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Title: Obstetrical Nursing - A Text-Book On The Nursing Care Of The Expectant Mother, - The Woman In Labor, The Young Mother And Her Baby
Author: Blarcom, Carolyn Conant Van
Language: English
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                          OBSTETRICAL NURSING


[Illustration]

                         THE MACMILLAN COMPANY

     NEW YORK · BOSTON · CHICAGO · DALLAS · ATLANTA · SAN FRANCISCO


                        MACMILLAN & CO., LIMITED

                 LONDON · BOMBAY · CALCUTTA · MELBOURNE


                   THE MACMILLAN CO. OF CANADA, LTD.

                                TORONTO

[Illustration:

  THE CARESS

  _From the painting by Gari Melchers_
]

             I hold you close: and I could cry
             Because you seem so new and dear;
             And such a helpless warder I
             To keep your candle burning clear:

             The curious candle of your breath,
             Body’s and spirit’s throbbing breath.

                                     FANNY STEARNS GIFFORD.



                          OBSTETRICAL NURSING
 A TEXT-BOOK ON THE NURSING CARE OF THE EXPECTANT MOTHER, THE WOMAN IN
                  LABOR, THE YOUNG MOTHER AND HER BABY


                                    BY

                     CAROLYN CONANT VAN BLARCOM, R.N.

 FORMERLY, ASSISTANT SUPERINTENDENT AND INSTRUCTOR IN OBSTETRICAL NURSING
    AND THE CARE OF INFANTS AND CHILDREN AT THE JOHNS HOPKINS HOSPITAL
                        TRAINING SCHOOL FOR NURSES

                                Author of
                         “The Midwife in England”


                   WITH 200 ILLUSTRATIONS AND 8 CHARTS


                                 New York

                          THE MACMILLAN COMPANY

                                   1922

                          _All rights reserved_


                PRINTED IN THE UNITED STATES OF AMERICA


                            COPYRIGHT, 1922,
                       BY THE MACMILLAN COMPANY.

             Set up and electrotyped. Published May, 1922.


                                Press of
                      J. J. Little & Ives Company
                          New  York, U. S. A.


                         THIS BOOK IS DEDICATED

                                 TO THE

                         SPIRIT OF HELPFULNESS

                     WHICH HAS MADE ITS PREPARATION
                     POSSIBLE WITH THE HOPE THAT IT
                     MAY BE OF HELP TO THOSE NURSES
                   WHO TAKE YOUNG MOTHERS AND BABIES
                            INTO THEIR CARE.

------------------------------------------------------------------------



                                PREFACE


In writing this book on obstetrical nursing I have been influenced by
certain steadily deepening impressions which have been received in the
course of my contact with maternity work in this country, Canada and
England during the past twenty years. It has been borne in upon me, in
the first place, that very often there is something akin to bewilderment
among those nurses who have been trained to care for patients according
to the teachings of one group of obstetricians and who later find
themselves nursing the patients of other doctors who hold different, or
even opposite views. And not infrequently I have found in the nurses a
degree of loyalty to their training which made them sceptical, or even
intolerant, of nursing methods which differed from those which they had
been taught.

I have become convinced, therefore, that a book on obstetrical nursing
which would be helpful to and widen the outlook of all nurses, no matter
where nor by whom trained, must of necessity describe the underlying
principles of obstetrical nursing and offer a survey of the nursing
methods which are employed in maternity wards and hospitals of
recognized excellence and in the practice of acknowledged authorities
upon obstetrics.

This is, I am aware, a unique attitude, for the present text books on
obstetrics for nurses reflect, in each instance, the wishes of one
doctor, almost entirely, or advocate the methods employed in one
hospital. My experience in teaching obstetrical nursing makes me feel
that a parallel description of dissimilar nursing procedures serves to
broaden the nurse’s attitude toward her work and her grasp of the entire
subject, both because she becomes aware of the fact that methods, other
than those with which she is familiar, are employed in hospitals of high
standing and because she appreciates the fact that these unfamiliar
methods may be as efficacious as those in which she has become expert.

Accordingly I have devoted the better part of the past year and a half
to a study of the scope and methods of the present training in maternity
nursing in several hospitals, in this country and Canada, in which the
obstetrical work is of a conspicuously high character, and have
presented a composite of this teaching in the succeeding pages.

But that there might not be apparent inconsistencies in the different
methods of maternity care described, I have given an explanation of the
purposes and general principles of the care, including nursing, which
the nurse is likely to find is given to all obstetrical patients, the
country over.

For the sake of simplicity and clarity I have divided the book into
seven parts, following an introduction which describes the requisites
and opportunities of obstetrical nursing and the importance of the
nurse’s own attitude toward her work and her patient. The first two
parts, dealing with the normal anatomy and physiology of the female
generative tract and the development of the fetus, are designed to
supply the nurse with enough technical information to make her
ministrations intelligent and effective. In this respect, I have
doubtless given less than some nurses will wish and possibly more than
others will think necessary, but I have given about the average amount
of instruction that is found satisfactory in the training schools of
high standing. Four of the succeeding parts are devoted respectively to
a description of the nurse’s duties during pregnancy, labor, the
puerperium and early infancy. In each of these I have explained, first,
the normal physiological processes which take place; then, the nurse’s
duties under average conditions and finally, her responsibilities in the
event of complications or abnormalities. A separate part is devoted to a
description of the organized care and instruction of the maternity
patient, by public health nurses, both before and after delivery, which
have proved to be satisfactory.

While describing various hospital procedures, I have deemed it of
practical importance to explain, in each instance, how similar results
might be obtained, with improvised appliances, in a patient’s home
whether in a city or a rural community. In short, I have endeavored to
make clear the essentials of obstetrical nursing without regard to the
status or location of the patient.

Since the patient’s state of nutrition and her frame of mind are of
vital importance throughout pregnancy, labor and the puerperium, I have
not only dwelt upon them in all descriptions of the nurse’s duties
during these periods but have devoted an entire chapter to a simple
explanation of the principles of each of these two important subjects.

My varied contact with obstetrical nurses has convinced me that those
nurses who appreciate the never ending wonder and beauty of this miracle
of the beginning of a new life, derive peculiar satisfaction from the
care of the maternity patient. At the same time, in many hospitals, even
where the patients are given the most conscientious care, the nurses are
often so nearly overwhelmed by the long, irregular hours and the
insistent demands of routine duties, that they do not grasp the
significance of the event in which they are participants. Accordingly, I
have made a sustained effort throughout the following pages to give the
young nurse something of a feeling of reverence for this great mystery
of birth.

In the course of my survey of the present training in obstetrical
nursing, I have met the warmest generosity on the part of the
obstetrical and nursing staffs in all of the hospitals which I have
visited. Accordingly, I find it very difficult to find adequate
expression for my sense of gratitude to the doctors and nurses of the
Montreal Maternity Hospital; the Burnside Obstetrical Department of the
Toronto General Hospital; The Hospital of the University of
Pennsylvania; Bellevue Hospital; The Long Island College Hospital; The
Brooklyn Hospital; The Cleveland Maternity Hospital and to Dr. J.
Whitridge Williams and Miss Elsie Lawler for making available the entire
resources of the wards, clinics, laboratories and class and lecture
rooms at Johns Hopkins Hospital.

I wish to offer an expression of deepest possible appreciation to Dr.
John W. Harris for the generosity with which he has given of his time,
thought and wide experience in an effort to provide accurate and
practical information, and to set a high standard of work and ideals for
those nurses who would be influenced by this book. Having taught and
lectured to nurses, as well as medical students, for years, Dr. Harris
is in a position to give counsel and criticism of peculiar value to a
book on obstetrical nursing and he has given these throughout the entire
preparation of this book.

Because of their concern with any effort to better the state of mothers
and babies, I have been given suggestions, assistance and inspiration
with the most selfless generosity by The Reverend Father John J. Burke;
Dr. J. Clifton Edgar; Dr. Frederic W. Rice; Dr. J. P. Crozer Griffith;
Dr. Caroline F. J. Rickards; Dr. Esther Loring Richards; Dr. E. V.
McCollum; Miss Nina Simmonds and Dr. John R. Fraser. Among the many
nurses with whom I have conferred, I have met a characteristic spirit of
helpfulness which has expressed itself in their eager readiness to pass
on to other nurses the benefits of their own training and experience.
Those to whom I am especially indebted, for aid and suggestions, are
Miss Calvin MacDonald; Mrs. Bessie Amerman Haasis; Miss Robina Stewart;
Miss Caroline V. Barrett; Miss Katherine de Long; Miss Jean Gunn; Miss
Mary E. Robinson; Miss Sara Cooper; Miss Laura F. Keesey; Miss Chelly
Wasserberg; Miss Kate Madden; Mrs. Minnie S. Brown; Miss Anne Stevens;
Miss Madge Allison and Miss Katherine Tucker.

To Mrs. Elizabeth Porter Wyckoff I am under heavy obligation for most
discriminating editorial assistance and for her farsighted criticisms
toward increasing the clarity of the text. And I feel sure that the
tender little poem on the miracle of motherhood, which Mrs. Elizabeth
Newport Hepburn wrote expressly for this book, will be as warmly
appreciated by my readers as it is by me.

I wish to express my deep gratitude to Mr. Max Brodel for his invaluable
counsel and guidance in planning and assembling the illustrations to
elucidate the text. And I am very grateful to Mr. Gari Melchers for the
spirit which I believe is infused into this book through the
reproduction of two of his lovely paintings of a mother and baby, and to
Mr. Russell Drake for his valuable drawings. I wish further to thank Mr.
J. Norris Myers, of The Macmillan Company, for unfailing courtesy and
helpfulness in facilitating all matters relating to the publication of
this book.

For statistical information I am indebted to Dr. Louis I. Dublin and for
authority in offering the scientific background of the teaching I have
drawn from “The Practice of Obstetrics” by J. Clifton Edgar;
“Obstetrics” by J. Whitridge Williams; “The Diseases of Infants and
Children” by J. P. Crozer Griffith and “The Prospective Mother” by J.
Morris Slemons.

                                             CAROLYN CONANT VAN BLARCOM.

 New York City, 149 East 40th Street



                           TABLE OF CONTENTS


                                                                    PAGE

 PREFACE                                                              xi

 INTRODUCTION                                                          3


                                 PART I.

                         ANATOMY AND PHYSIOLOGY

 CHAPTER

      I. ANATOMY OF THE FEMALE PELVIS AND GENERATIVE ORGANS           19

     II. PHYSIOLOGY                                                   45


                                PART II.

                       THE DEVELOPMENT OF THE BABY

    III. DEVELOPMENT OF THE OVUM, EMBRYO, FETUS, PLACENTA, CORD AND
           MEMBRANES                                                  61

     IV. PHYSIOLOGY OF THE FETUS                                      84

      V. SIGNS, SYMPTOMS, AND PHYSIOLOGY OF PREGNANCY                 93


                                PART III.

                          THE EXPECTANT MOTHER

     VI. PRENATAL CARE                                               111

    VII. MENTAL HYGIENE OF THE EXPECTANT MOTHER                      145

   VIII. PREPARATION OF ROOM, DRESSINGS, AND EQUIPMENT FOR HOME
           DELIVERY                                                  155

     IX. COMPLICATIONS AND ACCIDENTS OF PREGNANCY                    164


                                PART IV.

                          THE BIRTH OF THE BABY

      X. PRESENTATION AND POSITION OF THE FETUS                      217

     XI. SYMPTOMS, COURSE, AND MECHANISM OF NORMAL LABOR             232

    XII. NURSE’S DUTIES DURING LABOR                                 243

   XIII. OBSTETRICAL OPERATIONS AND COMPLICATED LABORS               295


                                 PART V.

                            THE YOUNG MOTHER

    XIV. PHYSIOLOGY OF THE PUERPERIUM                                317

     XV. NURSING CARE DURING THE NORMAL PUERPERIUM                   323

   XVII. THE NURSING MOTHER                                          357

   XVII. NUTRITION OF THE MOTHER AND HER BABY                        368

  XVIII. COMPLICATIONS OF THE PUERPERIUM                             391


                                PART VI.

                 THE MATERNITY PATIENT IN THE COMMUNITY

    XIX. ORGANIZED PRENATAL WORK                                     405

     XX. CARE OF THE MOTHER AND BABY BY VISITING NURSES              437


                                PART VII.

                          THE CARE OF THE BABY

    XXI. CHARACTERISTICS AND DEVELOPMENT OF THE AVERAGE NEW-BORN
           BABY                                                      451

   XXII. NURSING CARE OF THE AVERAGE NEW-BORN BABY                   461

  XXIII. COMMON DISORDERS AND ABNORMALITIES OF EARLY INFANCY         518

   XXIV. A FINAL WORD                                                544



                    LIST OF ILLUSTRATIONS AND CHARTS


                              ILLUSTRATIONS

                         ANATOMY AND PHYSIOLOGY.

      FIG.                                                          PAGE

      1 a. Normal female pelvis                                       21

        b. Normal male pelvis                                         21

        2. Diagram of pelvic inlet seen from above                    22

        3. Diagram of pelvic outlet seen from below                   23

        4. Sagittal section of the pelvis                             24

        5. Two types of pelvimeters                                   25

        6. Diagram showing method of measuring distance
             between crests, spines and trochanters                   26

        7. Diagram showing method of measuring Baudelocque’s
             diameter                                                 27

        8. Diagram showing method of estimating true conjugate        28

        9. Diagram showing method of measuring intertuberous
             diameter                                                 29

       10. Anterior view of external and internal female
             generative organs                                        31

       11. Diagrams of sections of virgin and multiparous
             uteri                                                    32

       12. Sagittal section of female generative tract                35

       13. Diagram of external female genitalia                       39

       14. Sagittal section of breast                                 42

       15. Front view of breast                                       43

       16. Diagram of human ovum                                      47


                         DEVELOPMENT OF THE BABY

       17. Diagram of human spermatozoa                               61

       18. Diagram of segmenting rabbit’s ovum                        65

       19. Ovum about 13 days old embedded in the decidua             66

       20. Diagram of developing fetus, cord, membranes and
             placenta in utero                                        69

       21. Diagram of structure of placenta                           71

       22. Photograph of placental vessels                            72

       23. Maternal surface of the placenta                           74

       24. Fetal surface of the placenta                              75

       25. Embryo about 5.5 cm. long in amniotic sac                  77

       26. Outlines of fetus at different stages                      78

       27. Full term fetus in utero                                   81

       28. Diagram of fetal circulation                               85

       29. Diagram of circulation after birth                         87

       30. Side and top view of fetal skull                           90


                          THE EXPECTANT MOTHER.

       31. Height of fundus at different stages of pregnancy          94

       32. Contour of abdomen at ninth month                          95

       33. Contour of abdomen at tenth month                          95

       34. Front view of home-made abdominal binder                  123

       35. Side view of same                                         123

       36. Back view of same                                         123

       37. Abdominal binder used in above                            124

       38. Front view of home-made stocking supporters               124

       39. Back view of same                                         124

       40. Patient in right-angled position to relieve
             varicose veins                                          138

       41. Elevated Sims position                                    139

       42. Gloves, ready for dry sterilization                       160

       43. Delivery pad of newspapers and old muslin                 161

       44. Diagram of centrally implanted placenta prævia            174

       45. Partial placenta prævia                                   175

       46. Diagram of marginal placenta prævia                       176

       47. Champetier de Ribes’ bag inserted in uterus               177

       48. Patient in hot pack given with dry blankets               197

       49. Method of giving infusion                                 202


                         THE BIRTH OF THE BABY.

       50. Attitude of fetus in uterus at term                       217

       51. Illustration from first text-book on obstetrics           218

       52. Attitude of fetus in breach presentation                  219

       53. Attitude of fetus in vertex presentation                  220

       54. Diagram of six positions in a vertex presentation         222

       55. Diagram of six positions in a face presentation           223

       56. Diagram of six positions in a breech presentation         223

       57. First maneuver in abdominal palpation                     225

       58. Second maneuver in abdominal palpation                    226

       59. Third maneuver in abdominal palpation                     227

       60. Fourth maneuver in abdominal palpation                    228

       61. Diagrams showing positions of nurse’s hands in four
             maneuvers of abdominal palpation                        229

       62. Ascertaining position of fetus by rectal
             examination                                             230

   63, 64, Diagrams showing stages of dilatation and
   65, 66.   obliteration of cervix                                  234

       67. Characteristic position of patient during first
             stage pains                                             235

       68. Diagram indicating rotation and pivoting of head
             during birth                                            236

       69. Anterior shoulder being slipped from under
             symphysis                                               237

       70. Birth of posterior shoulder                               238

       71. Diagrams of Duncan and Schultze mechanisms of
             placental separation                                    239

       72. Section showing thinness of uterine wall before
             birth of fetus                                          240

       73. Section showing thickness of uterine wall
             immediately after labor                                 241

       74. Preparing patient for vaginal examination or
             delivery                                                250

       75. Patient draped for vaginal examination                    251

       76. Wrong and right methods of boiling gloves                 253

       77. Powdering hands before putting on dry gloves              254

       78. Successive steps in proper method of putting on
             gloves                                                  255

       79. Bed and simple equipment ready for normal delivery        258

       80. Instruments shown in Fig. 79                              260

       81. Old prints showing early methods of delivery              261

       82. Patient draped with sterile dressings for delivery        262

       83. Patient pulling on straps while bearing down during
             second stage                                            264

       84. Palpating baby’s head through perineum                    265

       85. Baby’s head appearing at vulva                            266

       86. Head farther advanced                                     267

       87. Holding back head at the height of a pain                 268

       88. External rotation following birth of head                 269

       89. Wiping mucus from baby’s mouth                            270

       90. Stroking baby’s back to stimulate respirations            271

       91. Two clamps on cord after pulsation has ceased             272

       92. Wrong and right method in tying knot in cord
             ligature                                                272

       93. Stimulating baby’s respirations                           274

   94, 95. Stimulating baby’s respirations                      275, 276

   96, 97. Resuscitating baby by holding under warm water       277, 278

       98. Resuscitation by means of direct insufflation             279

       99. Delivery of the placenta                                  280

      100. Twisting membranes while withdrawing placenta             281

      101. Massaging fundus through abdominal wall                   282

      102. Showing prolapsed cord between head and pelvic brim       285

      103. Giving chloroform for obstetrical anæsthesia              287

 104, 105. Giving ether for obstetrical anæsthesia              289, 290

      106. Giving ether for complete anæsthesia                      293

      107. a. Tarnier forceps, b. Simpson forceps                    301

      108. Patient in position and draped for forceps
             operation                                               302

      109. Forceps sheet used in Fig. 108                            303

      110. Two types of leggings for obstetrical use                 304

      111. Rubber bougie                                             311

      112. Champetier de Ribes’ bag                                  311

      113. Voorhees’ bag                                             312

      114. Bag held in forceps for introduction into uterus          312

      115. Syringe for filling above bags after insertion            312


                            THE YOUNG MOTHER.

      116. Height of fundus on each of first ten days after
             delivery                                                327

      117. Patient draped for postpartum dressing                    336

      118. Equipment in rack used in Fig. 117                        337

      119. Method of covering nipples with sterile gauze             339

      120. Baby nursing through a nipple shield                      341

      121. Nipple shield used in Fig. 120                            342

      122. Supporting heavy breasts by means of folded towels        343

      123. Ice caps applied to engorged breasts                      344

      124. Y binder before application                               345

      125. Y binder applied                                          346

      126. The same seen from the other side                         347

      127. Indian binder                                             347

      128. Method of stripping                                       348

 129, 130, Bed exercises taken during the puerperium
 131, 132,
 133, 134,                                                        350 to
      135.                                                           353

      136. Knee-chest position                                       354

      137. Exercising by walking on all fours                        354

      138. Position of mother and baby for nursing in bed            359

      139. The Nursing Mother (from a painting by Gari
             Melchers)                                               361

      140. Baby partially blind as a result of a faulty diet         378

      141. Rachitic and normal babies of the same age                381

      142. Chest walls of normal and rachitic rats of the same
             age                                                     383

      143. Interior of specimens in Fig. 142                         384


                 THE MATERNITY PATIENT IN THE COMMUNITY.

      144. Baby’s bed improvised from a market basket                415

      145. Layette recommended to expectant mothers by
             Maternity Centre Association                            416

      146. Breast tray recommended to expectant mothers by
             Maternity Centre Association                            417

      147. Baby’s toilet tray recommended to expectant mothers
             by Maternity Centre Association                         417


                                THE BABY.

      148. Diagram of first teeth                                    456

      149. Umbilical cord immediately after birth                    457

      150. The same four days later                                  457

      151. Umbilicus immediately after separation of cord            458

      152. Well healed umbilicus                                     458

      153. Nursery at Manhattan Maternity Hospital                   465

      154. Bathing the baby                                          467

      155. Preparation for circumcision                              468

      156. Baby draped with sterile sheet, in above                  469

      157. Cord dressed with dry sterile gauze                       470

      158. Abdominal binder applied over cord dressing               471

      159. Satisfactory baby clothes                                 473

      160. Diagonally folded diaper applied                          474

      161. Longitudinally folded diaper applied                      474

      162. Sutton poncho to protect baby for outdoor sleeping        479

      163. Training the baby to use a chamber                        481

      164. Stiff cuffs to prevent thumb sucking                      483

      165. Hammer cap to prevent ruminating                          484

      166. Ruminating cap applied                                    485

      167. Proper method of carrying baby                            487

      168. Preparing the baby’s milk                                 493

      169. Giving the baby his bottle                                496

      170. Holding baby upright after feeding                        497

      171. Dr. Griffith’s table of fat percentages                   500

      172. Reverse side of above card                                501

      173. Baby in a basket ready to travel                          507

      174. Quilted robe with hood for the premature baby             509

      175. Premature baby in lined basket, being fed with
             Boston feeder                                           510

      176. Bed for premature baby improvised from small
             clothes basket                                          511

      177. Putting the baby in a wet pack                            521

      178. Baby in wet pack                                          522

      179. Diagrams showing successive steps in giving the
             baby a pack                                             522

      180. Baby wrapped in blanket preparatory to gavage             523

      181. Gavage                                                    524

      182. Obtaining a fresh specimen of urine from the baby         526

      183. Obtaining a 24–hour specimen of urine from the baby       527

      184. Band to hold baby’s legs while obtaining specimens
             of urine                                                527

      185. Belt used to hold tube for specimen                       528

      186. Giving the baby an enema                                  530

      187. Irrigating the eye with a blunt nozzle                    536

      188. Method of holding baby for treating gonorrhœal
             ophthalmia                                              537


                                 CHARTS.

