 47 Scalp tumors, 258 Scrofula, 266 Sea voyages, 52 Senses, of infants, 215 Sitting up (first) ,177 Skin of infant, 213 Sleep after labor, 145 of infants, 217 272 INDEX. Snuffles, 257 Soap suppository, 245 Soiled clothing after labor, 145 Sore eyes, 253 mouth, 219 Spice plaster, 237 Sponge bath, 182, 187 Sterilized milk, 206 Sterilizer, 208 Stomach of infant, 203 rash, 249 Stools of infant, 220 Striae, 28 Suppression of urine, 250 Sutures, foetal, 71 Swaddling, 230 Syphilis, 54 Syringe, 245 U. Umbilical vegetations, 261 Urinalysis, 42 Urinary organs during pregnancy, Urination of infants, 220 Uterus, 13 V. Vaccination, 267 Vagina, 13 Varicose veins, 46 Vernix caseosa, 180, 181 Version, 140 Visitors, 146 Vomiting during labor, 115 pregnancy, 48 of infants, 247 40 Tact, 116 Tarnier's couveuse, 225 Teeth during pregnancy, 48 of infants, 221 Temperature of infant, 218 of mother, 172 Thrush, 247 Toilet, first, of infant, 180 Tongue-tie, 259 Trachelorrhaphy, 138 Training of infant, 189 Transverse presentation, 85 Tub, 188 Twins, 131 Tying cord, 130 W. Walking of child, 223 Washing for infants, 146 for mother, 146 "Water on the brain," 26 Weaning, 243 Weighing of infants, 186 Weight of infant, 197, 216 Wet-nurse, 191 "Whites" in infants, 250 Worms, 247 Y. Y-bandage, 164 m\ One copy del. to Cat. Div. It 191!