       NO.
        1. Showing drop in blood pressure and albumen, after
             delivery, in eclampsia                                  204

        2. Showing persistence of high blood pressure and
             albumen in the urine, after delivery, in
             nephritic toxæmia with convulsions                      206

        3. Showing temperature curve in streptococcus
             infection                                               397

        4. Showing temperature curve in gonorrhœal infection         398

        5. Showing normal weekly gain in weight during first
             year of life                                            454

        6. Showing normal daily gain in weight during first
             two weeks                                               520

        7. Showing loss of weight in inanition fever
             contrasted with No. 6                                   520

        8. Showing rise in temperature in inanition fever            520



                          OBSTETRICAL NURSING


           “Can there be any higher work than this?
           Can any woman wish for a more womanly work?”
                                         Florence Nightingale



                              INTRODUCTION


The avowed purpose of care given to the maternity patient to-day is to
minimize the discomforts and perils of her pregnancy, labor, and the
puerperium, and so safeguard her and her baby that both will emerge from
the lying-in period in a satisfactory condition and with a bright
prospect of having permanently good health.

The striking difference between obstetrics as practiced to-day, and that
of former times, is that it now lays as much stress upon the future
health of the mother and baby as it does upon their immediate safety.

Happily, the present-day obstetrician, who assumes the care of an
expectant mother, does so with confidence and optimism because of the
available knowledge upon which he may draw for her benefit. Progress in
the various branches of medicine and nursing is steadily pointing the
way toward greater and more effective safeguards for the maternity
patient and her baby.

The value of these safeguards is attested to by the satisfactory results
of the care which is given to the patients in well conducted hospitals
or in their homes by careful physicians; by various out-patient
departments and nursing organizations to patients within their reach.
These results are in the form of a large proportion of mothers and
babies who are well and continue to be well.

That is one view of the matter. Looking at it from another aspect, we
discover that more than seven women still lose their lives for each
1,000 births that occur in this country, the actual number varying in
different localities. Childbirth is still second to tuberculosis as a
cause of death among women between fifteen and forty-five years of age,
and in spite of the proved value of care in making maternity a safe
adventure, the larger proportion of these women die from infection or
toxæmia which are almost entirely preventable.

The incredible fact in this connection is that, while there has been a
decline in the deaths from such other controllable conditions as typhoid
fever and some of the infectious diseases of childhood, there has been
an actual increase in deaths from preventable causes associated with
child-bearing.

Dr. Dublin estimates that throughout the United States as a whole,
during 1920, the total number of deaths due to childbirth was about
20,000.

In addition to the high death rate among mothers the mortality among
babies is even greater. Dr. Dublin estimates that out of every 1,000
babies born during 1920, about 85 died before they were a year old, or
about 200,000 in the course of the year, and that the large majority of
these died from congenital causes, from infection or nutritional
disturbances. Another 100,000 babies perish, yearly, through still
births. As all of these conditions are preventable to a greater or
lesser degree, we have to acknowledge that many babies die whom we know
how to save. There is sound reason, therefore, for the belief that
proper care would save the lives of about two-thirds of the mothers and
half of the babies who now die and half of the babies who are born dead.

And let it be remembered that conditions which destroy life, also
destroy or greatly impair health and resistance to disease. Although we
may count the number of mothers and babies who fail to survive the too
severe test to which they are put during crucial periods in the lives of
both, we cannot count, nor even approximately estimate, the number of
those who escape death only to be imprisoned in frail, deformed, or
diseased bodies. Therein lies much of the tragedy which follows in the
wake of neglect—the lifelong handicaps, suffering, and inefficiency that
need not have been.

This lack of care is not due to limitations in medical knowledge, for
the efficacy of known methods is being constantly demonstrated. And our
instant and generous response, the country over, to appeals for help in
relieving various forms of need and disaster does not suggest a national
cold-bloodedness, or even indifference, to needless suffering. But still
a legion of mothers and babies die each year from lack of care, and
almost at our very thresholds.

Perhaps the root of the difficulty lies in the fact that childbirth, as
well as the attendant suffering and death, are so familiar that they are
regarded as being normal incidents in the ordinary course of affairs.

One of the most dramatic of all human events, the birth of a new being,
is accepted casually, almost without concern, because it is so
frequent—so commonplace.

Moreover, we are all accustomed to hearing stressed the fact that
child-bearing is not a disease, but is a normal physiological function.

Not so generally, however, do we hear emphasis made upon the equally
important facts that there is extreme danger of infection while these
physiological functions are in progress, and that they subject the
entire organism to such a strain that there results a dangerously narrow
margin between health and disease.

Accordingly, too much is expected, or taken for granted, from the
provisions which Nature has made to promote these functions, and not
enough assistance is given to protect the mother, while they are in
course, or to help the immature baby in adjusting himself to the
greatest change which he makes during the entire span of his existence.

When the time comes, and it seems to be approaching, that pregnancy,
labor, the puerperium and infancy are regarded as crucial periods in the
life history, demanding all the preventives and safeguards that all
branches of medicine and nursing can offer, these periods will cease to
be so enormously destructive of life and health.

We cannot build a strong race with sickly and maimed mothers and babies,
and we can scarcely have other than sickly and maimed mothers and babies
without care.

Apparently, then, our national health is in a large measure dependent
upon good obstetrics and good obstetrics includes good nursing.

Good nursing implies more than the giving of bed baths and medicines,
boiling instruments and serving meals. It is more than going on duty at
a certain time, carrying out orders for a certain number of hours and
going off duty again. It implies care and consideration of the patient
as a human being and a determination to nurse her well and happily, no
matter what this demands.

In carrying on her work, the maternity nurse may be called upon to aid
in prenatal supervision and instruction; to prepare for and assist with
a delivery, or to give either exclusive or visiting nursing care to a
young mother and her baby. These patients may be in a hospital or at
home and the home may be of any kind from a palace to a hut or a
tenement. The patients may be in a city, a small town, or a rural
community, and in the care of doctors whose methods vary widely.

But in spite of the diversity of conditions and the fact that no two
will be quite alike, the general need of all of these patients will be
the same.

Their need is care, which includes cleanliness in order to prevent
infection; suitable food; fresh air and exercise; regular and sufficient
rest and sleep; an equable body temperature; early treatment of
complications and correction of physical defects. In short, each patient
needs to be watched; needs clean care and to practice the approved
principles of personal hygiene from the beginning of pregnancy. This
without regard to race, color, creed, occupation, status, or location.
It means all maternity patients and their babies the country over.

There was a time when the obstetrician first saw his patient in labor or
shortly beforehand, and when the care of the baby began at birth or soon
afterward.

We know what this tardy attention has cost in human lives and suffering.

We know, too, that among the mothers, abortion, miscarriages, toxæmias,
difficult or impossible labors may be largely prevented through prenatal
care; while among babies, the enormously high death rate, during the
first month of life from causes which begin to operate before birth,
convinces us that we must begin to take care of the baby nine months
before he is born, if he is to have the greatest benefits of present
available knowledge. Such early care reduces still births and injury
during labor; it reduces premature births, which is important, because
the nearer the baby goes to term the better his chance of survival and
of good health, and prenatal care also increases the prospects of
satisfactory breast feeding.

Although we know that the ideal is to have all maternity patients
supervised and instructed entirely by a physician from the beginning of
pregnancy and then delivered in a well conducted hospital, it is
scarcely probable that this ideal will ever be realized. There will
always be patients who cannot afford to employ a doctor for so long a
period; there will always be communities in which hospital provisions do
not exist or are inadequate. There will always be expectant mothers whom
it would be unwise to remove from home, excepting under pressing
conditions, because of the influence exerted by their mere presence in
keeping the family group intact. And so on, through a number of
deterring conditions which will probably never cease to exist, and which
will keep the patient at home.

Since patients who are supervised during pregnancy and delivered in
hospitals usually recover, the high rate of death and injury, in this
country, is to be found among women who are unsupervised before labor
and subsequently delivered at home. Accordingly, if this widespread
injury is to be reduced, the essentials of the care which is found to be
efficacious must be made available for all patients throughout the
length and breadth of the land.

Prenatal care, clean deliveries, and intelligent motherhood will go far
toward solving the problem of a high maternal and infant death rate, and
these require not widespread care, alone, but widespread teaching as
well—impressing upon women and their families the importance of care and
precautions in connection with childbirth. Important as it is for men to
study and inform themselves in regard to the problems of finance and
cattle raising, for example, it is still more important for both men and
women to study and appreciate the problems of expectant and actual
motherhood.

It is in this teaching that the nurse may be immeasurably helpful, in
fact is indispensable, for the carrying of approved care into the home
and the general teaching of personal hygiene are inextricably bound up
with nursing.

The details of the care and teaching of patients are, of course,
specified by a doctor or a medical board, but the effectiveness of the
planning, whether for one or several patients, is very largely dependent
upon the nurse’s intelligence, interest and conscientiousness, and her
ability to teach.

This is borne out by the almost uniform recommendations, made by
official bodies, for provisions looking toward the reduction of maternal
and infant deaths including as they do the following:

1. The employment of public health nurses. (To give home care or
instruction or both.)

2. The establishment of prenatal clinics and baby health centers. (In
both of these the nurse aids in supervising and teaching the mother how
to take care of herself and her baby.)

3. Trained attendance during labor. (The nurse aids greatly in preparing
for and assisting with clean deliveries.)

4. Improved and increased hospital facilities. (There cannot be good
hospital work without good nursing.)

5. Prompt and accurate registration of births. (Here, too, the nurse may
be helpful by always making sure that the birth has been reported.)

Here is no light task nor mean privilege which is set before the nurse
and in order to meet them fitly she must be prepared. The indispensable
requisites for nursing and teaching the maternity patient, whether at
home or in a hospital, are training, an exacting conscience, and genuine
concern for her patient as an individual.

A certain amount of scientific knowledge is necessary, in this as in any
other field, to give the nurse an intelligent background and a kind of
definiteness and stability to her work. She should be trained in the
essentials of general nursing, of surgical nursing and operating room
technique, and in the care of babies. She must of necessity know
something of the anatomy and physiology of the female generative organs;
the physiological adjustments during pregnancy; the development of the
baby within the uterus; the normal process, or mechanism, of labor, and
the changes which ordinarily take place during the puerperium. Such
information will make clear to her the reasons for the care which she
gives to her patient, and accordingly her care will be more intelligent.
And she will be better able to recognize the difference between
evidences of normal physiological changes and the symptoms of
complications.

Two of the newer branches of medicine—nutrition and mental hygiene or
psychiatry—have a more and more apparent relation to the safety and
welfare of the maternity patient, and accordingly are of moment to the
maternity nurse. For, it must be remembered, it is the purpose of
obstetricians to-day to establish future health for their patients as
well as immediate safety. The nurse should endeavor to help with all
that the doctor attempts to do toward these ends, and in order to help
she must understand.

The maternity nurse can scarcely be expected to specialize in nutrition
or in psychiatry, but she may give to her patients the practical
benefits of many valuable discoveries in these fields. She may not be
able to remember, for example, all of the sources and purposes of lime
in the diet, nor of each of the protective substances, often referred to
as vitamines, but any nurse can remember and be guided by the fact that
her patient will not be satisfactorily nourished either before or after
the birth of the baby unless she has a varied diet containing milk,
eggs, and green vegetables. She also can explain to her patients that
faulty dietaries are responsible for the tradition that each child costs
the mother a tooth, as well as the fact there may be undernourishment
even among babies who are fed at the breast, if the mother’s diet is
inadequate.

And though the mass of nurses cannot be expected to grasp all of the
intricacies of psychiatry, they may without exception apply one of its
most important principles by adopting a warm and sympathetic attitude
toward their patients and by this means win their trust and confidence.
The restfulness of this; the relaxation and general state of mind that
this will engender in a large proportion of patients will exert a
definitely beneficial effect upon the physical well-being of the
expectant mother, the woman in labor and the nursing mother.

These simple applications of important scientific discoveries that
relate to the everyday life of her patient—these are things for the
maternity nurse to bear in mind. She is nursing a human being who is
passing through crucial periods and anything that affects her as a human
being affects her as a patient.

Apparently, then, the work of the obstetrical nurse necessitates a
training in general nursing and its various branches, in addition to
obstetrics, for there seems to be no aspect of nursing which may not,
under some condition, have its place in the care of the mother or her
baby. All of this training, however, will prepare her for effective work
only if she herself has a spirit of eagerness and enthusiasm. But if she
has these and even a little training, she may do much.

Accordingly, let the nurse who has been prepared by a general and
special training, and who wants to be of the greatest possible service
to the maternity patient start by appreciating a few general principles
which will be absolutely indispensable to the success of her work. They
may be expressed somewhat as follows:

1. _Cleanliness_—under all conditions, to protect both mother and baby
from infection.

2. _Watchfulness_—for early symptoms of complications in either mother
or baby.

3. _Adaptability_—to the patient, the doctor, and the surroundings.

4. _Sympathy_—for every mental and physical stress which the patient may
suffer.

If the nurse convinces herself of the import of these requirements and
is exacting of herself in giving them broad interpretation, she cannot
but nurse her patients well.

She will appreciate the invariable need for cleanliness and watchfulness
if she will hark back to the fact that our mothers and babies die in
distressingly large numbers from infections, toxæmias, and nutritional
disturbances, all of which are usually amenable to preventive or early
treatment.

In order to be always clean, always watchful, and always ready to
execute, both in letter and spirit, the orders of doctors whose methods
of treatment will differ, the nurse will need to be very adaptable. She
will need to keep a clear head and an open mind and to remember always
the ends that are being striven for: the immediate safety and the future
wellbeing of the mother and the baby. And she may rest assured that, no
matter how they vary as to details, all doctors want all of their
patients to be given clean care; watched for symptoms of complications;
and given good general nursing.

Considering the need for cleanliness in a very broad and practical
sense, the nurse will realize that the test of her ability to protect
her maternity patients from infection is not what she is able to do in a
hospital where there is every facility for clean work. It is not the
ability to maintain asepsis in a tiled operating room that counts, where
she is aided by sterilizers, basins, and solutions of various kinds and
colors, a wealth of ingenious appliances and a corps of co-workers. It
is the understanding and imagination which will enable her, perhaps
single-handed, to carry the principles of such work into a patient’s
home; to do clean work, from the standpoint of avoiding infection, in a
mountain hut or a city tenement where everything is dirty.

The nurse will do well to begin to develop her powers of adaptability
while she is still in training. She may greatly increase the value of
her hospital experience by trying always to understand the purpose of
the care which she is giving and trying at the same time to imagine how,
in an average home, she would accomplish the results of this or that
procedure which is made easy of execution in the hospital by special
equipment. She should never lose sight of the fact that she is not being
trained solely to conform to any one hospital routine or to become
expert in only one method of nursing care. She is being prepared to go
out and give nursing care to any young woman and her baby who need it,
no matter where or how they are situated or by what methods they are
treated.

If conditions are such that the doctor’s orders and the patient’s
requirements seem impossible of fulfillment, then the nurse must attempt
the impossible and attempt it with confidence of success.

It is clear that the nurse must cultivate adaptability and
resourcefulness if she is to give good care to all her patients under
all conditions. But even the most efficient and intelligent work will
not be wholly satisfactory unless it is infused with a spirit of
sympathy for the woman as an individual.

The thing that counts in this connection is what the nurse, herself,
means to the woman who is facing a very important and mysterious event,
who, after every known aid has been given, must still go through a great
deal alone, both mentally and physically. It is not helpful to a woman
in such a situation to be told that women have borne children since the
dawn of Creation and that they all have had pain; that she will have to
go through with it, as they have, and that the less fuss she makes about
it the better. But it does help her to have the nurse say that she has
been with so many women in labor that she knows they suffer intensely,
and because she knows it so well she wants to do all that lies in her
power to give even a little relief. The nurse may never know just how
she has helped and reassured; how a pain was made a little easier to
bear, not only by the hand slipped under an aching back, but also by the
sympathy that the act conveyed. But she may be sure that she has helped.

In such a connection, the nurse must guard against the mistake of
dividing her patients into well defined groups: those who are poor and
those who are more favored. If she unfailingly looks for the human being
beyond the patient she will find some of the most sensitive and
appreciative of women among the simplest and poorest and they will be
warmly responsive to a thoughtful, considerate attitude. And at the same
time, the patient in comfortable circumstances who seems to be
surrounded by all that one could desire, is often pathetically lonely
and isolated. She, too, will be appreciative of encouragement and an
attitude of concern for her comfort.

Suffering and anxiety make no class distinctions and have a very
leveling effect, for prince and pauper, alike, need sympathy when
afflicted.

From the standpoint of the nurse herself, there might be discouragement
in this description of what is expected of her, and what are her
opportunities in this work of caring for mothers and babies, if she did
not go straight to the heart of the matter and see that all that is
needed, after all, is good nursing. She must realize, of course, that
good nursing necessitates training and a spirit of such eager service
that she will do for her patient all that lies in her perhaps limited
power, and then try to learn of still more that she may offer. And she
may rest assured that the value of her work will be quite as dependent
upon such a spirit as upon her training.

Obstetrical nursing may be defined, with accuracy, as the nursing care
of an obstetrical patient, but its true significance is limited only by
the nurse’s ability, resourcefulness, and vision. And the more
spirituality which pervades this work the more effective will be the
nurse’s skilled ministrations and the more satisfying will it all be to
her.

This aspect of maternity nursing—what it means to the nurse
herself—should be given full recognition, for although the demands which
are made upon her are exacting, she will find more than compensating
interest and gratification in her work.

It provides a channel of expression for some of her most elemental and
deeply rooted impulses. The desire to create exists within most of us,
and surely the nurse tastes of the joys of creation when she watches the
beautiful baby body grow and develop under her care. And she has a
consciousness of patriotic service, too, for while helping to secure the
immediate safety and future health of the baby citizen she is helping to
build a strong race.

But this work goes still further and offers even more than these.

The average nurse has a deep maternal instinct. She may not be conscious
of it as such, but it is this instinct which prompts her to select
nursing from the wide range of occupations and professions which are
open to her. And it is entirely natural that she should derive great
satisfaction from this vicarious motherhood—this giving of her knowledge
and skill in service to the woman with a baby in her arms.

The opportunities for self-expression which are open to the nurse who
gives this form of service make us wonder if she should not be included
in the enviable group of those others whose life work is an expression
of themselves—the poets and painters; the architects, musicians, and
sculptors—those who create and build because of an urge within them.
Surely, the spirit and the results of the work of the nurse who thus
gives of herself may be ranged with the efforts of those others whose
work is an expression of themselves.


  “The body is the crowning marvel in the world of miracles in which
  we live. Fearfully and wonderfully made, it claims our respect not
  only because God fashioned it, but because He fashioned it so
  well—because it is a thing of beauty, a perfection of mechanism.”

             _The Splendor of the Human Body_—BISHOP BRENT.



                                 PART I

                         ANATOMY AND PHYSIOLOGY

  CHAPTER I. ANATOMY OF THE FEMALE PELVIS AND GENERATIVE ORGANS. Normal
    Female Pelvis. Pelvimetry. Female Organs of Reproduction. Internal
    Genitalia. Uterus. Fallopian Tubes. Ovaries. Vagina. Bladder.
    Rectum. External Genitalia. Mons Veneris. Labia Majora. Labia
    Minora. Vestibule. Vaginal Opening. Fossa Navicularis. Bartholin
    Glands. Perineum. Breasts.

  CHAPTER II. PHYSIOLOGY. Puberty. Ovulation. Menstruation.
    Modifications of Menstruation. Menopause.



                               CHAPTER I
           ANATOMY OF THE FEMALE PELVIS AND GENERATIVE ORGANS


                          NORMAL FEMALE PELVIS

The present broad knowledge of the anatomy of the female pelvis has
resulted in an enormous reduction in death and injury among obstetrical
patients and their babies.

This knowledge of the pelvic anatomy, relating as it does, to both
normal and malformed pelves, has made possible a system of taking
measurements, termed _pelvimetry_, which gives the obstetrician a fair
idea of the size and shape of his patient’s pelvis. Such information,
coupled with observations upon the size of the child’s head, gives a
foundation upon which to base some expectation of the ease or difficulty
with which the approaching delivery is likely to be accomplished.

Since each patient’s pelvic measurements are considered from the
standpoint of their comparison with normal dimensions, it is manifestly
important that the obstetrical nurse have a clear idea of the structure
of the normal female pelvis, and also of its commonest variations.

Viewed in its entirety, the pelvis is an irregularly constructed,
two-storied, bony cavity, or canal, situated below and supporting the
movable parts of the spinal column, and resting upon the femora or thigh
bones. (Fig. 1, A. and B.).

Four bones enter into the construction of the pelvis: the two hip bones
or _ossa innominata_, on the sides and in front with the _sacrum_ and
_coccyx_ behind.

=The innominate bones= (ossa innominata), symmetrically placed on each
side, are broad, flaring and scoop-shaped. Each bone consists of three
main parts, which are separate bones in early life, but firmly welded
together in adults: the _ilium_, _ischium_ and _pubis_. The ilia are the
broad, thin, plate-like sections above, their upper, anterior
prominences, which may be felt as the hips, are the _anterior superior
spinous processes_ used in making pelvic measurements. The margins
extending backward from these points are termed the _iliac crests_.

The ischii are below and it is upon their projections, known as the
_tuberosities_, that the body rests when in the sitting position, and
which also serve as landmarks in pelvimetry. The pubes form the front of
the pelvic wall, the anterior rami uniting in the median line by means
of heavy cartilage and forming the _symphysis pubis_.

=The sacrum and coccyx= behind are really the termination of the spinal
column, the sacrum consisting, usually, of five rudimentary vertebrae
which have fused into one bone. It sometimes consists of four bones,
sometimes six, but more often of five. The sacrum completes the pelvic
girdle behind by uniting on each side with the ossa innominata by means
of strong cartilages, thus forming the _sacro-iliac joints_. The spinal
column rests upon the upper surface of the sacrum. The coccyx, a little
wedge-shaped, tail-like appendage, which ordinarily has but slight
obstetrical importance, extends in a downward curve from the lower
margin of the sacrum, to which it has a cartilaginous attachment, the
_sacro-coccygeal joint_. This joint between the sacrum and coccyx is
much more movable in the female than in the male pelvis.

We find, therefore, that although the pelvis constitutes a rigid, bony,
ringlike structure, there are four joints: the symphysis pubis, the
sacro-coccygeal, and the two sacro-iliac articulations. As the
cartilages in these joints become somewhat softened and thickened during
pregnancy, because of the increased blood supply, they all permit of a
certain, though limited amount of motion at the time of labor. This
provision is of considerable obstetrical importance, since the
sacro-coccygeal joint allows the child’s head to push back the
forward-protruding coccyx, as it passes down the birth canal, thus
removing what otherwise might be a serious obstruction. And when, as is
sometimes necessary, because of a constricted inlet, the pubic bone is
cut through (the operation known as pubiotomy), the hingelike motion of
the sacro-iliac joint permits of an appreciable spreading of the two hip
bones and a consequent widening of the birth canal.

[Illustration:

  A. Normal female Pelvis.
]

[Illustration:

  B. Normal male Pelvis.

  FIG. 1.—Normal Pelves. Note the broad, shallow, light construction of
    the female pelvis, A, as compared with the more massive male pelvis,
    B.
]

=The pelvic cavity= as a whole is divided into the _true_ and _false
pelves_ by a constriction of the entire structure known as the _brim_ or
_inlet_. The inlet is not round, its antero-posterior diameter being
shortened by the _sacro-vertebral joint_ which protrudes forward and
gives the opening something of a blunt, heart-shaped outline. (Fig. 2.)

[Illustration:

  FIG. 2.—Diagram of the pelvic inlet, seen from above, with most
    important diameters.
]

As the pelvis occupies an oblique position in the body, the plane of
this brim is not horizontal, but slopes up and back from the
symphysis-pubis to the promontory of the sacrum. Being swung upon the
heads of the femora, the relation of the pelvis to the entire body
differs in the sitting and standing positions. When a woman stands
upright, her pelvis is so markedly oblique in its position that she
would tip backward but for strong tendons attached to the pelvis and
running down the front of the thighs. Added strain upon these tendons
during pregnancy may account for some of the apparently undue fatigue
experienced by the expectant mother.

The shallow, expanded portion of the pelvis above the brim is the large,
or false pelvis, its walls being formed by the sacrum behind, the
fan-like flares of the ilia on each side, with the incompleteness of the
bony wall in front made up by abdominal muscles.

=The false pelvis= ordinarily serves simply as a support for the
abdominal viscera, which do not occupy the true pelvis unless forced
down by some such pressure as that caused by tight, or poorly fitting
corsets. The false pelvis is of little obstetrical importance, its
function during pregnancy being to support the enlarged uterus, while at
the time of labor it acts as a funnel to direct the child’s body into
the true pelvis below.

[Illustration:

  FIG. 3.—Diagram of pelvic outlet, seen from below, with most important
    diameters.
]

=The true pelvis=, on the other hand, is of greatest possible
obstetrical importance since the child must pass through its narrow
passage during birth. It lies below and somewhat behind the inlet; is an
irregularly shaped, bottomless basin, and contains the generative
organs, rectum and bladder. Its bony walls are more complete than those
of the false pelvis, and are formed by the sacrum, coccyx and innominate
bones. Its lower margin constitutes the _outlet_, or _inferior strait_,
and being longer in its antero-posterior dimension than in its
transverse measurement, its long axis is at right angles to the long
axis of the inlet. (Fig. 3.) A baby’s head, accordingly, must twist or
rotate in making its descent through this bony canal, for the long
diameter of the head must first conform to one of the long diameters of
the inlet, either transverse or oblique, and then turn so that the
length of the head is lying antero-posteriorly, in conformity to the
long diameter of the outlet, through which it next passes.

The posterior wall of the pelvis, consisting of the sacrum and coccyx,
forms a vertical curve and is about three times as deep as the anterior
wall formed by the narrow symphysis pubis. The structure as a whole,
therefore, curves upon itself, resembling a bent tube with its concavity
directed forward. (Fig. 4.)

[Illustration:

  FIG. 4.—Diagram of sagittal section of the pelvis showing curve of the
    bony canal, with most important diameters.
]

Thus it becomes apparent that the structure of the pelvis requires the
child’s head, not only to rotate in its passage through the birth canal,
but also to describe an arc, since the part of the head which passes
down the posterior wall travels farther in a given time than the part
which passes under the pubis.

This twisting and curving of the birth canal must be appreciated in
order to understand the mechanism of labor.

In considering the question of pelvimetry, we find that there are both
external and internal measurements to be taken, all for the purpose of
estimating as accurately as possible the shortest diameter of the inlet
through which the baby must pass. (Fig. 5.)

According to a common system of mensuration, the first external
measurement is the _inter-spinous_, the distance between the
anterior-superior spines, those bony points which are uppermost as the
patient lies on her back. This distance is normally 26 centimetres.
(Fig. 6.)

[Illustration:

  FIG. 5.—Two types of pelvimeters frequently used in taking
    measurements of the pelvic inlet and outlet.
]

The second measurement is the _inter-crestal_, or the distance between
the iliac crests, and is normally 28 centimetres.

_Baudelocque’s diameter_ is the third measurement and is taken with the
patient lying on her side. (Fig. 7.) It is the distance from the top of
the symphysis to a depression just below the last lumbar vertebra. This
depression is easily located as it also marks the upper angle of a space
just above the buttocks, which in normal pelves is quadrilateral. In
malformed pelves this quadrangle may be so misshapen as to become almost
a triangle with the apex directed either up or down. This dimension is
sometimes called the _external conjugate_ and ordinarily measures 21
centimetres.

The fourth measurement is the distance between the _great trochanters_,
or heads of the femora, and normally is 32 centimetres.

All of these measurements, which after all are only approximate, relate
to the top of the pelvis and are valuable in that they help in
estimating the dimensions of the inlet, which are the important ones,
and obviously cannot be measured on a live woman.

[Illustration:

  FIG. 6.—Diagram showing method of measuring distances between iliac
    crests and spines and the trochanters.
]

The inlet has four measurements of obstetrical importance: the
_antero-posterior_, or _true conjugate_, which is the distance from the
top of the symphysis pubis to the prominence of the sacrum, and is
normally 11 centimetres; the _transverse diameter_, which is at right
angles to the true conjugate and is the greatest width of the inlet,
measuring from a point on one side of the brim to the corresponding
point on the other, is normally 13.5 centimetres, and the two diagonal
measurements, known respectively as the _right_ and _left oblique
diameters_, which are normally 12.75 centimetres.

Although it is very important to the expectant mother that all of these
dimensions be of normal length, the length of the true conjugate, or
_conjugata vera_, is of the gravest importance of all because it is the
shortest diameter through which the child’s head must pass. If it is
shorter than normal, the channel may be too constricted for the
full-term baby’s head to pass through comfortably, thus making a
spontaneous delivery extremely difficult, or even impossible.

[Illustration:

  FIG. 7.—Diagram showing method of measuring Baudelocque’s diameter.
]

The length of the all important, true conjugate is estimated by
introducing the first two fingers of one hand into the vagina until the
tip of the second finger touches the promontory of the sacrum. (Fig. 8.)
The point at which the inner margin of the symphysis then rests upon the
forefinger is measured, thus giving the length of the _diagonal
conjugate_. This normally measures 12.5 centimetres or more, and is
estimated as being 1.5 centimetres longer than the true conjugate.

The most important measurement of the outlet is the _intertuberous
diameter_, the distance between the tuberosities of the ischii. This is
the shortest diameter through which the child must pass in the inferior
strait, and normally measures something more than 8 centimetres, usually
about 11 centimetres. (Fig. 9.)

It is possible, by studying such measurements as these, made upon an
expectant mother, and comparing them with dimensions which have been
accepted as normal, to form a reasonably accurate estimate of the size
and shape of her pelvis.

[Illustration:

  FIG. 8.—Diagram showing method of estimating the true conjugate by
    measuring the length of the diagonal conjugate.
]

A delivery may be, and frequently is, accomplished through a pelvis
which is not entirely normal in size or shape. But the obstetrician of
to-day is closely observant of the patient whose pelvic measurements
depart from the normal by more than the accepted margin of safety, and
he plans for labor in accordance with the indications in each case.

Disproportion between the measurements of the mother’s pelvis and the
size of the child’s head must be considered in this connection. A small
pelvis may permit of the spontaneous delivery of a small child, but be
too narrow for the passage of a full-sized baby, while a woman with a
normal pelvis may have an extremely difficult labor because of an
unusually large child.

The size and shape of the pelvis is found to vary among different races
and in different individuals. And the size and contour of the inlet may
be so altered by rickets, lack of proper exercise during early life, or
by growths upon the pelvic bones, as to seriously interfere with normal
labor.

[Illustration:

  FIG. 9.—Diagram showing method of measuring the inter-tuberous
    diameter.
]

The various kinds of malformed pelves may be loosely classified as
generally contracted or small; flat; simple funnel; generally contracted
funnel; and the rachitic pelves, both flat and generally contracted.
There may be a contracted inlet, or a contracted outlet, or both may
occur in the same pelvis.[1]

Rachitic pelves are common among negroes and not altogether rare among
white women.

The normal _male pelvis_ is deep, narrow, rough and massive as compared
with the female structure (see Fig. 1.), and the angle of the pubic
arch, formed by the two pubic bones, is deeper and more acute in the
male than in the female skeleton.

The normal female pelvis, on the other hand, is light, broad, shallow,
smooth and large, giving evidence of the infinite wisdom and skill that
entered into constructing it for the high purpose it was designed to
serve.


                     FEMALE ORGANS OF REPRODUCTION

The female organs of reproduction are divided into two groups, the
_internal_ and the _external genitals_. With them are usually considered
certain other structures: the _ureters_, _bladder_, _urethra_, _rectum_
and the _perineum_, because of their close proximity (Fig. 10.); and the
breasts, because of their functional relation to the reproductive
organs.

=Internal Genitalia=. The internal organs of generation are contained in
the true pelvic cavity and comprise the _uterus_ and _vagina_ in the
centre, an _ovary_ and _Fallopian tube_ on each side, together with
their various ligaments, membranes, nerves and blood vessels and a
certain amount of fat and connective tissue.

The =uterus= is the largest of these organs. In its nonpregnant state,
it is a hollow, flattened, pear-shaped organ about three inches long,
one and a quarter inches wide, at its broadest point, three-quarters of
an inch thick and weighing about two ounces.

[Illustration:

  FIG. 10.—Anterior view of female generative tract, showing both
    external and internal organs. Drawn by Max Brodel. (Used by
    permission of A. J. Nystrom & Co., Chicago.)
]

Ordinarily it is a firm, hard mass, consisting of irregularly disposed,
involuntary (unstriped or plain) muscle fibres and connective tissue,
nerves and blood vessels. The arrangement of the uterine muscle fibres
is unique, for they run up and down, around and crisscross, forming a
veritable network. This strange arrangement of the fibres is favorable
to the growth of the uterine musculature during pregnancy, and a factor
in preventing hemorrhage after delivery.

The abundant blood supply to the uterus merits a word. It is derived
from the uterine arteries, arising from the internal iliacs, and the
ovarian artery from the aorta. The arteries from the two sides of the
uterus are united by a branch where the neck and body of this organ
meet, thus forming an encircling artery. A deep cervical tear during
labor may break this vessel and a profuse hemorrhage occur as a result.

[Illustration:

  FIG. 11.—Diagrams of sections of virgin and multiparous uteri.
]

The uterus is covered, front and back, by a fold of the _peritoneum_,
except the lower part of the anterior wall where the peritoneum is
reflected up over the bladder. It is lined with a thick, velvety, highly
vascular mucous membrane, the _endometrium_, the surface of which is
covered by ciliated, columnar epithelium. Embedded in the endometrium
are numerous mucous glands which dip down into the underlying, muscular
wall.

The uterus as a whole is comprised of three parts: the _fundus_, that
firm, rounded, head-like part above; the _body_, or middle portion, and
the _cervix_, or neck, below. It is in the body and cervix that we find
the long, narrow uterine cavity, divided by a constriction into two
parts. The cavity of the body is little more than a vertical slit, being
so flattened from before backward that the anterior and posterior
surfaces are nearly if not quite in apposition. It is somewhat
triangular in shape with an opening at each angle. (Fig. 11.) The lower
of these openings leads into the cavity of the cervix through a
constriction termed the _internal os_, while at the _cornua_, or two
upper angles, are the openings into the Fallopian tubes.

The cavity of the cervix is spindle-shaped, being expanded between its
two constricted openings, the internal os above and the _external os_
below, which opens into the _vagina_. The external os in the virgin is a
small round hole but has a ragged outline in women who have borne
children.

This oblong, muscular body, the uterus, is suspended obliquely in the
centre of the pelvic cavity by means of ligaments. In its normal
position the entire organ is slightly curved forward, or ante-flexed,
the fundus being directed upward and forward and the cervix pointing
down and back. This position is affected by a distended bladder or
rectum, and also by postural changes in the body as a whole. The
_cervix_ protrudes into the anterior wall of the vagina for about
one-half inch and almost at right angles, since the vagina slopes down
and forward to the outlet.

The upper part of the uterus is held in position by means of ligaments,
the lower part being embedded in fat and connective tissue between the
bladder and rectum. This more or less of a floating position makes
possible the enormous increase in size and upward push or extension of
the uterus during pregnancy. The pregnant uterus becomes soft and
elastic as it grows. At term it is about a foot long, eight to ten
inches wide, and reaches up into the epigastric region. This growth is
due in part to the development of new muscle fibres and in part to a
growth of the fibres already existing in the uterine wall.

After labor the uterus returns almost, but never entirely, to its former
size, shape and general condition.

=The Fallopian tubes= are two tortuous, muscular tubes, four or five
inches long, extending laterally in an upward curve, from the cornua of
the uterus and within the folds of the upper margin of the _broad
ligament_, by which they are covered. At their juncture with the uterus,
the diameter of these tubes is so small as to admit of the introduction
of only a fine bristle, but they gradually increase in size toward their
termination in wide trumpet-shaped orifices, which open directly into
the peritoneal cavity. Finger-like projections called _fimbriæ_, fringe
the margins of these openings.

The mucous lining of the tubes is covered with ciliated epithelium and
is continuous with that of the uterus. At the fimbriated extremities of
the tubes this lining merges into the peritoneum, the serous lining of
the abdominal cavity.

Just here it will be well to say a word about the peritoneum because of
the possibility of its becoming infected during labor and the lying-in
period, and the very grave consequences of such infection. It is a
delicate, highly vascular, serous membrane which both lines the
abdominal cavity and covers the abdominal and pelvic organs, which press
into its outer surface and are covered much as one’s fingers would be
covered by pushing them into the outer surface of a child’s toy balloon.
The continuity of this membrane is broken only where it is entered by
the Fallopian tubes.

=The ovary=, the sex gland of the female, is a small, tough ductless
gland, about an inch long and three-quarters of an inch wide, or about
the size and shape of an almond. It is greyish pink in color and
presents a more or less irregular, dimpled surface. An ovary is
suspended on either side of the uterus, in the posterior fold of the
broad ligament, by which it is partly covered. Its outer end is usually
attached to the longest of the fimbriated extremities of the Fallopian
tube, the _fimbria ovarica_, which has the form of a shallow gutter, or
groove. The inner end of the ovary is attached to the _ovarian
ligament_, which in turn is attached to the uterus below and behind the
tubal entrance.

The ovary consists of two parts, the central part or _medulla_, composed
of connective tissue, nerves, blood and lymph vessels, and the _cortex_,
in which are embedded the vesicular _Graafian follicles_ containing the
ova. At birth each ovary contains upwards of 50,000 of these ova, which
are the germ cells concerned with reproduction and the process of
menstruation.

These ovarian glands perform two vital functions, for in addition to
their prime function of producing and maturing the germinal cell of the
female, they provide an internal secretion which exercises an
immeasurably important, though imperfectly understood, influence upon
the general well-being of the entire organism.

[Illustration:

  FIG. 12.—Sagittal section of female generative tract. Drawn by Max
    Brodel. (Used by permission of A. J. Nystrom & Co., Chicago.)
]

=The vagina= is an elastic, muscular sheath or tube, about four inches
long, lying behind the bladder and urethra and in front of the rectum.
It leads interiorly up and backward from the vulva to the cervix, which
it encases for about half an inch. The space between the outer surface
of the cervix that extends into the vagina, and the surrounding vaginal
walls, is called the _fornix_. For convenience of description, this is
divided into four sections or fornices: the anterior, posterior and
lateral fornices.

Between the posterior fornix and the rectum a fold of the peritoneum
drops down and forms a blind pouch known as _Douglas’ cul-de-sac_. At
this point the delicate peritoneum is separated from the vagina by only
a thin, easily punctured, muscular wall. This is a fact of grave
surgical significance, for unless instruments and nozzles introduced
into the vagina are very gently and skillfully directed, they may easily
pierce this thin partition. Septic material may thus gain entrance to
the peritoneal cavity and peritonitis result.

The bore of the vaginal canal ordinarily permits of the introduction of
one or two fingers. It is somewhat flattened from before backward, and
on cross section resembles the letter H. During labor this canal becomes
enormously dilated, being then four or five inches in diameter, and
permits the passage of the full term child.

The vagina is lined with a thick, heavy, mucous membrane which normally
lies in transverse folds or corrugations called _rugæ_. These folds are
obliterated and the lining stretched into a smooth surface as the canal
dilates during labor.

Attention must be drawn to the fact that the vagina, cervix, uterus and
tubes form a continuous canal from the vulva to the easily infected
peritoneum, a fact which makes absolute surgical cleanliness in
obstetrics virtually a matter of life or death to the patient.

This muscular tube is lined throughout its entire length with mucous
membrane, which, though continuous, changes somewhat in character along
its course. The epithelial cells of the lining of the tubes and body of
the uterus have hair-like projections, cilia, which maintain a constant
waving motion from above downward. The effect of this sweeping current
is to carry down toward the outlet any object or secretion which may be
upon the surface of the lining of the tubes or uterine cavity. The
unfertilized ovum is thus swept down to meet the germ cell of the male
and become fertilized.

Along this variously constructed canal, at different periods in the life
of the individual, pass the matured ovum, the menstrual flow, the
uterine secretions, the fetus, the placenta and lochia, (the discharge
which occurs during the puerperium).

Although the bladder and rectum are not organs of reproduction, they are
contained in the pelvic cavity and lie in such close proximity to the
internal genitalia that at least a passing word must be devoted to their
description.

=The bladder= is a sac of connective tissue which serves as a reservoir
for the urine and is situated behind the symphysis pubis and in front of
the uterus and vagina. Urine is conducted into the bladder by the
_ureters_, two slender tubes running down on each side from the basin of
the kidney across the pelvic brim to the upper part of the bladder,
which they enter somewhat obliquely, at about the level of the cervix.
It is thought that pressure of the enlarged pregnant uterus upon the
ureters at this point may be one factor in the causation of pyelitis, a
frequent complication of pregnancy. The bladder empties itself through
the _urethra_, a short tube which terminates in the _meatus urinarius_,
a tiny opening in the vulva.

=The rectum=, the lowest segment of the intestinal tract, is situated in
the pelvic cavity behind and to the left of the uterus and vagina. It
extends downward from the sigmoid flexure of the colon to its
termination in the anal opening. The _anus_ is a deeply pigmented,
puckered opening situated an inch and a half or two inches behind the
vagina. It is guarded by two bands of strong circular muscles, the
_internal_ and _external sphincter ani_. The skin covering the surface
of the body extends upward into the anus where it becomes highly
vascular and merges into the mucous lining of the rectum. Pressure
exerted during pregnancy by the enlarged uterus is felt in both the
rectum and bladder, frequently causing a good deal of discomfort and
almost painful desire to evacuate their contents.

The blood vessels in the anal lining just within the external sphincter
sometimes become engorged and inflamed, even bleeding during pregnancy,
as a result of the pressure exerted by the greatly enlarged uterus. The
distended blood vessels, which in this condition are called hemorrhoids,
not infrequently protrude from the anus and become very painful.

After having considered the structure and relative positions of the
pelvic organs one is able to picture more clearly the arrangement and
disposition of the _uterine ligaments_, all of which are formed by folds
of the peritoneum. They are twelve in number, five pairs and two single
ligaments, namely: two _broad_, two _round_, two _utero-sacral_, two
_utero-vesical_, two _ovarian_, one _anterior_ and one _posterior_
ligament.

=The broad ligaments= are in reality one continuous structure formed by
a fold of the peritoneum, which drops down over the uterus, investing
the fundus, body, part of the cervix, and part of the posterior wall of
the vagina. It unites on each side of the uterus to form a broad, flat
membrane which extends laterally to the pelvic wall, dividing the pelvic
basin into an anterior and posterior compartment, containing
respectively the bladder and rectum. Between the folds of the broad
ligament are situated the ovaries and ovarian ligaments, the Fallopian
tubes, the round ligaments and a certain amount of muscle and connective
tissue, blood vessels, lymphatics and nerves.

=The round ligaments=, one on each side, are narrow, flat bands of
connective tissue derived from the peritoneum and muscle prolonged from
the uterus, and containing blood and lymph vessels and nerves. They pass
upward and forward from their uterine origin just below and in front of
the tubal entrance, finally merging in the mons veneris and labia
majora.

=The utero-sacral ligaments=, of which there is one on each side, arise
in the uterus and, extending backward, serve to connect the cervix and
vagina with the sacrum.

=The utero-vesical ligaments=, one on each side, extend forward and
connect the uterus and bladder.

=The ovarian ligaments=, as previously described, are attached to the
uterine wall and to the inner end of the ovary, one on each side.

=The anterior ligament= is a portion of the peritoneum which dips down
between the bladder and uterus, forming a pouch. It is known also as the
uterine-vesical pouch, or the vesico-uterine excavation.

=The posterior ligament= is formed in much the same manner by a portion
of the peritoneum dipping down behind the uterus, in front of the
rectum, and forming the recto-vaginal pouch. This is the Douglas’
cul-de-sac previously referred to.

=External Genitalia.—The vulva=, or external genitalia, are situated in
the _pudendal crease_ which lies between the thighs at their junction
with the torso, and extends posteriorly from the pubis to a point well
up on the sacrum. (Fig. 13.)

=The mons veneris= is a firm cushion of fat and connective tissue, just
over the symphysis pubis. It is covered with skin which contains many
sebaceous glands and after puberty is abundantly covered with hair.

[Illustration:

  FIG. 13.—Diagram of external female genitalia. (Redrawn from
    Dickinson.)
]

=The labia majora= are heavy ridges of fat and connective tissue,
prolonged from the mons veneris and extended down and back almost to the
rectum, on each side, forming the lateral boundaries of the groove. They
are lined with mucous membrane and covered with skin and hair, the
latter growing thinner toward the perineum until it finally disappears.

=The labia minora= are two small cutaneous folds lying between the labia
majora on each side of the vagina. Like the larger folds, they taper
toward the back and practically disappear in the vaginal wall. Their
attenuated posterior ends are joined together behind the vagina by means
of a thin, flat fold called the _fourchette_. The labia minora divide
for a short distance before joining at an angle in front, thus forming a
double ridge anteriorly. In the depression between these ridges is the
_clitoris_, a small, sensitive projection composed of erectile tissue,
nerves and blood vessels and covered with mucous membrane. The meatus
urinarius is just below the clitoris and between two small folds of the
mucous membrane.

=The vestibule= is the triangular space between the labia minora, and
into it open the meatus urinarius, the vagina and the more important
vulvo-vaginal glands.

=The vaginal opening= is below the vestibule and above the perineum. It
is partially closed by the hymen, a fold of mucous membrane disposed
irregularly around the outlet, somewhat after the fashion of a circular
curtain. The hymen is ragged or more or less scalloped in outline, and
varies greatly in size in different women, in some instances extending
so far over the opening as nearly or quite to close it.

=The fossa navicularis= is a depressed space between the hymen and
fourchette, so named because of its boat-like shape.

=The Bartholin glands=, probably the largest and most important of the
vulvo-vaginal glands, are situated one on each side of the vagina and
open into the groove between the hymen and labia minora. Reference is
made to these glands because of the danger of their becoming infected. A
gonorrheal infection of these glands is particularly troublesome.

=The perineum= is a pyramidal structure of connective tissue and muscle
which occupies the space between the rectum and vagina, and by forming
the floor of the pelvis serves as a support for the pelvic organs. The
lower and outer surface of this mass, representing the base of the
pyramid, lies between the vaginal opening and the anus and is covered
with skin. As the anterior part of the perineum is incorporated in the
posterior wall of the vagina, the entire structure becomes stretched and
flattened when the vagina is dilated during labor by the passage of the
child’s head.

Unless very carefully guarded at the time of delivery, and often even
then, the perineum gives way under the great tension undergone at that
time, and a tear is the result. The injury may be only a slight nick in
the mucous membrane or it may extend to, or into the _levator ani_, the
most important muscle of the perineal body, or if a “complete tear” will
extend all the way through the perineum and completely through the
sphincter ani. Such a tear is lamentable, as a break in the ring-shaped
sphincter muscle guarding the anal opening robs a woman of control of
her bowels, and is repaired with difficulty.


                                BREASTS

=The breasts= are large, specially modified skin glands of the compound,
racemose or clustering type, embedded in fat and connective tissue and
abundantly supplied with nerves and blood vessels. They are situated
quite remotely from the pelvic organs, but because of the intimate
functional relation between the two, the breasts of the female may be
regarded as accessory glands of the generative system. They exist in the
male, also, but only in a rudimentary state.

Although the breasts sometimes contain milk during infancy, their true
function is to secrete, in the parturient woman, suitable nourishment
for the human infant during the first few months of its life.

These glands are symmetrically placed, one on each side of the chest,
and occupy the space between the second and sixth ribs extending from
the margin of the sternum almost to the mid-axillary line. A bed of
connective tissue separates them from the underlying muscles and the
ribs. (Fig. 14.)

They vary in size and shape at different ages, and with different
individuals, particularly in women who have borne and nursed children,
when they tend to become pendulous. But in general they are
hemispherical or conical in shape with the nipple protruding from
one-quarter to one-half inch from the apex. The nipples are largely
composed of sensitive, erectile tissue and become more rigid and
prominent during pregnancy and at the menstrual periods. Their surfaces
are pierced by the orifices of the milk ducts, which are fifteen or
twenty in number. (Fig. 15.)

[Illustration:

  FIG. 14.—Sagittal section of breast showing structure of secretory
    apparatus.
]

The breasts are covered with very delicate, smooth, white skin,
excepting for the _areolæ_, those circular, pigmented areas one to four
inches in diameter, which surround the nipples. The areolæ are darker in
brunettes than in blonds, and in all women grow darker during pregnancy.
The surface of the nipples and of the areolæ is roughened by small,
shot-like lumps or papillæ known as the _tubercles of Montgomery_. This
roughness becomes more marked during pregnancy, since the papillæ grow
larger and sometimes even contain milk.

[Illustration:

  FIG. 15.—Front view of breast showing areola, tubercles of Montgomery
    and orifices of milk ducts.
]

The secretory apparatus of the breasts is divided into fifteen or twenty
lobes, these in turn being divided into clusters of lobules. The lobules
in turn are composed of tiny, secreting cells, called _acini_, in which
the milk is elaborated from the blood. The acini are minute globules
lined by a single layer of cells and enveloped by a very delicate
membrane. Tiny ducts carry the milk from the acini to the main duct of
the lobule, around which the acini cluster. These ducts empty the milk
into the larger duct of the lobe, which runs straight to the nipple and
opens upon the surface. Just before reaching the surface, each of these
lactiferous sinuses expands into an _ampulla_, a minute reservoir for
collecting the milk, which is secreted during the periods between
nursings.

These clusters of acini uniting to form lobules with tiny ducts leading
into the main duct of each lobule, closely resemble a bunch of grapes.
The separate grapes correspond to the acini, their small stems
correspond to the tiny ducts of the glands which lead to a larger one,
and the central stem of the grape cluster, to the milk duct that opens
upon the nipple.

The secretory tissue really constitutes a small part of the breasts
until they begin to function. But during lactation the acini become
enormously developed and enlarged. After lactation ceases, the acini
assume a more or less tubal form, many of them undergoing atrophic
changes.



                               CHAPTER II
                               PHYSIOLOGY


=Puberty= is that period during which childhood develops into sexual
maturity, and the individual becomes capable of reproduction.

The age at which puberty occurs varies with climate, race, occupation
and with individuals of the same status. But the average age for girls,
in temperate climates, is from the twelfth to the sixteenth year; for
boys from the fourteenth to the seventeenth year. Girls in southern
climates sometimes mature as early as the eighth or ninth year, while in
colder regions puberty may be delayed until the eighteenth or twentieth
year.

At this time there are many physical and psychical manifestations of the
maturing changes in the internal female generative organs. The
undeveloped girl grows rapidly at this stage. Her entire body rounds out
and assumes a more graceful contour; her breasts increase in size; her
hips broaden; the external genitalia enlarge and hair appears over the
pubis and on other parts of the body.

As this physical maturity progresses, there is a dawning sex
consciousness and the developing girl becomes shy, modest, retiring and
introspective. She is very likely to be emotional and hysterical and to
display a lack of stability and nervous control, which are not in accord
with her usual temperament. A formerly dependable child may become
capricious, erratic, and perplexingly inconsistent. One day she may be
quite her normal, little-girl self and the next show inexplicably mature
qualities. Or she may display a bewildering number of moods and fancies
in the span of one short day.

Too much cannot be said of the importance of wise supervision and
guidance of the girl’s physical, mental and emotional life at this
critical, emotional period. Many gynecological, obstetrical and
neurological difficulties in her later life may be averted by her
observance of sane rules of personal hygiene.

Vigorous and regular out-of-door exercise; a simple, nourishing and
well-balanced diet; adequate sleep in a well-ventilated room; regular
bathing, and correction of any discoverable physical defects are the
essentials.

But of equal, if not greater, importance is an understanding and
sympathetic oversight of the girl’s mental and emotional life, a
steadying sort of comradeship.

Her extreme sensitiveness and impressionability should be recognized and
borne in mind, and every effort made to save her from strain and shock.
Her nervous forces should be sedulously conserved by protecting her
against experiences and diversions which would be unduly stimulating or
irritating. Nor should demands be made upon her uncertain nervous
endurance which she is able to meet only by great strain, if at all.

It is important to her future poise and health that her confidence be
courted, and when it is won, that all of her outpourings be received
with a respect and seriousness commensurate with their great importance
to her. Ridicule, and even unresponsiveness or indifference to her
interests, may, and often do, result in a hurtful repression of one form
or another. The logical consequence of such repression is an
increasingly damaging neurosis later on in her life, capable of greatly
impairing her health, happiness and usefulness.

In short, all phases of the life of the adolescent girl should be made
as wholesome, tranquil and free from stress and strain as is humanly
possible.

These comments upon the importance of mental hygiene at puberty may seem
irrelevant to a discussion of obstetrical nursing. But the preparation
of the entire female organism for its supreme function—that of
child-bearing—is of concern to the obstetrical nurse, and should be
understood by her. Moreover, every nurse is inevitably a health teacher,
either by precept or example, or both. An awareness on her part of the
maturing girl’s needs will fit her to help many perplexed mothers whom
she meets along the way to a happy solution of this grave and vexing
problem.

The occurrence of puberty marks the establishment of _ovulation_ and
_menstruation_. These two functions are usually performed once a month,
ovulation probably occurring about midway during the intermenstrual
period.

=Ovulation=, which is the prime function of the ovary, may be defined as
the formation and development of the ovum, and its expulsion, when
mature, from the ovary.

The formation of each woman’s full quota of ova is probably complete at
birth, though the process may continue until about the second year. At
this time it is variously estimated that each of the two ovaries
contains from 50,000 to 70,000 ova, but they remain unmatured until
puberty, the period at which ovulation is most active.

[Illustration:

  FIG. 16.—Diagram of human ovum.
]

As the entire complex human body has its origin in this tiny ovum, its
course of development is of momentous importance to us, and at the same
time it provides a tale of intense interest.

In its unmatured state, the ovum, termed a _primordial follicle_, or
_oöcyte_, is a single cell, 1/125 inch in diameter, consisting of clear
protoplasm, the _vitellus_, and a surrounding _vitelline membrane_
composed of small, spindle-shaped epithelial cells. The protoplasm
contains a fairly large _nucleus_, or _germinal vesicle_, within which
lies a _nucleolus_ known as the _germinal spot_. (Fig. 16.)

The primordial follicle probably lies dormant in this state until
puberty, when developmental changes take place, though it is the belief
of some authorities that follicles are in the process of development
from birth until the end of sexual life, though none fully mature until
puberty.

With the advent of puberty the cells composing the vitelline membrane
change in character and proliferate rapidly, with the result that the
ovum is surrounded by several layers of epithelial cells. Some of the
inner cells degenerate and liquify, thus surrounding the ovum with fluid
which is contained in a membrane of vascular connective tissue, the
_theca folliculi_; this in turn is lined with epithelial cells, the
_membrana granulosa_. This structure constitutes a _Graafian follicle_,
named for Dr. de Graaf who first described it, and in the course of its
maturation is pushed toward the surface of the ovary, where it presents
more or less the appearance of a clear blister.

At one point in the enveloping membrana granulosa, the cells proliferate
into a mass in which the floating ovum becomes embedded. This mass is
termed the _discus proligerus_ and the fluid which surrounds it is the
_liquor folliculi_.

Usually for some strange reason, one, and only one, ovum ripens
regularly each month during the years from puberty to the menopause,
excepting during pregnancy, when this function is suspended.
Occasionally, however, several ova mature at once, a condition which may
be one factor in the development of twins. After puberty the ovary
contains ova in all stages of development, from the primordial follicle
to the Graafian follicle just described.

When a Graafian follicle containing a matured ovum reaches the ovarian
surface, its membrane becomes thinner and finally ruptures because of
increased tension in the ovary, due to certain circulatory changes. The
ovum surrounded by the discus proligerus is thus discharged into the
peritoneal cavity near the fimbriated end of the tube. Some ova enter
the tube and others float about in the peritoneal cavity, finally
disintegrate and are lost.

The torn envelope of the follicle which remains in the cortex of the
ovary becomes filled with blood, which forms into a clot. This clot is
first surrounded, and then invaded, by cells containing bright yellow
pigment called _lutein_. The membrane formed from these cells compresses
the clot and brings about other changes which speedily transform it into
the _corpus luteum_.

If the discharged ovum becomes fertilized, the corpus luteum remains
practically unchanged for months and is termed the _corpus verum_ or
corpus luteum of pregnancy. Its secretion is believed to influence the
implantation of the ovum and to promote the woman’s general well-being
during the period of gestation. It continues to exist throughout
pregnancy, and until after delivery, when it is soon absorbed and
replaced by normal ovarian tissue, without the formation of scar tissue.

If fertilization does not occur, the body in the ovarian cortex, which
is then termed the corpus luteum of menstruation, or _false corpus_,
undergoes rapid degenerative changes and is almost wholly absorbed
within a few weeks.

By means of this rather complicated procedure the ovary is saved from
becoming a steadily enlarging mass of scar tissue, and consequently
devoid of reproductive powers, which would be the case if the wound made
by the rupturing of each Graafian follicle were to heal by the usual
formation of cicatricial tissue.

Ordinarily the ovum remains unfertilized and is propelled down the
Fallopian tube, by the cilia in its lining, to the uterine cavity, where
it is lost in the uterine secretions and ultimately carried out in the
menstrual flow.

Each time that an ovum matures, however, and is discharged from the
ovary the lining of the uterine cavity increases in vascularity and
becomes thicker and more velvety; a condition which facilitates an
attachment of the ovum in case of fertilization. This preparation of the
endometrium is termed “pre-menstrual swelling,” or in popular language,
nest-building.

Of the enormous number of ova existing in each woman, relatively few
mature and it is apparent that still fewer are fertilized, since each
impregnation results in an abortion, a premature labor or a full term
child.

Nature’s lavish provision of something more than 100,000 ova for each
woman, who uses only about 500 in the course of her life, excites no
little wonder. But whatever the purpose of this enormous supply, its
existence makes possible the removal of all but a small fragment of
ovarian tissue in cases of disease, without interference with the
process of ovulation, which in turn permits reproduction.

=Menstruation=, which is the evidence of sexual maturity, is a monthly
hemorrhage from the uterus which escapes through the vagina, normally
recurring throughout the entire child-bearing period, except during
pregnancy and lactation. The duration of this child-bearing period, or
sexual activity, is about thirty years and continues from puberty to the
menopause.

The frequency of the menstrual periods varies in different women from
twenty-one to thirty days, but the normal interval between periods is
twenty-eight days, which corresponds in point of time to the menstrual
cycle. Thus it is usually four weeks, or a lunar month, from the
beginning of one period to the beginning of the period following, making
thirteen menstrual periods during each calendar year.

Just why menstruation occurs about every twenty-eight days is not known,
but the belief is that, although menstruation is in some way dependent
upon ovulation, its periodicity is regulated by the corpus luteum. It is
also believed that the corpus luteum of pregnancy holds menstruation in
check during the nine months of gestation.

The menstrual cycle is divided into four stages, and though there is not
entire unanimity of opinion concerning the changes which take place
during these four stages, the preponderance of evidence is in favor of
the following processes.

=The first or constructive stage= lasts about seven days. It is during
this stage that the preparative changes, which have been described, are
made for the reception of the matured ovum. The uterus becomes engorged
with blood and is somewhat enlarged and softened as a result. The
endometrium grows deep red, thick and velvety, partly because of the
greatly augmented blood supply, and partly because of an actual increase
of connective tissue in its structure. There is also an increase in the
size and activity of the uterine glands and in the amount of their
secretions. If the ovum remains unfertilized, which is usually the case,
it does not attach itself to this elaborately prepared lining, but
passes out with the uterine discharges, and all of this preparation and
increased vascularity not only go for naught, but must be undone.

=The second stage=, therefore, which lasts about five days, is the
destructive stage, during which the newly developed tissues are broken
down and the menstrual discharge occurs. During this period the greatly
increased secretions of the uterine glands mix with the blood that oozes
from the engorged endometrium and with the disintegrated uterine
tissues, and pour from the vagina as the menstrual flow.

=The third, or reparative stage=, which follows, occupies about three
days. During this stage the destroyed uterine tissues are regenerated by
new growth from the deeper, uninjured tissues, and the entire organ
returns to its normal state.

=The fourth, or quiescent stage=, now follows, the damage having been
repaired, and lasts twelve or fourteen days. This is the time remaining
before Nature with unwearying patience begins all over again to prepare
for the reception and attachment of the next matured ovum, in case of
its possible fertilization.

It will be seen that the duration of the menstrual period, which is
coincident with the destructive stage of the menstrual cycle, is about
five days, but it is entirely within normal bounds if it varies in
length from two to seven days.

The discharge is usually scant at the beginning of the period,
increasing in amount until about the third day, after which it
diminishes steadily until its cessation. The normal odor of this
discharge, consisting as it does of blood and uterine secretions, has
been likened to that of marigolds.

The average amount of blood lost is from six to ten ounces, but it
varies greatly among women who are otherwise normal and in good health.
Some women regularly lose what seems to be an alarming quantity of blood
at each period without suffering any apparent ill effect. Others lose so
little that they are scarcely aware of their menses.

As a rule the menstrual flow is more profuse among women in warm
climates than in cold regions. English women, for example, frequently
menstruate profusely while in India, and upon their return to England
note a marked decrease in the amount of the discharge. The same is often
true of American women who move from Southern to Northern states, while
removal from a low to a high altitude usually results in a more profuse
flow.

The quantity of the menstrual discharge is affected also by diet, living
conditions and by any form of mental or physical excitement or
stimulation.

Accordingly, the highly strung, richly nourished women living in
luxurious circumstances are likely to menstruate more freely than those
less favored who are overworked and poorly nourished.

A shock or great grief, or any great emotional experience; a sea voyage
or a long railroad journey may bring on a period before it is due, while
the regularity of the periods may be much disturbed, temporarily, by a
marked change of climate or altitude, a serious illness or a decided
change in one’s daily régime.

The function may be entirely suspended for several months or a year in
women who suddenly take up hard work or violent exercise, and persist
with it regularly. In such cases the periods gradually recur and finally
become normal and regular.

The menstrual period is frequently attended by evidences of marked
mental and physical disturbances. While many women are fortunate enough
to suffer little or no inconvenience during menstruation, the vast
majority are more or less wretched and miserable at this time, although
in good health in all other respects. Many are tired, have less
endurance than usual and are likely to take cold easily. Headaches with
a sense of fullness, dizziness, and heaviness are common accompaniments.
Backache is a frequent source of discomfort, while abdominal pain,
varying from an uncomfortable sense of dragging heaviness to almost
unendurable agony, is the rule rather than the exception. And there may
be pain in the hips and thighs as well.

This state of wretchedness is sometimes increased by a loss of appetite,
nausea and even vomiting. At the same time there are changes in the
breasts which are much the same as, though slighter than, those
occurring during pregnancy. They are firmer, may be somewhat increased
in size, and many women experience a burning, tingling sensation,
soreness and even pain. The nipples are turgid and prominent and the
pigmented areas grow darker for the time being.

The skin over the rest of the body sometimes changes in appearance and
pimples are common; some women are pale and others are flushed during
their periods.

These physical disturbances accompanying menstruation vary so widely in
different women, and in the same women at different times and under
different conditions, that it is not possible to draw a classical
picture of the condition. But all of the symptoms above described will
persist with more or less severity throughout the entire menstrual life
of one woman, while perhaps only one or two of them will occasionally
disturb another. Whatever discomfort there may be usually begins from
one day to a week before the discharge appears; is at its height during
the following day and from that time subsides steadily, until the
normally comfortable state is regained. In fact, many women feel better
at the end of their periods and during the days immediately following
than at any other time during the cycle.

Heat applied to the abdomen and lumbar region during the uncomfortable
days; hot baths, rest and quiet, will usually give great relief, as
might be expected when there is local congestion and general nervous
irritability. In this connection, it is worth mentioning that the
discomfort of many women is needlessly increased by their heeding the
widespread but fallacious belief that general bathing during
menstruation is injurious. While cold plunges and cold showers are not
recommended, certainly warm baths are innocuous and immensely
satisfying.

In addition to the physical discomfort which is coincident with
menstruation, and quite as common, are the evidences of mental and
nervous instability. These often show themselves in the form of
unwarranted irritability, and in a lack of poise and self-control.
Drowsiness and mental sluggishness are not uncommon, and many otherwise
cheerful women are almost overwhelmed by depression during menstruation.

All of these departures from what we are accustomed to regard as the
normal, or average, mental and physical state of women are very
baffling, as they may persist after every discoverable defect has been
corrected.

But aside from all other considerations it is of obstetrical importance
for the sufferer to ascertain the cause of her discomfort if possible.
For example, a misplacement of the uterus is a frequent cause of
dysmenorrhea and, if it remains uncorrected, may make conception
impossible; or if conception perchance does take place, the malposition
of the uterus may later be the cause of an interrupted pregnancy.

Endometritis is another cause of menstrual difficulty and if allowed to
persist may be one factor in the causation of abnormalities in the
attachment of the placenta.

There is evidently an intimate relation between the process of
menstruation and the functions of the ductless glands throughout the
body; a relation which is far from being understood.

For example, the administration of various preparations of ductless
glands for maladies which are apparently unrelated to menstruation,
results not alone in an improvement of the condition treated, but
frequently in much more comfortable menstrual periods, as well.

It should be borne in mind, also, that the influence exerted by a
woman’s mental, or psychic, state upon her menstrual periods is so
apparent that it is being given increasingly serious recognition. It is
frequently observed that patients who are under treatment for nervous
and mental disorders, who are also sufferers from painful menstruation,
grow more comfortable during their periods as their neurosis improves.

We have constantly before us examples of painful menstruation being
relieved coincidently with an improved mental state among women situated
at the two extremes of the social and financial scale. Indolent,
self-centred and unoccupied women at one end often become excessively
nervous and irritable, and suffer great pain with each period, while the
overworked, harassed, poverty-stricken women at the other extreme have
similarly trying menstrual experiences. When the self-indulgent sister
can be persuaded to engage in some form of physical activity and to
interest herself in some work which requires mental effort, and which
perhaps makes an emotional appeal as well, she frequently finds that her
menstrual difficulties become less troublesome.

In the case of the woman in poorer circumstances, an improvement in her
mode of living which approaches the normal, and a relief from undue
stress and anxiety, will very often be followed by more comfortable
menstruation.

A recognition of these rather intangible facts is of consequence to the
nurse, as it deepens her appreciation of the necessity for nursing her
patient as a complete entity, mentally, physically, spiritually and
emotionally. We are insistently reminded at every turn that no one part
of the patient, no one aspect of her condition can be separately
considered and the remainder overlooked.

The patient can be nursed quite satisfactorily only when she is nursed
completely.

=Relation Between Ovulation and Menstruation.=—Menstruation and
ovulation are apparently associated and interdependent, but the exact
relation between the two is still obscure and puzzling. It is generally
accepted that complete removal of the ovaries stops ovulation and is
followed by a cessation of menstruation, and yet cases have been
recorded which suggest that these two functions are not invariably
correlative.

Evidence of this possible independence is that, although pregnancy must
be preceded by ovulation, it has occurred before puberty or after the
menopause. And not infrequently pregnancy occurs during lactation, a
period when the menstrual function is usually suspended.

It has been claimed by some observers that menstruation has occurred
after the complete removal of both ovaries, which would, of course,
preclude the possibility of further ovulation. It is possible, however,
that in such cases either the ovaries were not entirely removed, though
believed to be, or that an accessory ovary existed, since a very small
fragment of ovarian tissue will permit the occurrence of ovulation.

As to their chronological relation, information available at present
suggests that ovulation occurs about ten or twelve days after the close
of the preceding period, and that the corpus luteum formed at the site
of the rupture reaches its highest development some ten or twelve days
later, and that the degenerative changes in the corpus luteum, in case
of non-fertilization of the ovum, give rise to menstruation.

=Modifications of Menstruation.= =Dysmenorrhea= is painful menstruation.

=Menorrhagia= is an abnormally copious menstrual flow.

=Amenorrhea= is irregularity or, to be exact, suppression of the menses.
The suppression may be due to an obliteration of the neck of the uterus,
or to an occlusion of the vaginal opening.

=Vicarious menstruation= is an escape of blood from other parts of the
body coincident with menstruation. Blood may ooze through the skin
covering the breasts; also from hemorrhoids or from the surface of
ulcers. Or there may be nose-bleeding, vomiting of blood or pulmonary
hemorrhage, particularly among tuberculous patients. Vicarious
menstruation usually occurs among nervous, high-strung women and may be
regarded as an evidence of ill health. The amount of blood lost in this
way is much less than the amount of the menstrual flow.

=The menopause=, also termed the climacteric and the change of life,
marks the permanent cessation of menstruation and of sexual activity. It
occurs ordinarily between the ages of forty and fifty; the majority of
women stop menstruating at their forty-sixth year. The menopause has
occurred as early as the twenty-fifth year, and as late as the eightieth
or ninetieth year. But such cases are, of course, extremely rare and
their infrequent occurrence is of interest rather than of importance in
an effort to ascertain the general average.

As the child-bearing period is normally about thirty years in duration,
the prevailing belief is that the menopause comes earlier to women who
began menstruating early, than to those who did not reach puberty until
later. Some authorities contend, however, that early menstruation
indicates extreme vitality, and that this vitality tends to prolong the
child-bearing period. According to this theory, then, the menopause
would come late to those who matured early and vice-versa.

As the menopause approaches, menstruation occurs irregularly; the
discharge sometimes increases slightly but usually diminishes in amount
and finally disappears altogether, while the generative organs all
undergo atrophic changes.

Bearing in mind the disquieting effect of adolescence, and of ovulation,
upon the general nervous, mental and physical state, we may reasonably
expect that a complete cessation of the ovarian function would be
attended by more or less disturbance of the general well-being.

It is true that very many women suffer a certain amount of nervous
instability at the menopause; they tire easily; have “hot flashes” and
possibly headaches. But under ordinary conditions the discomfort is not
great, and after the function has entirely ceased and they become
physiologically adjusted to the new order of things, these women often
enjoy better health than ever before.

Unfortunately wide currency has been given to exaggerations concerning
the symptoms of the menopause. The result is that serious organic
diseases which are in no way related to the climacteric are not
infrequently attributed to it. For this reason excessive bleeding, heart
symptoms and what not are all too often accepted as a matter of course,
and accordingly neglected until the patient is beyond medical aid. This
is particularly and tragically true of cancer of the uterus.

It is a wise precaution, therefore, to regard with apprehension an
increase in the amount of the menstrual flow of any woman past thirty,
and not to accept it as a normal forerunner of the menopause.


                 In the dark womb where I began
                 My mother’s life made me a man.
                 Through all the months of human birth
                 Her beauty fed my common earth.
                                       —JOHN MASEFIELD.



                                PART II
                      THE DEVELOPMENT OF THE BABY

  CHAPTER III. DEVELOPMENT OF THE OVUM, EMBRYO, FETUS, PLACENTA, CORD
    AND MEMBRANES. The Ovum. The Spermatozoon. Fertilization. Heredity.
    Sex-determination. Most Favorable Age for Motherhood. The Morula.
    Growth in the Uterus. The Decidua. Ectoderm. Mesoderm. Entoderm. The
    Chorion and Placenta. The Amnion. The Umbilical Cord. The Fetus.
    Growth by Months. Factors Influencing the Size of Child. Multiple
    Pregnancy. Extra-uterine Pregnancy.

  CHAPTER IV. GROWTH AND PHYSIOLOGY OF THE FETUS. Circulation. Kidneys.
    Bowels. Head. Fontanelles. Occipital Measurements.

  CHAPTER V. SIGNS, SYMPTOMS, AND PHYSIOLOGY OF PREGNANCY. Duration of
    Pregnancy. Date of Labor. Signs of Pregnancy: Presumptive, Probable,
    and Positive. Physiological Changes in the Maternal Organism:
    Uterus. Cervix. Vagina. Tubes and Ovaries. Abdomen. Umbilicus.
    Breasts. Cardio-Vascular System. Respiratory Organs. Digestive
    Tract. Urinary Apparatus. Bony Structures. Skin. Carriage.
    Temperature. Mental and Emotional Changes. Ductless Glands.



                              CHAPTER III
THE DEVELOPMENT OF THE OVUM, EMBRYO, FETUS, PLACENTA, CORD AND MEMBRANES


As we learned in the last chapter, some of the ova which are discharged
into the peritoneal cavity enter the fimbriated end of the tube, while
very many others perish. As a rule an ovum enters the tubal opening
adjacent to the ovary from which it has been discharged, but it is
possible for this tiny cell to travel across the body and enter the tube
on the opposite side.

This migration of the ovum, as it is termed, has been demonstrated in
cases in which pregnancy has followed removal of the ovary on one side
and the tube on the other.

[Illustration:

  FIG. 17.—Diagram of spermatozoa, the male cells of germination.
]

There are various theories as to how and why an occasional migrating
ovum, floating around in a relatively large cavity, ever enters the
tubal opening, which, after all, is not large. The most widely accepted
belief is that the motion of the cilia lining the tubes creates a
suction which draws the microscopical cell into the opening, the same
cilia being the means by which the ovum is later propelled downward
through the tube to the uterus.

This journey of the ovum through the tube is of enormous consequence.
During its course occur the events which decide whether the ovum shall,
like most of its fellows, be simply swept along to no end and lost, or
whether by chance it is to receive the mysterious impulse which begins
the development of a new human being.

The amazing power which enables this cell to reproduce itself, and to
develop with unbelievable complexity, is acquired somewhere in the tube
by meeting and fusing with a _spermatozoon_, the germinal cell of the
male. (Fig. 17.)

The spermatozoa look very much like microscopic tadpoles, with their
flat, oval heads, tapering bodies and long tails. As these tails serve
somewhat as propellers, the male cells are capable of very rapid motion.
But in spite of their strange appearance, they are cells after all, and
resemble the female cells in that each one contains a nucleus, or
germinal spot.

An almost inconceivably large number of spermatozoa, floating in the
seminal fluid, is deposited in the vagina at the time of intercourse.
Nature evidently supplies the male and female cells with equal
lavishness, in order to provide for the large number of both kinds which
must inevitably be lost, and still have enough survive to accomplish the
high purpose of their creation. A very considerable number of
spermatozoa enter the uterus, and are enabled through their powers of
motility, to travel up into the tubes, in spite of the downward current
created by the cilia. And in the tube, usually in the upper end, they
meet a recently matured and discharged ovum which is being swept
downward, and are attracted to it somewhat as bits of metal are drawn to
a magnet. Although the ovum which is destined to be fertilized is
surrounded by several spermatozoa, only one actually enters and fuses
with it.

This fusion is termed _impregnation_, _fertilization_, or, in lay
parlance, _conception_, and the instant at which it occurs marks the
beginning of pregnancy. The establishment of this fact is of no little
importance, since it does away with any possible controversy concerning
the time at which a new life begins. The origin of the child is exactly
coincident with the fusion of the male and female germinal cells.

And furthermore, the sex of the child and any inherited traits and
characteristics are also established at this decisive instant. No amount
of dieting, exercise nor mental effort on the part of the expectant
mother can alter or influence them in the smallest degree, for the
father has made his complete contribution toward the creation of the new
being, and after this event the mother provides nourishment only.

All told, probably more than five hundred theories have been advanced to
explain what it is that decides of which sex the forthcoming child will
be.

In 1907 Dr. Schenck attracted world wide attention by announcing his
belief that either sex could be produced in the expected child through
the simple expedient of regulating the mother’s diet. Liberal feeding
would result in boys, the sturdier sex, and frugality in girls, the
smaller, frailer type of baby. But as the results of applying Schenck’s
theory have scarcely borne out his claims, it is given but scant
attention to-day.

The present belief regarding the causation of sex is that although there
is but one kind of ovum, there are two kinds of spermatozoa, one capable
of producing a male, and the other a female child. These two kinds are
evidently deposited in the vagina in about equal numbers, and the
sex-determining form that fertilizes any one ovum is a matter of the
merest chance. Statistics show, however, that more male than female
babies are born, the usual proportion being about 105 boys to 100 girls
among those that reach full term. Among abortions and premature births
there is also a larger number of boys than girls, and in elderly
primiparæ the ratio increases to about 130 boys to 100 girls. But as
more boys die in infancy than girls, the two sexes about even up in the
number of those living to adult age.

Apparently, then, there is some factor operating slightly in favor of
the purposeful activities of the male-producing spermatozoa. But so far
no accurate means has ever been found whereby it was possible to
influence the development or discover the sex of a child before its
birth.

There is a wide difference of opinion concerning the time of the month
when fertilization is most likely to occur. Observations made upon the
wives of sailors and under a variety of conditions suggest that the most
favorable period is just before or just after menstruation which
represents the second stage of the menstrual cycle.

Dr. Williams believes, however, that fertilization is most likely to
occur about midway during the intermenstrual period. But since it is
probable that spermatozoa are constantly present in the tubes of women
who are exposed to the possibility of becoming pregnant, it is difficult
to do more than speculate about the time of the month at which fertility
is greatest.

Another moot question relates to the age of the woman at which it is
most desirable that the first child shall be born. Recent observations
made by Dr. John W. Harris upon a large number of pregnancies occurring
in very young girls indicates that from a standpoint which considers
solely the physical welfare of the mother and her infant, sixteen years
is the most satisfactory age at which to bear the first child.

However, when motherhood is considered from all standpoints, social,
ethical, spiritual as well as physical, the consensus of opinion seems
to be that the twenty-third year is the most favorable age for
motherhood to begin. Children have been born to little girls nine years
old and to women of sixty-two, but the extremes of the reproductive
years are not favorable periods for child-bearing.

As soon as a spermatozoon enters an ovum, it disappears and is
completely absorbed, and, as the ovum in turn is instantly possessed of
new powers, the result of this union is a cell which was previously
non-existent.

This new cell is not only capable of reproduction by means of
_segmentation_ or cell division, but in the course of its sub-division
and proliferation, it forms groups of cells which develop into tissues
and structures widely different from each other. The entire complex
human body, in addition to the placenta, cord, and membranes, arises
from the single, extraordinary cell.

It first divides into two; these two divide into four; the four into
eight and thus the process of division and sub-division continues until
a solid mass is formed, shaped something like a mulberry and called the
_morula_. (Fig. 18.)

While these developmental changes are taking place, the morula is being
carried down the tube toward the uterus, by the sweeping motion of the
ciliated membrane. The time consumed by this journey has not been
definitely ascertained and though possibly it may be made in a few
hours, it probably takes from five days to a week. Since the embryo is
constantly moving during this time, it quite evidently has no attachment
to the mother and cannot, therefore, derive any great amount of
nourishment directly from her. The growth and development to this point,
then, must be due chiefly to inherent powers within the mass of cells
itself.

In all probability, the embryo is still in the morula stage and is about
the size of the head of a pin when it reaches the uterus, where it finds
that the endometrium has been prepared for its reception by the
premenstrual swelling. The mucosa has grown thicker, more velvety and
vascular, and its glands have increased in number and activity. The
columnar epithelium of the endometrium is replaced by a thick layer of
large, vacuolated cells, called decidual cells, and the uterine lining
from now on is termed the _decidua gravidatis_. While the normal uterine
mucosa is thin, averaging from 1 to 3 millimetres (0.039 to 0.117 inch)
in thickness, it increases to a thickness of about 1 centimetre (⅞ inch)
during pregnancy.

[Illustration:

  FIG. 18.—Diagram of segmenting rabbit’s ovum.
]

The point at which the embryo attaches itself to this spongy membrane is
entirely a matter of chance. It usually rests somewhere in the upper
part of the uterine cavity, promptly destroys the minute underlying area
of tissue by digestive action and burrows into the decidua. As the
margins of the opening thus made meet and fuse above the ovum, it is
completely incapsulated in a cavity of its own that has no connection
with the uterine cavity. (Fig. 19.)

After this occurrence the decidua consists of three portions: the
hypertrophied membrane which lines the uterus as a whole, called the
_decidua vera_, which atrophies during the latter part of pregnancy and
is also thrown off in part with the membranes during labor, and later in
the uterine discharges; the _decidua basalis_, or the _decidua
serotina_, is that portion lying directly beneath the embryo which later
enters into the formation of the placenta; and the _decidua reflexa_,
which surrounds and covers the buried embryo, consists of the developed
and fused margins of the pit in the mucosa, that have grown over the
embryo.

[Illustration:

  FIG. 19.—Ovum about 13 days old, embedded in the decidua. (The
    Bryce-Teacher ovum from Human Embryology by Keibel and Mall.)
]

As the cellular activity continues within the morula, fluid appears in
the centre with the result that the cells are rearranged and pushed
toward the periphery, thus forming a sac. At this stage the embryo is
called the _blastodermic vesicle_.

At one point on the inner surface of this vesicle the cells proliferate
and form a mass which is sometimes called the internal cell mass, or
_embryonic area_, and the single layer of cells comprising the remainder
of the vesicular wall, the _primitive chorion_. The cells in the mass
are at first disposed in layers, the outer layer being termed the
_ectoderm_; the inner layer the entoderm, while a third layer which
appears a little later is called the _mesoderm_.

Although these three primitive layers of cells have all arisen from the
single cell formed by the fused spermatozoon and ovum, they are even now
very different in character. The differences steadily increase until
finally all of the complex fetal organs and tissues, the membranes, cord
and placenta, result from their further specialization and development,
as follows:

=From the ectoderm= arises the skin with its appendages, and the
salivary and mammary glands; the nasal passages, upper part of the
pharynx and the anus; the crystalline lens, the external ear, the entire
nervous system, the sense organs and, in part, the fetal membranes.

=From the mesoderm= are derived the urinary and reproductive organs; the
muscles, bones, and connective tissues and the circulatory systems.

=From the entoderm= are developed the alimentary canal, the thymus,
thyroid, liver, lungs, pancreas, bladder and the various small glands
and tubules.

It was formerly believed that the human being existed in miniature in
the first cell and that its development during pregnancy was entirely a
matter of increase in size. But the microscope has disproved this, and
we now know that embryonic development comprises both growth and
evolution.

Much of the information accepted to-day is, of course, speculative,
having been deduced from observations made upon the reproductive
processes of lower mammals, since the youngest human ovum which has been
discovered and examined was probably two weeks old. But the evidence
points quite convincingly to the belief that the early stages of
development consist of proliferation of and alterations in the kinds of
cells, their arrangement into groups, and a differentiation of the
functional activity of these groups of cells before the mass assumes
human form and develops organs.

As to terminology, some authorities call this mass the embryo during
this stage of grouping and differentiation, which corresponds to the
first six weeks of pregnancy, and the fetus from then until the time of
delivery. By others it is designated the ovum during the first two weeks
of pregnancy, the embryo from the third to the fifth week, after which
it is known as the fetus.

From the nurse’s standpoint these distinctions are of no consequence,
for the mass may safely be called a fetus from the time that the
expectant mother looks to the nurse for guidance and care.

It is scarcely warrantable to take the time and space which would be
necessary to trace in detail through its various stages the intricate
development of the human body, with its attached membranes. But the
whole question is so important and so interesting that we shall at least
have a word of description as to its size and characteristics at
successive periods.

Although the exact length of time required for the maturation of the
fetus is not known, it is estimated that two hundred and eighty days, or
ten lunar months, elapse between the beginning of the last menstrual
period and the beginning of labor. And in spite of the difference in
size among the mothers, it is found that the products of conception
develop and grow at a fairly uniform rate of speed.

A new human being is the ultimate result of conception, but the chorion,
amnion, placenta and umbilical cord must also be created to serve as
aids in building and protecting the developing child during its uterine
life. The part played by these accessory structures is so vital, in
spite of being temporary, that it will be well for us to look into their
origin and functions before considering the fetus itself which they
serve.

=The Chorion and Placenta.= Very early in pregnancy, probably while the
fertilized ovum is journeying down the tube, tiny, thread-like
projections, called _villi_, appear over the surface of the primitive
chorion, giving it the shaggy appearance of a chestnut burr. Shortly
after this shaggy ovum reaches the uterus and is embedded in the lining,
the chorion, or the outer fetal membrane, is formed, being partly
derived from the ectodermal layer of cells growing within the
blastodermal vesicle. The chorion grows rapidly in size and thickness,
and the villi upon its surface increase in size, number and complexity
by frequent branching. In so doing the villi push their way into the
maternal tissues surrounding them, and destroy the capillary walls with
which they come in contact. Maternal blood escapes through the destroyed
walls, forming tiny hemorrhagic areas, or “lakes of blood.” The
chorionic villi float freely in these pools of maternal blood, which is
constantly being refreshed by an inflow of arterial and an outflow of
venous blood through the mother’s vessels.

Blood vessels soon appear in these chorionic villi, and fetal blood then
circulates through them. It becomes apparent, therefore, that the
maternal and fetal blood streams are in such close relation that they
are separated by only the thin membrane which forms the walls of the
vessels in the villi. (Fig. 20.)

[Illustration:

  FIG. 20.—Diagram of fetus, cord, membranes and placenta in utero at an
    early stage of their development.
]

This arrangement makes it possible for the steadily proliferating villi
to discharge one of their functions, which is to receive from the
maternal blood nourishment for the embryo, and give up to the parent
waste products from the growing body. This exchange of nourishment and
waste matter takes place by means of osmosis. But freely as the exchange
of materials occurs, there is never any contact, or mixing of maternal
and fetal blood, nor does maternal blood at any time flow through fetal
vessels. It was believed at one time that the fetus was nourished by
milk which was in some way secreted by the gravid uterus, but this is
disproved by present knowledge of the placental function.

The second function of the villi, particularly after they have developed
to the placental stage, is to assist in securely attaching the embryo to
the uterine wall.

The villi are equally distributed over the surface of the chorion at
first, but as the sac increases in size and pushes out into the uterine
cavity, they gradually atrophy and disappear, excepting over the small
area beneath the vesicle where the chorion is in contact with the
decidua basalis. At this site the villi become much more abundant, and
it is here that the placenta eventually develops. This part of the
chorion is termed the _chorion frondosum_, while the remainder, which is
in contact with the decidua capsularis, is the _chorion læve_.

As pregnancy advances and the fetal sac enlarges, the chorion læve
covered by the decidua capsularis, or reflexa, is pushed farther out
into the uterine cavity, until finally it quite reaches the opposite
wall, meets the decidua vera and obliterates the entire space which had
existed between the two membranes. This means that instead of a uterine
cavity lined with decidua, and a tiny capsule somewhere off to the side
lined with chorion, the latter has distended until it completely fills
and really becomes the cavity within the uterine walls, thus lining the
uterus with chorion and crowding the original lining out of existence.
The decidudae capsularis and vera fuse in time and finally the
capsularis degenerates and disappears.

=The Amnion.= Returning for a moment to the blastodermal stage of the
ovum, we find that the amnion, or inner membrane, first appears as a
tiny vesicle over the dorsal surface of the embryo. Very soon, however,
it invests the embryo completely, and the membranous sac is intact,
excepting where it is pierced by the umbilical cord. The amnion, too, is
derived in part from the ectoderm, but is a stronger, denser membrane
than the chorion. At first there is an appreciable space, and some
fluid, between the two membranes, but as the amnion increases in size
with the advance of pregnancy, it comes in contact with and is loosely
adherent to the chorion.

Very early in its development the amniotic sac contains a pale yellow
fluid known as the _amniotic fluid_, or _liquor amnii_, in which the
fetus floats. This fluid increases in amount until the end of pregnancy
and though the quantity is variable, it usually amounts to about a
quart.

The source of the liquor amnii is not definitely known, but it is
generally believed to be of maternal origin, secreted from the amniotic
membrane, though the possibility of its consisting partly of fetal urine
cannot be overlooked. It is about 99% water, containing particles of
dead skin and lanugo, a soft downy hair cast off from the body of the
fetus, traces of albumen and both organic and inorganic salts.

[Illustration:

  FIG. 21.—Diagram showing general structure and relation of membranes,
    placenta and cord.
]

The amniotic fluid serves a variety of purposes. Since the intestines of
the fetus contain lanugo and particles of dead skin, it is evident that
the child swallows some of this fluid during its uterine life, and
possibly obtains in this way much of the fluid necessary for its
development.

The increasing bulk of the fluid serves to distend the fetal sac and
surrounding uterus, and thus provides the fetus with room for growth and
movement. It also prevents adhesions between the child’s skin and the
amnion, which are a factor, when by mischance they do occur, in causing
monstrosities and intrauterine amputations. The fluid with which it is
surrounded keeps the fetus at an equable temperature in spite of
variations of temperature in the mother’s environment, and minimizes the
danger of injury to the fragile little body, from pressure or blows on
the mother’s abdomen. And by acting as a water wedge, forced down by
uterine contractions at the time of labor, it dilates the cervix
sufficiently to permit the expulsion of the full term child.

[Illustration:

  FIG. 22.—Placental blood vessels. Note their branching, tree-like
    arrangement. (Photographed from an injected specimen in the
    Obstetrical Laboratory, Johns Hopkins Hospital.)
]

=The placenta.= The placenta, in lay parlance the after-birth, is really
a thickened, amplified portion of the fetal sac, which has developed at
the site of the implantation of the ovum. It is partly fetal and partly
maternal in origin, being developed jointly from the chorion frondosum
with its branching villi, and the underlying decidua basalis.

The chorionic villi already referred to grow and branch in a tree-like
fashion (Fig. 22), and push their way farther and farther into the
uterine tissues creating the intervillous spaces which fill with
maternal blood. From the time that the first fetal blood vessels appear
in these floating villi, until the child is born, there is a constant
exchange of nutriment and waste matter between the maternal and fetal
blood; the arterial maternal blood in the intervillous spaces giving to
the fetal blood in the villi the oxygen and other substances necessary
to nourish and build the growing young body, and receiving in return the
broken-down products of fetal activity. The waste is carried by the
maternal blood stream to the mother’s lungs, kidneys and skin, by which
it is excreted.

This exchange of substances is accomplished by osmosis and also by
selective powers of the cells in the villi. Thus the placenta virtually
serves the fetus as lungs, stomach, intestines and kidneys throughout
its uterine life.

In addition to the nutritive substances in the mother’s blood, such as
albumen, iron and fat which are so altered by cell action as to be
absorbable through the villi, certain protective substances as the
anti-toxines of diphtheria, tetanus, colon and typhoid bacilli are
evidently transmitted from the maternal to the fetal circulation. It is
claimed by some authorities that pathogenic organisms, for example,
anthrax, pneumonia and tubercle bacilli, may be transmitted from mother
to fetus, but the reported cases are so rare that the accepted belief is
that organisms are seldom transmitted, if the placenta is healthy and
intact. But, according to Dr. Williams, the transmission of typhoid
occurs frequently, though malarial parasites cannot pass through the
villous membranes.

Only during comparatively recent years has accurate knowledge of the
origin and function of the placenta been available. Many varied and
interesting beliefs and superstitions gained currency in the past, but
all of them were erroneous.

The description of the circulation of the blood by William Harvey in
1628 shed considerable light upon this puzzling question concerning the
exchange of fuel and ash between the parent and fetal bodies. But a
mistaken belief that the maternal blood actually entered and flowed
through the fetal vessels resulted from his valuable discovery.

[Illustration:

  FIG. 23.—Maternal surface of the placenta, surrounded by the membranes
    and cord. (From a photograph taken at Johns Hopkins Hospital.)
]

When we examine this interesting structure, the placenta, after it is
cast off, we find it to be a flattened, fairly round, spongy mass, eight
or nine inches in diameter, about an inch thick where the cord arises
and thinning out toward the margin. Continued from the margin are the
filmy fetal membranes, which together form a ruptured sac. The rupture
in these membranes is the opening through which the amniotic fluid
escapes, and the child passes during birth.

[Illustration:

  FIG. 24.—Fetal surface of the placenta showing origin of cord. (From
    photograph taken at Johns Hopkins Hospital.)
]

The placenta weighs about a pound and a quarter, or ⅙ as much as the
child, and accordingly varies in size and weight with the baby. The
maternal surface (Fig. 23) having been detached from the uterine wall,
is rough and bleeding and is irregularly divided into lobes while the
inner, or fetal, surface is smooth and glistening and covered with the
amnion. The fetal surface (Fig. 24) is traversed by a number of large
blood-vessels which converge toward the point of insertion of the
umbilical cord, from the vessels of which they really arise. These
vessels branch and divide until their termination in the innumerable
chorionic villi floating in the lakes of maternal blood.

=The Umbilical Cord.= The cord, or _funis_, is a bluish white cord about
three-quarters of an inch in diameter, twisted and tortuous throughout
its length of about twenty inches. It is the one actual link between the
mother and her unborn child, one end being attached to the abdomen of
the fetus, about midway between the ensiform and the pubis, and the
other to the inner surface of the placenta. The cord is derived from the
_abdominal pedicle_ and is merely an extension of the caudal or tail end
of the embryo. It is covered with a layer of ectoderm which is
continuous with the ectodermal covering of the fetus.

The cord consists of a gelatinous mass known as Wharton’s jelly, in the
centre of which are embedded three blood vessels; two arteries through
which the vitiated blood flows to the placenta, where it gives up its
ash; and one vein which carries oxygenated, nourishment-bearing blood
back to the fetus. The life of the fetus, therefore, is absolutely
contingent upon an uninterrupted, two-way flow of blood through the
cord.

=The Fetus.= In tracing the development of the ovum after its
implantation in the uterine lining, we begin, as previously stated, with
a shaggy-looking vesicle, containing fluid, with a clump of cells
hanging toward the centre from their point of attachment on the inner
surface of the sac. This clump develops into the embryo.

=During the first month= the mass increases in size, becomes somewhat
elongated and curved upon itself with the two extremities almost in
contact. The abdominal pedicle, which later becomes the umbilical cord,
appears; the alimentary canal exists as a straight tube and the thymus,
thyroid, lungs and liver are recognizable. The heart, eyes, nose, ears,
and brain appear in rudimentary form and the extremities begin to be
evident as tiny, bud-like projections on the surface of the embryo.

=By the end of the fourth week= the sac is about the size of a pigeon’s
egg and has two walls. The outer wall, or chorion, as we have already
seen, is covered with villi, and the amnion, or inner wall, is smooth;
the contained embryo is surrounded by amniotic fluid and measures about
10 millimetres or 4 inches in length.

[Illustration:

  FIG. 25.—Embryo, about 5.5 centimetres long in amniotic sac; uterine
    wall incised, chorion split and turned back. Drawn by Max Brodel.
    (From The Umbilicus and Its Diseases, by Thomas R. Cullen, M.D.)
]

=By the end of the second month, or eighth week=, the head end of the
embryo has greatly increased in size and is about as large as the rest
of the body. Bone centres appear in the rudimentary clavicles; the
kidneys and supra-renal bodies are formed; the limbs are more developed,
webbed hands and feet are formed, the external genitalia are apparent
but the sex is not distinguishable. The amnion is distended with fluid,
but it is not yet in contact with the chorion; the chorionic villi have
become more luxuriant on that part of the chorion resting on the decidua
basalis, the future site of the placenta. The approximate weight of the
embryo is 4 grams and its length 25 millimetres or an inch.

=By the end of the third month, or twelfth week=, centres of
ossification have appeared in most of the bones, the fingers and toes
are separated and bear nails in the form of fine membranes; the
umbilical cord has definite form, has increased in length and begun to
twist. The neck is longer, teeth are forming and the eyes have lids. The
amnion and chorion are now in contact, and the villi have disappeared
excepting at one point where a small, but complete placenta has
developed. The embryo is about 9 centimetres long and weighs about 30
grams.

[Illustration:

  FIG. 26.—Diagram showing appearance of fetus at different stages in
    its development.
]

=By the end of the fourth month, or sixteenth week=, all parts show
growth and development; lanugo appears over the body; the sex organs are
clearly distinguishable and there is tarry fæcal matter, called
_meconium_, in the intestines. The placenta is larger, the cord longer,
more spiral and also thicker because of the Whartonian jelly which is
beginning to form. The fetus is about 15 centimetres long and weighs
about 120 grams.

=By the end of the fifth month, or twentieth week=, the fetus has both
grown and developed markedly. It is now covered with skin on which are
occasional patches of _vernix caseosa_, a greasy, cheesy substance
consisting largely of a secretion of the sebaceous glands. There is some
fat beneath the skin but the face looks old and wrinkled. Hair has
appeared upon the head and the eyelids are opening. It is usually during
the fifth month that the expectant mother first feels the fetal
movements which are commonly referred to as “quickening.” The body is
about 25 centimetres long and weighs about 280 grams.

=By the end of the sixth month, or twenty-eighth week=, the fetus still
looks thin and scrawny, the skin is reddish and is well covered with
vernix caseosa and the intestines contain an increased amount of
meconium. If born at this time the child will move quite vigorously and
cry feebly. Although it is not likely to live for any length of time,
every effort should be made to save its life, for it may be that the
high rate of mortality at this age is due to the inadequacy of the
attempts which are usually made to save the child rather than to the
frailty of the child itself. It is about 35 centimetres long and weighs
about 1200 grams.

=By the end of the eighth month, or thirty-second week=, the child has
grown to about 42 centimetres in length and 1900 grams in weight, but
continues to look thin and old and wrinkled. The nails do not extend
beyond the ends of the fingers but are firmer in texture; the lanugo
begins to disappear from the face but the hair on the head is more
abundant. If born at this stage, the baby will have a fair chance to
live, if given painstaking care. This is true in spite of the ancient
superstition, still widely current, that a seven months’ baby is more
viable than one born at eight months (meaning calendar months). The fact
is that after the eighth lunar month, a little more than seven calendar
months, the probability of the child’s living increases rapidly with the
length of its intra-uterine life.

=By the end of the ninth month, or thirty-sixth week=, the increased
deposit of fat under the skin has given a plumper, rounder contour to
the entire body; the aged look has passed and the chances for life have
greatly increased. The baby now weighs about 2500 grams and is about 46
centimetres long.

=The end of the tenth month, or fortieth week=, usually marks the end of
pregnancy. (Fig. 27.) The average, normally developed baby has attained
a length of 50 centimetres (20 inches), and a weight of 3250 grams, or
about 7¼ pounds, boys usually being about three ounces heavier than
girls.

It must be remembered, however, that these figures merely represent the
average drawn from a large number of cases, for there may be a variation
in weight among entirely normal healthy babies from a minimum of 2300
grams (5 pounds) to as high as 5000 grams (11 pounds), or more. Babies
actually weighing more than 12 pounds are seldom born, in spite of
legends and rumors to the contrary.

The length of a normal baby is less variable than the weight. In fact,
it is so nearly constant in its increase during the successive months of
pregnancy, that the age of a prematurely born fetus may be fairly
accurately estimated from its length. This fact is of no little
practical importance, since it aids the obstetrician in making a
prognosis as to the child’s prospect of living, for he can estimate its
intra-uterine age from its body length.

The size of the baby is affected by race, colored babies, for example,
averaging a smaller weight than white babies. And, as might be expected,
the size of the parents is likely to be reflected in the size of their
infants, large parents tending to have large children and vice versa.

The number of children which the mother has previously borne is also a
factor, since the first child is usually the smallest, the size of those
following showing an increase with the mother’s age up to her
twenty-eighth or thirtieth year, provided the successive pregnancies do
not occur at too frequent intervals.

The expectant mother’s general state of health, her state of nutrition,
the character of her surroundings and her mode of living may be expected
to influence her baby’s welfare. Hence, women who live in comfortable,
or luxurious circumstances usually have more robust babies than those
who are run down, poorly nourished or overworked. All of which hints at
the great value of prenatal care which will be taken up in detail in a
later chapter.

[Illustration:

  FIG. 27.—Full term fetus in utero. Drawn by Max Brodel. (Used by
    permission of A. J. Nystrom & Co., Chicago.)
]

=A multiple pregnancy= is one in which the pregnant uterus contains two
or more embryos, these being termed twins when there are two and
triplets when there are three; quadruplets, quintuplets and sextuplets
when there are four, five and six embryos, respectively, six being the
largest accredited number on record.

The tendency to multiple pregnancies is apparently inherited, and it
sometimes happens that several members of the same family connection
have this predisposition, as evidenced by the number of twins and
triplets to be found among relatives. It is estimated that twins occur
once in 90 pregnancies and triplets once in about 7000 cases.

Twin pregnancies may result from the fertilization of one or of two ova,
and are designated as single ovum or double ovum twins respectively. In
single ovum twins the egg becomes divided early in its development and
two embryos are formed. In such a case there is one placenta, one
chorion and two amnions and the babies are of the same sex.

In double ovum twins two ova are fertilized; both may come from the same
ovary or there may be one from each side. When double ovum twins occur,
there are two placentæ, as a rule, though they may be somewhat fused;
two amnions and two chorions and the babies may be of the same sex or
each of a different sex.

Twins are often prematurely born and each one is likely to be smaller
than a baby resulting from a single pregnancy, but their combined weight
is greater than that of one normal baby.

=An extra-uterine pregnancy= may be defined as a pregnancy which
develops outside of the uterus, usually in a tube or ovary. Although in
the normal course of events the fertilized ovum travels down the tube
and becomes attached to the uterine lining, it is possible for it to
stop, and more or less completely develop at any point along the way
between the Graafian follicle, from which it has been projected, and the
uterus toward which it is traveling. If the fetus develops in the ovary,
it is termed an ovarian pregnancy, and a tubal pregnancy if it occurs in
the tube, the latter being the most frequent variety of extra-uterine
pregnancy.

In the opinion of Dr. Mall, only about 1 per cent of all extrauterine
pregnancies are capable of going to term. There may be an abortion, when
the fetus and membranes are partly or completely extruded from the
fimbriated end of the tube into the peritoneal cavity; or a rupture of
the tube, when the fetus, with or without the membranes, may be expelled
into the peritoneal cavity, or between the folds of the broad ligament.
If the greater part of the placenta remains attached to the site of its
development, in the case of a ruptured tube, it is possible for the
fetus to live and grow and even go to term. But if the placenta is
nearly, or completely separated, the fetus perishes and may be largely
absorbed by the maternal organism, or mummified, or putrefactive changes
may take place. It is usually customary to terminate an extra-uterine
pregnancy as soon as it is diagnosed, for only a very small number can
be expected to go to term, the majority aborting, or rupturing the tube,
with serious hemorrhage from the mother as a frequent result.

To sum up the normal pregnancy, we find that in the course of ten lunar
months, following the fertilization of an ovum, the uterus grows from a
small, flattened, pelvic organ, three inches in length, to a large,
globular, muscular sac, constituting an abdominal tumor about fifteen
inches long; it increases its weight thirty-two times, that is from two
ounces to two pounds, while the capacity of the uterine cavity is
multiplied five hundred times. Within the cavity is a child weighing
about seven and a quarter pounds, surrounded by a quart or so of
amniotic fluid. This fluid is contained in the sac composed of the fetal
membranes, the amnion and chorion, which are excessively developed at
one point into the placenta. The placenta, in turn, is attached to the
child by means of the umbilical cord. The total weight of the uterus and
its contents at term is usually about fifteen pounds.

Quite as mysterious and inexplicable as the development of these complex
structures from one tiny cell is the fact that when the new human being
is ready to begin life as a separate entity, further changes occur
within the mother’s body which produce uterine contractions of such a
character as to entirely empty the uterus of its contents.



                               CHAPTER IV
                   GROWTH AND PHYSIOLOGY OF THE FETUS


Although the fetus at term is in many respects simply a diminutive,
immature man, or woman, its anatomy and physiology present certain
characteristics which have adapted it to a protected existence in a sac
of fluid. Some of the fetal structures and functions become increasingly
active after birth, while others subside and disappear.

We have seen that after the first month of pregnancy the placenta serves
the fetus as a combined respiratory and digestive apparatus, not alone
in supplying the oxygen and nourishment requisite for life and growth,
but also in excreting the broken-down products of fetal life. It
apparently acts somewhat as a liver, too, in performing something akin
to a glycogenic function.

Obviously, then, the fetus must possess a circulatory mechanism which is
peculiar to itself alone, and not found in the independently existing
human body, in which the lungs and alimentary tract are functioning as
intended. This mechanism is provided by means of certain structures
which exist in the fetal circulatory system and which automatically
disappear shortly after birth. The nurse must be aware of these
anatomical changes that take place, in addition to growth, if she is to
have an intelligent grasp of her tiny patient’s possible needs.

The structures which change or disappear after birth are the _foramen
ovale_, a direct opening between the right and left auricles, and four
blood vessels: the _ductus arteriosus_, _ductus venosus_ and the two
_hypogastric arteries_. An understanding of the functions of these
vessels involves an understanding of the course followed by the fetal
blood currents, as indicated in Fig. 28, page 85.

We see that there are three vessels within the umbilical cord: the
umbilical vein and two arteries. In spite of its name, the vein conveys
arterial blood from the placenta to the fetus. After piercing the baby’s
abdominal wall, it divides into two vessels; the larger one, called the
ductus venosus, empties into the inferior or ascending vena cava, while
the smaller branch joins the portal vein, which enters the liver. The
relatively large amount of arterial blood sent directly to the liver may
in part account for the large size of this organ in the fetus. Upon its
emergence from the liver, this blood stream flows into the inferior vena
cava.

[Illustration:

  FIG. 28.—Diagram showing course of fetal circulation through
    hypogastric arteries, ductus venosus, ductus arteriosus and the
    foramen ovale. (From The American Text Book on Obstetrics.)
]

The ascending vena cava, then, pours into the right auricle a mixture of
arterial blood, which has come directly from the placenta, and venous
blood returned from the liver, intestines and lower extremities. There
is a difference of opinion concerning the course of the blood stream
after reaching the right auricle. The general teaching, however, is that
the eustachian valve, guarding the foramen ovale, deflects the current
through this opening from the right into the left auricle. It then pours
into the left ventricle, is pumped into the arch of the aorta, from
which most of the blood is sent to the head and upper extremities,
though a small part carries nourishment to other parts of the body.

The descending, or superior, vena cava, carrying blood returning from
the head and arms also empties into the right auricle; this stream
presumably crosses the stream which is directed toward the foramen
ovale, flows into the right ventricle by which it is pumped into the
pulmonary artery. The circulation of blood through the lungs, however,
is for their own nourishment, and not for aëration as with the adult.
For this reason most of the contents of the fetal pulmonary artery
empties into the aorta through the ductus venosus, one of the temporary
fetal structures already referred to. From the aorta the stream is
directed in part to the lower extremities and the pelvic and abdominal
viscera, but most of it flows into the hypogastric arteries. These are
also temporary arteries. They lead to the umbilical cord and, as the
umbilical arteries, carry the venous or vitiated blood through the cord
to the placenta where it is oxygenated, freed of its waste in the
chorionic villi and returned to the fetus through the umbilical vein.

As soon as the child is born and it is obliged to obtain its oxygen from
the surrounding air, its pulmonary circulation of necessity becomes
immediately more important and is greatly increased in volume. In fact,
the entire fetal circulation is readjusted to meet the needs of the new
and independent functions which the little body now assumes. The
temporary structures are obliterated, since they are no longer needed,
and the lungs and intestines become more active in compensation.

[Illustration:

  FIG. 29.—Diagram showing circulation of the blood after birth, with
    hypogastric arteries, ductus venosus, ductus arteriosus and foramen
    ovale in process of obliteration and pulmonary circulation greatly
    increased. (From The American Textbook on Obstetrics.)
]

As the ductus venosus and hypogastric arteries terminate in blind ends
and become useless as soon as the umbilical cord is cut, they soon begin
to atrophy and are obliterated within a few days after birth. This means
that less blood is poured into the right auricle, which naturally
results in relatively less tension in the right heart and an increased
pressure in the left, which tends to close the foramen ovale. The
foramen ovale does not entirely disappear at once, however, but closes
gradually, sometimes remaining open for months. Occasionally it remains
open permanently, and though some people have gone through life
comfortably with a patent foramen ovale, its ultimate failure to close
usually results in serious circulatory trouble. This is also true of the
ductus arteriosus, which sometimes, but not often, fails to close.

The rule is that as the lungs expand and an increased amount of blood is
carried to them for aëration, the ductus arteriosus deflects a steadily
diminishing stream from the right ventricle to the arch of the aorta.
Thus it gradually ceases functioning in most cases and disappears in the
course of a few weeks. The abandoned vessels may degenerate and
disappear in time or they may persist in the form of small fibrous
cords. (Fig. 29.)

Although the circulatory system shows the most elaborate adjustments to
the protection afforded by intra-uterine life, there are also other
adaptations made by the fetal organism.

The baby acquires about 90 per cent of its weight during the latter half
of pregnancy, as well as a steadily increasing proportion of solids and
a decrease of fluids in its tissues, for in its early days the embryo
consists largely of water. But for all of that, its existence and growth
in utero, and the functioning of its heat producing centre require
surprisingly little oxygen and nourishment. The amniotic fluid keeps the
fetus at an equable temperature, about 1° above that of the mother, and
as space within the uterine cavity permits of only limited movement,
there is very little combustion for the liberation of heat and energy.

=The kidneys= assume functional form at a very early fetal age, probably
about the seventh week, and the presence of albumen and urea in the
amniotic fluid suggest that small amounts of urine may be voided,
particularly during the latter part of pregnancy.

=The bowels=, on the other hand, are normally inactive, this is in spite
of the fact that the baby evidently obtains fluid, and possibly some
nutriment by swallowing amniotic fluid. But a discharge of meconium may
be caused by pressure on the cord or by any condition which interferes
with the umbilical circulation. For this reason, meconium stained fluid
escaping during labor in a head presentation may be taken as an evidence
of imminent asphyxiation, due to an interruption of the umbilical
circulation.

=The head= is the most important part of the fetus, from an obstetrical
standpoint, since the process of labor is virtually a series of
adaptations of the size, shape and position of the fetal skull to the
size and shape of the maternal pelvis. And since the pelvis is rigid and
inflexible the adjustment must all be made by the fetal head, which is
mouldable because of being incompletely ossified at birth. If the head
passes through the inlet safely, the rest of the delivery will usually
be accomplished with comparative safety. But a marked disproportion
between the diameters of the head and pelvis, or limited mouldability of
the head, constitutes a serious complication, which will be discussed
later in connection with obstetrical operations.

A baby’s head is larger, in proportion to its body, than an adult’s,
while the face forms a relatively smaller part of the baby’s than of the
adult’s head. The major portion is the dome or vault-like structure
forming the top, sides and back of the head, which in turn is made up of
separate and as yet ununited bones. They are the two _frontal_, two
_parietal_, two _temporal_ and the _occipital_ bone, with which the
wings of the _sphenoid_ bones, though less important, may be included.

These bones are not joined in the fetal skull, but are separate
structures, with soft, membranous spaces between their margins, called
_sutures_; while the irregular spaces formed by the intersection of two
or more sutures are called _fontanelles_, possibly so called by the
early observers because the pulsation of the soft tissues beneath these
spaces suggests the spurting of a fountain.

The sutures are named and situated as follows: The _frontal_ lies
between the two frontal bones; the _sagittal_ extends antero-posteriorly
between the parietal bones; the _coronal_ between the frontal bones and
the anterior margins of the parietal, while the _lambdoidal_ suture
separates the posterior margin of the parietal from the upper margin of
the occipital bone. There are also the temporal sutures between the
upper margins of the temporal bones and the lower margins of the two
parietals, but they are of no obstetrical importance, as they cannot be
felt on vaginal examination. (Fig. 30.)

There are two fontanelles of obstetrical significance. The greater, or
_anterior fontanelle_, also called the _bregma_ or _sinciput_, is
located at the meeting of the coronal, sagittal and frontal sutures. It
is diamond or lozenge shaped, about an inch in diameter and is not
obliterated during labor.

[Illustration:

  FIG. 30.—Side and top views of fetal skull giving average length of
    important diameters.
]

The smaller or _posterior fontanelle_ is the triangular space at the
inter-section of the sagittal and lambdoidal sutures, and may be
obliterated as the surrounding bony margins approach each other during
labor.

The coronal, frontal, lambdoid and sagittal sutures and the anterior and
posterior fontanelles are of greatest diagnostic value as they can be
felt through the vagina during labor. It is by recognizing and locating
these sutures and fontanelles at this time that the accoucheur is
enabled to determine the exact position and presentation of the fetus.

The fact that the skull is made up of separate bones, with soft
membranous spaces interposed between them, permits of its being
compressed or moulded to a considerable extent as it passes through the
birth canal. Opposing margins may meet, or even overlap, to such a
degree that the diameter of the head will be appreciably diminished and
permit of its passage through a relatively narrow canal. This
mouldability varies greatly, however, and the difference in the degree
of compressibility of heads of approximately the same size may spell the
difference between an easy and a difficult, or even an impossible labor.

A new-born baby’s head may be so distorted and elongated by the moulding
process that it is unsightly and gives the young mother great concern.
But the nurse can be quite confident in her assurances that the little
head will assume its normal, rounded outline in a very few days.

The five most important diameters of the new-born baby’s head are:

  =1. The occipito-frontal= (abbreviation, O.F.), measured from the
  root of the nose to the occipital protuberance, is 11.75
  centimetres.

  =2. The biparietal= (B.I.P.) is the longest transverse diameter,
  being the distance between the parietal protuberances, and measures
  9.25 centimetres.

  =3. The bi-temporal= (B.T.) is the greatest distance between the
  temporal bones and measures 8 centimetres.

  =4. The occipito-mental= (O.M.) is the greatest distance from the
  lower margin of the chin to a point on the posterior extremity of
  the sagittal suture, and measures 13.5 centimetres.

  =5. The sub-occipito bregmatic= (S.O.B.) is measured from the under
  surface of the occiput, where it joins the neck, to the centre of
  the anterior fontanelle, a distance of 9.5 centimetres.

The greatest circumference of the fetal head is at the plane of the
occipito-mental and biparietal diameters and measures 38 centimetres.
The smallest circumference is at the plane of the sub-occipito-bregmatic
and biparietal diameters, and measures 28 centimetres.

These figures, however, like all of those which it is possible to give,
simply represent averages taken from a large number of cases. Individual
variations will be found among normal babies, for boys’ heads, for
example, are usually larger than girls’ while the head of the first
child is likely to be smaller than the heads of those born subsequently.



                               CHAPTER V
              SIGNS, SYMPTOMS, AND PHYSIOLOGY OF PREGNANCY


=Signs and Symptoms of Pregnancy.= Unfortunately for all parties
concerned, the exact duration of pregnancy has never been ascertained,
since there is no way of knowing when the ovum is fertilized, the moment
which marks the beginning of pregnancy.

It is obviously impossible, therefore, to foretell exactly the date of
confinement. But labor usually begins about ten lunar months, forty
weeks or from 273 to 280 days after the onset of the last menstrual
period.

Thus the approximate date of confinement may be estimated by counting
forward 280 days or backward 85 days from the first day of the last
period. Or what is perhaps simpler, and amounts to the same thing, one
may add seven days to the onset of the last period and count back three
months. For example, if the last period began on June third, the
addition of seven days gives June tenth, while counting back three
months indicates March tenth as the approximate date upon which the
confinement may be expected.

This is probably as satisfactory as any known method of computation, but
at best it is only approximate, being accurate in about one case in
twenty. But it comes within a week of being correct in half the cases,
and within two weeks of the date in eighty per cent of all pregnancies.

Another method sometimes employed by obstetricians is to estimate the
month to which pregnancy has advanced by measuring the height of the
fundus, and thus forecasting the probable date of confinement. It is
generally agreed that the ascent of the fundus is fairly uniform and
that at the fourth month it is half way between the symphysis and
umbilicus; at the sixth month, on a level with the umbilicus; at the
seventh month, three fingers’ breadth above; at the eighth month, six
fingers above the umbilicus and at the ninth month just below the
xiphoid. At the tenth month, or term, the fundus sinks downward to about
the position it occupied at the eighth month. (Figs. 31, 32 and 33.)

This method, however, is measuring by months, not days, and leaves a
wide margin for conjecture as to the exact date.

[Illustration:

  FIG. 31.—Height of fundus at each of the ten lunar months of
    pregnancy.
]

Still another method is to count forward 20 or 22 weeks from the day
upon which the expectant mother first feels the fetus move. As we shall
see presently, this experience, termed “quickening,” usually occurs
about the 18th or 20th week, but is so irregular that it is unreliable
as a basis for computation.

The possibility of estimating the date of confinement is still further
complicated by the fact that there is evidently considerable variation
in the length of entirely normal pregnancies. Many healthy children are
born before ten lunar months have elapsed, while more deliveries occur
after than on the expected date. The first pregnancy is usually shorter
than subsequent ones, and women who are well nourished and well cared
for have longer pregnancies, as a rule, than those less favored.

[Illustration:

  FIG. 32.—Contour of abdomen at ninth month of pregnancy, or before the
    waistline drops.
]

[Illustration:

  FIG. 33.—Contour of abdomen at tenth month of pregnancy, or after the
    waistline has dropped.
]

Although the symptoms of pregnancy have been observed throughout the
ages by women who have borne children, and accoucheurs of one sort and
another who have attended them, a positive diagnosis at an early stage
of this condition is sometimes still baffling to the most experienced
obstetricians.

So many symptoms of pregnancy are known to women the world over, that an
expectant mother frequently recognizes her pregnant state at a very
early date. This is particularly true of women who have previously borne
children. But as these same symptoms closely resemble those of other
conditions, they are not infrequently ascribed to impaired health, with
the result that the pregnancy is not discovered until it is well
advanced, and then sometimes only by accident. And one even hears of an
occasional case in which a woman is entirely unaware of her condition
until she goes into labor.

The converse is also true, for women sometimes erroneously believe
themselves pregnant because of the appearance of well recognized
symptoms, which are due to other causes. This condition is known as
_pseudocyesis_, or spurious pregnancy, and is usually found in women
approaching the menopause or in young women who intensely desire
offspring. It is a pathetic occurrence, and the patient is usually so
tenacious of her belief in her approaching motherhood that the
obstetrician dispels it only with great difficulty.

For all of these and other reasons it is customary to divide the signs
and symptoms of pregnancy into three groups, under self-explanatory
headings, namely: _presumptive_ symptoms, and _probable_ and _positive_
signs. Although it is never within the province of a nurse to make a
diagnosis, it is important that she be familiar with symptoms. In
obstetrics this seems to be particularly true, and especially so if the
nurse be engaged in prenatal work or in any branch of public health
nursing that brings her in touch with possible or expectant motherhood.
The wider her grasp of obstetrical knowledge, the more helpful and
reassuring can be her relation to her patient. To this end, therefore,
we will take up the most reliable symptoms and signs of pregnancy.

=The presumptive signs=, which consist largely of subjective symptoms
observed by the patient herself, are as follows:

  =1. Cessation of menstruation.= This is usually the first symptom
  noticed. A period may be omitted from any one of several causes, as
  has been explained in Chap. II but in a healthy woman of the
  childbearing age, whose menses have previously been regular, the
  missing of two successive periods after intercourse is a strong
  indication of pregnancy.

  =2. Changes in the breasts.= These also occur early. The breasts
  ordinarily increase in size and firmness, and many women complain of
  throbbing, tingling or pricking sensations and a feeling of tension
  and fullness. The breasts may be so tender that even slight pressure
  is painful. The nipples are larger and more prominent, while both
  they and the surrounding areolæ grow darker. The veins under the
  skin are more apparent and the glands of Montgomery larger. If in
  addition to these symptoms it is possible to express a pale
  yellowish fluid from the nipples of a woman who has not had
  children, pregnancy may be strongly suspected. But practically all
  of these symptoms may be due to causes other than pregnancy, and, in
  the case of a woman who has borne children, milk may be present in
  the breasts for months, or even years, after the birth of a child.

  =3. “Morning sickness,”= as the name suggests, is nausea, sometimes
  accompanied by vomiting, from which many pregnant women suffer
  immediately upon arising in the morning. It varies in severity from
  a mild attack when the patient first lifts her head to repeated and
  severe recurrences during the day, and even into the night. More
  frequently, however, the discomfort passes off in a few hours. When
  the vomiting persists, it is termed “pernicious vomiting” and is
  usually accepted as a possible symptom of a reflex, toxic or
  neurotic condition, all of which will be discussed with the
  complications of pregnancy. Morning sickness may begin immediately
  after conception, but sets in as a rule about the sixth week and
  continues until the third or fourth month. It occurs in about half
  of all pregnancies and is particularly common among women pregnant
  for the first time. But on the other hand, it must be borne in mind
  that many non-pregnant women suffer from nausea in the morning; many
  women go throughout the entire period of gestation without any such
  disturbance, while others are entirely comfortable in the morning
  and nauseated only during the latter part of the day.

  =4. Frequent micturition.= There is usually a desire to void urine
  frequently during the first three or four months of pregnancy, after
  which the tendency disappears, but recurs during the later months.
  The inclination may be due in part to nervousness, but is largely
  caused by pressure exerted by the enlarging uterus upon the bladder,
  and not to any functional disturbance of the kidneys, as is
  sometimes believed. Pressure on the outside of the bladder gives
  much the same sensation as is experienced when the bladder is
  distended with urine. After the uterus rises from the pelvic cavity
  into the abdomen, it no longer crowds the bladder, until it drops
  during the last month or six weeks, when it again presses upon this
  organ and cause a desire to void.

  =5. Increased discoloration= of the pigmented areas of the skin, and
  also of the mucous membranes, is another early symptom of pregnancy.
  In addition to the deepened tint of the nipples and surrounding
  areolæ, the so-called _linea nigra_ appears upon the abdomen,
  extending from the pubis toward the umbilicus. There are also the
  dark bluish or purplish appearance of the vulval and vaginal
  linings; the yellowish, irregularly shaped blotches which sometimes
  appear on the face and neck, known as _chloasma_: dark circles under
  the eyes and the _striæ_ on the abdomen.

  =6. “Quickening”= is the widely used term which designates the
  mother’s first perception of the fetal movements. It occurs about
  the eighteenth or twentieth week, and is regarded by some
  obstetricians as a positive and by others as merely a strongly
  presumptive sign of pregnancy. The sensation is likened to a very
  slight quivering or tapping, or to the fluttering of a bird’s wings
  imprisoned in the hand. Beginning very gently, these movements
  increase in severity as time goes on until they become very
  troublesome toward the latter part of pregnancy, amounting then to
  sharp kicks and blows. Women who have had children can usually be
  relied upon to distinguish between quickening and the somewhat
  similar sensation caused by the movement of gas in the intestines,
  but a woman pregnant for the first time may be deceived.

There are many other possible symptoms of pregnancy, but their value is
very uncertain. Even the ones described above are not entirely
dependable, but if two or more of them occur coincidently, they probably
indicate pregnancy. Dr. Slemons sums it up by saying, “If, for example,
menstruation has previously been regular and then a period is missed,
the patient has good reason to suspect she is pregnant; if the next
period is also missed and meanwhile the breasts have enlarged, the
nipples darkened, and the secretion of colostrum has begun, it is nearly
certain that she is pregnant; whether morning sickness and the desire to
pass urine frequently are present is of no importance.”[2]

=The probable signs of pregnancy= are chiefly discoverable by the
physician after careful examination. They also are numerous and
uncertain, but there are four which are considered fairly trustworthy.

  =1. Enlargement of the abdomen=, which is first in order of
  importance, is apparent about the third month. At this stage the
  growing uterus may be felt through the abdominal wall as a tumor
  which steadily increases in size as pregnancy advances. Rapid
  enlargement of the abdomen in a woman of child-bearing age,
  therefore, may be taken as fair, but not positive, evidence of
  pregnancy. But too much reliance cannot be placed in this sign, as
  the abdomen may be enlarged by a tumor, fluid or a rapid increase in
  fat.

  =2. Changes in the size, shape and consistency of the uterus= which
  take place during the first three months of pregnancy are very
  important indications. These are discoverable upon vaginal
  examination, which shows the uterus to be more ante-flexed than
  normal, considerably enlarged, somewhat globular in shape and of a
  soft, doughy consistency. About the sixth week the so-called
  _Hegar’s sign_ is perceptible through bimanual examination, the
  fingers of one hand being pressed deeply into the abdomen, just
  above the symphysis and two fingers of the other hand passed through
  the vagina until they rest in the posterior fornix, behind the
  cervix. The lower segment of the uterus, which may be felt between
  the finger tips of the two hands, is extremely soft and
  compressible. This sign, named for the man who first described it,
  is one of the most valuable signs in early pregnancy.

  =3. Softening of the cervix= occurs, as a rule, about the beginning
  of the second month. In some cases, such as certain inflammatory
  conditions and in carcinoma, this sign may not appear.

  =4. Painless uterine contractions=, called _Braxton Hicks_ from
  their first observer, begin during the early weeks of pregnancy and
  recur at intervals of five or ten minutes throughout the entire
  period of gestation. The patient is not conscious of these
  contractions, but they may be observed during the early months by
  bimanual examination, and subsequently by placing the hand on the
  abdomen. One feels the uterus growing alternately hard and soft as
  it contracts and relaxes.

But all of the probable signs of pregnancy, like the presumptive
symptoms, may be simulated in non-pregnant conditions; hence the
appearance of any one of them alone may not be deeply significant. But
two or more occurring coincidently constitute strong evidence of
pregnancy.

=The positive signs of pregnancy=, of which there are three, are not
apparent until the 18th or 20th week, and all emanate from the fetus.

  =1. Hearing and counting the fetal heart beat= is unmistakable
  evidence of pregnancy. The sound of the fetal heart beat is usually
  likened to the ticking of a watch under a pillow. The rate is from
  120 to 140 per minute, being about twice as fast as the maternal
  pulse. So long as its rhythm is regular, however, the rate may drop
  to 100 or increase to 160 beats per minute without being considered
  abnormal, or indicative of trouble with the fetus.

  =2. Ability to palpate the outline of the fetus= is also a positive
  sign of pregnancy, if the head, breech, back and extremities are
  unmistakably made out through the abdominal wall.

  =3. Perception of active and passive movements of the fetus= is
  accepted as a third incontrovertible sign of pregnancy. There is
  some difference of opinion concerning the value of “quickening”
  alone as a positive sign of pregnancy. But if the fetal movements
  are also perceptible by the obstetrician through the mother’s
  abdominal wall or by vaginal examination, there can be no doubt
  about the diagnosis. The movements felt by placing the hand upon the
  abdomen are termed _active movements_, while the _passive movements_
  result from internal or external _ballottement_. Ballottement is
  accomplished by giving a sharp or sudden push to the head or an
  extremity, and feeling it rebound in a few seconds to its original
  position. Passive movements may be felt early in the fourth month,
  and active movements after the 18th or 20th week.


                        PHYSIOLOGY OF PREGNANCY

A general understanding of the physiology of pregnancy is indispensable
to an appreciation of the importance of observing the present-day
teachings about the hygiene of pregnancy. Upon this, in turn, must rest
intelligently administered prenatal care, one of the most important
branches of obstetrics.

The physiology of pregnancy really represents an adjustment of the
various functions of the maternal organism, which are altered to meet
the demands made upon the mother’s organs by the body which is
developing, growing and functioning within hers. These adjustments are
in the nature of an emergency service, since they come into existence
and operate only while needed, which is during pregnancy, and promptly
disappear when the need for them ceases with the birth of the child. The
mother’s body then begins to return to its normal, non-pregnant state,
which, with the exception of the breasts, which function for nine or ten
months, is accomplished in a few weeks.

But in addition to the normal changes in physiology in the course of
pregnancy, there are frequently abnormal changes, too, which may be
symptoms of grave complications. The detection of these symptoms, and
the employment of treatment which they indicate, constitute one of the
most valuable aspects of prenatal care.

Although, as might be expected, the alterations in the structure and
functions of the maternal organism are most marked in the generative
organs, there are definite changes in other and remote parts of the body
as well. And there are adjustments in metabolism, which, though not
wholly understood, are now widely recognized as important. It is pretty
generally believed that as a direct, result of pregnancy, certain
substances are created, possibly by the corpus luteum, which circulate
in the blood and definitely influence the maternal functions. It is
possible that a development of the present imperfect knowledge of these
substances will result ultimately in the discovery of a blood reaction
which will serve to diagnose pregnancy in an early stage.

At present, we know that, in spite of the creation of an infant body
weighing upwards of seven pounds, a placenta weighing more than a pound,
together with an increase of about two pounds in the weight of the
uterine muscle, all in the short span of nine months, the expectant
mother has to eat very little more during this period than she
ordinarily does to maintain her own bodily functions. This suggests a
highly developed economy in the use of nutritive material by maternal
cells.

We also know that the mother excretes waste materials for the fetus and
must assume that this requires an increased, or adjusted, functional
activity of her excretory organs, the skin, lungs and kidneys. Moreover,
the secretory activity of the previously inactive mammary glands, in
spite of their remoteness from the pelvis, suggests a nervous or
chemical stimulation, or both, which occurs only during pregnancy.

The changes in the =uterus= itself, however, are unquestionably the most
marked that take place during the period of gestation. Those that relate
to the lining have been described in a previous chapter. The change and
growth in the muscle wall are amazing. New muscle fibres come into
existence; those already there increase greatly in size and there is a
marked development of connective tissue.

The actual substance of the uterus is so increased that it is converted
from an organ weighing two ounces into one weighing two pounds. From a
firm, hard, thick walled, somewhat flattened body in its non-pregnant
state, the gravid uterus assumes a globular outline and grows so soft
that the fetus may be felt through the walls.

During the first few months the =uterine walls= increase in thickness,
but later they grow progressively thinner, until by the end of pregnancy
they are only about 5 millimetres thick.

This early growth of the uterus is doubtless brought about by general
systemic changes rather than by the presence of the contained embryo.
Evidence of this is found in the case of tubal pregnancies when there is
a definite enlargement of the uterus during the early weeks. After the
third month, however, the growth of the uterus is apparently due to
pressure which the growing fetus makes on the uterine walls.

=The cervix= does not enlarge as a result of pregnancy, but it loses its
hard cartilaginous consistency, becoming quite soft, and the secretion
of the cervical glands is much more profuse.

The changes in the =vagina= are chiefly due to increased vascularity.
The blood vessels are actually larger, the products of the glands are
greatly increased and the normal pinkish tint of the mucous lining
deepens to red or even purple.

The most important changes in the =tubes and ovaries= is in their
position because of their being carried up from the pelvis by the
enlarging uterus into the abdominal cavity. Although they increase in
vascularity, ovulation is ordinarily suspended during pregnancy.

=The abdomen= as a whole changes in contour as it steadily enlarges, and
the skin and underlying muscles are somewhat affected as a result. The
tension upon the skin is so great that it may rupture the underlying
elastic layers which later atrophy and thus produce the familiar _striæ_
of pregnancy, known variously as the _striæ gravidarium_ and the _linea
albicantes_. Fresh striæ are pale pink or bluish in color, but after
delivery they take on the silvery, glistening appearance of scar tissue,
which they really are.

In a woman who has borne children, therefore, we find both new and old
striæ; those resulting from former pregnancies being silvery and
shining, while the fresh tears are pink or blue. Striæ may be found also
on the breasts, hips and upper part of the thighs, and as they are of
purely mechanical origin, are not necessarily associated with pregnancy
alone. They may result from a stretching of the skin by ascites, a
marked increase in fat or an abdominal tumor.

The same distension that causes striæ sometimes causes a separation of
the _recti muscles_. This separation, known as _diastasis_, is sometimes
slight but frequently very marked, the space between the muscles being
easily felt through the thinned abdominal wall.

The =umbilicus= is deeply indented during about the first three months
of pregnancy. But during the fourth, fifth and sixth months the pit
grows steadily shallower, and by the seventh month it is level with the
surface. After this it may protrude, in which state it is described as a
“pouting umbilicus.”

The increased pigmentation at the umbilicus and in the median line is
scarcely to be classified among the abdominal changes, as the skin
elsewhere presents the same discolored appearance. The degree of
pigmentation varies with the complexion of the individual, as blondes
may be but slightly tinted while the discolored areas on a brunette may
be dark brown, sometimes almost black.

The changes in the =breasts= during pregnancy were practically all
included in the enumerated signs and symptoms of pregnancy. They
increase in size and firmness and become nodular; the nipple is more
prominent and together with the surrounding areolæ, grows much darker;
the glands of Montgomery are enlarged; the superficial veins grow more
prominent, and after the third month a thin, yellowish fluid can be
expressed from the nipples. This fluid, called _colostrum_, consists
largely of fat, epithelial cells and colostrum corpuscles and differs
from milk, in its yellowish color, and in the fact that it coagulates
like the white of an egg when boiled. The previously quiescent mammary
glands develop very early in pregnancy an ability to select from the
blood stream the necessary materials to produce a secretion. Colostrum
is the product of their activity until about the third day after
delivery, when milk appears.

Changes in the =cardio-vascular system= are among those which are not
altogether understood, and it is still a moot question as to whether or
not there is an actual increase in the amount of maternal blood during
pregnancy. But results of the most recent investigations suggest that
there is a definite increase in both the cells and the plasma. This
increased amount circulating through the heart subjects it to a certain
amount of strain, with the result that the organ is slightly
hypertrophied and the pulse pressure is higher.

The =respiratory organs= do not show any marked alterations. The upward
pressure of the enlarging uterus gradually shortens the height of the
thoracic cavity, but if it grows sufficiently wide in compensation,
there is no decrease in the capacity of the lungs. If this does not
occur, the patient may suffer from shortness of breath. The larynx is
sometimes reddened and edematous, a fact which explains the damaging
effects which child-bearing may have upon the voice of singers.

Changes in the =digestive tract= during pregnancy are the morning
sickness already described, and constipation. The latter is suffered by
at least one half of all pregnant women, and is due chiefly to pressure
of the uterus on the intestines, though impaired tone of the stretched
abdominal muscles may be a factor. This condition is most troublesome
during the latter part of pregnancy. There also may be gastric
indigestion causing acidity, flatulence and heartburn, and intestinal
indigestion giving rise to diarrhea and cramp-like pains. The appetite
may be very capricious during the early weeks, and become almost
ravenous later on.

Changes in the =urinary apparatus= include frequency of micturition
mentioned among the symptoms of pregnancy.

The changes in the =bony structures= of the pregnant woman are
characterized by partial decalcification. This is accounted for by the
fact that the developing fetus requires a definite amount of calcium in
the formation of its osseous structures, and unless the expectant mother
absorbs an adequate quantity from her food, it must be extracted from
the bones and similar structures, such as the teeth. Her bones and teeth
accordingly grow softer, and we have the well-known adage, “for every
child a tooth,” as well as the fact that fractures during pregnancy
unite very slowly. There are also the softened cartilages which were
referred to in connection with the anatomy of the pelvis. A part of the
softening of the pelvic cartilages, however, is due to a temporarily
increased blood supply. As will be explained in the chapter on
nutrition, this partial decalcification of the mother is entirely
unnecessary, and the newer knowledge of nutrition points the way to its
prevention.

The =skin changes= consist chiefly in the appearance of striæ and the
increased pigmentation to which reference has already been made. There
is also an increased activity of the sebaceous and sweat glands and the
hair follicles, the latter sometimes resulting in the hair becoming much
more abundant during the period of gestation. Although the pigmented
areas on the breasts and abdomen never quite return to their original
hue, the _chloasmata_, sometimes called the “masque des femmes
enceintes,” practically always disappear and leave no trace, a fact that
is frequently a comfort to an expectant mother.

The =carriage= is somewhat affected during pregnancy because the
increased size and weight of the abdominal tumor shifts the centre of
gravity. In an effort to preserve an upright position the woman throws
back her head and shoulders and finally assumes a gait that may be
described as a waddle, particularly noticeable in short women.

=Temperature changes= are probably not caused by pregnancy _per se_,
though some authorities believe that there is normally a slight
elevation during the latter part of the day.

=Mental and emotional changes= are usually included among the
alterations which occur during pregnancy, but the present status of
psychiatry suggests that this may not be altogether true. It is a fact
that many pregnant women show marked mental and emotional unbalance, but
as yet there seems to be no evidence that these states are inherently
due to pregnancy, though the same condition may recur in the same woman
each time that she is pregnant.

We shall consider this important subject more at length in the chapter
on mental hygiene, so it may be enough simply to say at this juncture
that, in a sensitively strung or uncertainly poised woman, the state of
being pregnant may be merely the last straw, so to speak, that upsets
her equilibrium; and that some other experience, which would be an equal
strain upon her slender ability to make adjustments, would result in
exactly the same mental or emotional distortion, just as certain
physical signs in pregnancy may be produced also in the non-pregnant
state, and are not, therefore, necessarily inherent to the gravid state.

Changes in the =ductless glands= are in much the same category.
Functional disturbances of these glands occurring at any time may give
rise to great irritability, excitability or to other mental symptoms. A
non-pregnant woman with even a very slight degree of hyperthyroidism,
for example, may be noticeably unstable mentally or emotionally. Since
there is evidently an inter-relation and inter-dependence of the
functions of the ductless glands, and since ovulation, the function of
one of these glands, is suspended during pregnancy, we can readily
believe that other glands would undergo changes as a result. Alterations
in the thyroid are particularly apparent as it becomes enlarged and more
active in the majority of pregnant women, as does also the anterior lobe
of the pituitary body. This increased activity may tend to compensate
for the suspended function of the ovaries. But the alterations in the
functions of the other glands, compensatory though they be in part,
apparently produce much the same sort of nervous symptoms that they are
capable of producing in a non-pregnant woman.

Taking the condition as a whole, pregnancy is usually characterized by
an improved state of health. During the first few months there may be
lassitude and loss of weight, but the latter part of the period is
notable for an unusual degree of general well being and for an increase
in flesh over the entire body, which may amount to as much as
twenty-five or thirty pounds.

About fifteen pounds of the increased weight is lost at the time of
labor and a still further reduction occurs during the succeeding weeks
when the mother’s body returns approximately to its original condition.
But it sometimes happens that the improved state of nutrition acquired
during pregnancy becomes permanent.


             There was a time when you were not,
             You merry sprite, save as a strain,
             The strange dull pain
             Of green buds swelling
             In warm, straight dwelling
             That must burst to the April rain.
             A little heavy I was then
             And dull—and glad to rest. And when
             The travail came
             In searing flame ...
             But, sprite, that was so long ago!—
             A century!—I scarcely know.
             Almost I had forgot
             When you were not.
                                         —EUNICE TIETJENS.



                                PART III
                          THE EXPECTANT MOTHER

  CHAPTER VI. PRENATAL CARE. Instruction of the Mother, Examinations,
    and Observations. Importance of Prenatal Care. The Nurse’s Part.
    Personal Hygiene of Pregnancy. Excretions. Kidneys. Urine Tests.
    Skin. Bowels. Clothes: corsets, binders, shoes. Diet. Fresh Air and
    Exercise. Rest and Sleep. Care of the Breasts. Teeth. Travelling.
    Marital Relation. Common Discomforts during Pregnancy. Nausea and
    Vomiting. Heartburn. Distress. Flatulence. Diarrhea. Pressure
    Symptoms. Swelling of the Feet. Varicose Veins. Hemorrhoids. Cramps
    in the Legs. Shortness of Breath. Vaginal Discharge. Itching. Early
    Symptoms of Complications of Pregnancy: Toxemias, Premature
    Terminations, Hemorrhage.

  CHAPTER VII. MENTAL HYGIENE OF THE EXPECTANT MOTHER. Common Causes of
    Mental and Nervous Breakdown during Pregnancy. Nurse’s Attitude.

  CHAPTER VIII. PREPARATION OF ROOM, DRESSINGS AND EQUIPMENT FOR HOME
    DELIVERY.

  CHAPTER IX. COMPLICATIONS AND ACCIDENTS OF PREGNANCY. Premature
    Terminations of Pregnancy. Definition of Terms. Abortions. Causes:
    Abnormalities of Fetus; Abnormalities in the Generative Tract; Acute
    Infectious Diseases; Mental or Emotional Stress; Physical Shocks.
    Premonitory Symptoms. Prevention, Treatment, and Nursing Care of
    Threatened, Incomplete, and Complete Abortions. Missed Abortion.
    Therapeutic Abortion. Clerical and Legal Aspects of Abortion.
    Criminal Abortion. Premature Labor: Causes, Treatment and Nursing
    Care. Ante-partum Hemorrhage. Placenta Prævia: Cause, Symptoms,
    Treatment and Nursing Care. Premature Separation of a Normally
    Implanted Placenta: Cause, Symptoms, Treatment and Nursing Care.
    Toxemias of Pregnancy. Pernicious Vomiting of Pregnancy. Symptoms,
    Treatment and Nursing Care of Reflex Vomiting, Neurotic Vomiting,
    Toxemic Vomiting. Pre-eclamptic Toxemia: Symptoms, Prevention,
    Treatment and Nursing Care. Eclampsia: Symptoms, Treatment and
    Nursing Care. Nephritic Toxemia: Cause, Symptoms, Treatment and
    Nursing Care. Acute Yellow Atrophy of the Liver: Cause, Symptoms,
    Treatment and Nursing Care. Other Important Complications of
    Pregnancy: Syphilis. Heart Lesions. Pulmonary Tuberculosis.
    Thyroidism. Pyelitis. Gonorrhea.



                               CHAPTER VI
                             PRENATAL CARE


The day is long since past when the obstetrician’s concern for his
patient began when she went into labor. The obstetrician of to-day
watches and cares for his patient throughout pregnancy, for he knows
that by so doing he greatly increases her chances of surviving the
ordeal of childbirth, and the baby’s prospect of living through that
perilous first year.

Although many conditions that result in invalidism or death occur during
labor or the puerperium, they have their beginnings during pregnancy.
Their prevention, then, or early recognition, followed by prompt and
efficient treatment, will avert many of the dreaded complications and
emergencies associated with childbearing.

In order to prevent these disasters it is necessary to supervise the
expectant mother and care for her from early in pregnancy—from the time
of conception if possible—until the onset of labor, and this is prenatal
care. It may be divided into instruction, examinations and observations,
as follows:

  1. a. Teaching the expectant mother the principles of personal
  hygiene, as especially adapted to meet her needs, and helping her to
  adopt them;

  b. Describing to her the more apparent, normal changes of pregnancy
  which she is likely to notice and perhaps not understand, and also
  the common symptoms of complications which she may detect and should
  report;

  2. The doctor’s preliminary examination, early in pregnancy,
  comprising a study of the size, shape and proportions of the pelvis,
  and later their relation to the size and mouldability of the baby’s
  head; a Wassermann test for syphilis; urinalysis and measuring the
  blood pressure. In addition to these, a complete physical survey is
  made, consisting of examinations of the heart, lungs, breasts,
  abdomen, a vaginal smear for gonorrhea, and the patient’s height,
  weight and temperature;

  3. Constant watching for early symptoms of the complications of
  pregnancy, with speedy treatment of such symptoms when they appear,
  and relieving the common discomforts of pregnancy; making
  observations upon the presentation and size of the fetus, later in
  pregnancy, in order to plan ahead of time for the delivery, if the
  patient’s condition makes this advisable.

Prenatal care of this character is essentially preventive for both the
mother and the new-born baby.

We gain a faint impression of what it may prevent when we learn that
year after year, about 17,000 young women die in the United States from
causes associated with childbirth, which are known to be largely
preventable (during 1918 the number was 23,000); and that each year
about 112,000 babies are born dead, and 100,000 of those born alive
perish during the first month of life, also from causes which are
largely controllable.

But 17,000 dead mothers and 200,000 dead babies, most of whom might have
lived, are not all that enter into the annual erection of this national
monument to neglect. There are also the unrecorded and uncounted victims
of little or no obstetrical care who have had too much vigor to succumb
completely and die, and who, therefore, live on through years of
wretched invalidism. Sometimes, it is true, their disability is slight,
so slight as to be uninteresting, and of no statistical importance. But
to the woman herself, who must resume the functions of mother,
homemaker, wife and general utility person, the disability may be enough
to make life endlessly dreary and discouraging. And yet, she is perhaps
only just below the physical level upon which she could live her life
with joy and eagerness; and proper care when the baby came would have
left her upon that level.

The effect of the mother’s impairment reaches far beyond her own
invalidism, for such women are not as well able to rear and care for
their children satisfactorily as are fresh, buoyant mothers. Whatever
makes for good obstetrics, therefore, makes for a better race, and, as
we shall see later, measures that tend to improve the health of the race
tend to lessen the hazards of childbearing.

Ideal prenatal care, then, would really begin during the expectant
mother’s own infancy, but we must be content here with a description of
the care that is advisable, and desired, for expectant mothers from the
beginning of pregnancy.

There is considerable difference of opinion among physicians concerning
the stage of pregnancy at which it is desirable to see the expectant
mother for the first time, and the frequency of subsequent observations.
But the growing tendency is for the doctor to see his patient as early
as possible, for the preliminary examination, and to follow a fairly
uniform routine in the kind and frequency of subsequent observations,
and in the personal hygiene which the patient is advised to adopt.

Thus, it has become generally customary to see the patient, take her
temperature, pulse and blood pressure and make a urinalysis once a month
during the first half of pregnancy, and then every two weeks until the
onset of labor, or possibly once a week toward the end. These periodic
examinations keep the physician constantly informed about his patient’s
condition, and frequently disclose very early symptoms of a complication
which is easily amenable to treatment at that stage, but which might
prove serious if allowed to progress unchecked. Albumen in the urine,
for example, or an increase in the blood pressure, in a woman who had no
other symptoms, would suggest the advisability of watching for further
symptoms of toxemia; while an elevation of temperature, even though the
patient was not uncomfortable, might lead to the early discovery of
tuberculosis, pyelitis or some other infection not otherwise apparent.

It is this stitch in time that means so much to the pregnant woman and
her expected baby.

But the most painstaking obstetrician requires the co-operation of his
patient in innumerable little ways, if she is to have the fullest
benefits of his skill; for it is not so much what the doctor advises
that counts as how the patient lives.

It is at this point that nurses are more and more being given
opportunity for immensely gratifying service. A private patient who is
in the care of an obstetrician is, of course, supervised and instructed
by her doctor. But there are other patients—women who cannot afford this
individual care, but who need care none the less. And it is these
expectant mothers that nurses are helping the doctors to instruct in the
principles of right living, and are watching for danger signs, through
visiting nurse societies, out-patient departments of hospitals and
through prenatal clinics.

The character and extent of the instruction and supervision given by the
nurses is, of course, decided by the medical board of her organization,
and is often affected by the conditions under which the work is
conducted. The nurses in a rural community, for example, may take blood
pressures and test urine for albumen, while in cities, rich in doctors
and medical institutions, these observations might not be among their
duties.

In addition to this definite relation to expectant mothers, nurses are
meeting them, unofficially and informally, at every turn; women who are
needing, but not receiving, care from a doctor or an organization; women
who are puzzled or troubled over their condition, but do not know where
nor how to obtain advice; women who could employ a physician but do not
appreciate the importance of his care.

Every nurse should recognize it as her duty to advise an unsupervised,
pregnant woman to place herself under medical care, no matter under what
conditions she meets her.

In the discharge of her duties, the nurse will sometimes need no little
ingenuity to adapt the routines of prenatal care, as prescribed by her
organization, to the mentality, traditions and varied demands of the
daily lives of her patients. But this will have to be done, for though
in a general way the needs of all expectant mothers are the same, their
circumstances and personalities are infinitely varied.

It may require undreamed-of tact and resourcefulness to convince a
patient that details of care, which seem wholly unrelated to her or her
baby’s welfare, will actually increase their chances for life and
health. For this reason, it is of almost prime importance that the nurse
win her patient’s friendship and confidence. She will then scarcely
realize that she is being taught, but will do and continue to do as she
is advised, because of an almost insensible reliance upon the judgment
and sincerity of her counsellors.

It is not the single examination of a specimen of urine that counts, nor
the exercise taken with pleasure and enthusiasm during the first few
days of its novelty. It is not the rest, fresh air nor proper food,
taken according to rule for a week or two, that will keep her fit. It is
the aggregate and repetition of the infinite number of details that make
up the expectant mother’s mental and physical life during twenty-four
hours in each day, seven days a week, throughout forty long weeks, that
grow longer and more monotonous as pregnancy advances; it is the mosaic
that she makes out of the minutiae of her daily life that counts. And
paradoxical as it seems, she must shape her days to meet her own and her
baby’s needs with such steady persistence that she finally lives them
almost unconsciously of what she is doing, and also without
introspection.

Obviously, then, the expectant mother’s mental attitude is of
considerable importance.

She should in general continue the diversions, work and amusements that
she is accustomed to and enjoys, if they are not contra-indicated;
cultivate a cheerful, hopeful frame of mind; guard against being
self-centred and over watchful of symptoms, and at the same time not
adopt the dangerous habit of uncomplainingly ascribing to pregnancy all
of the discomforts and unfamiliar conditions which may arise. In short,
to forget that she is pregnant in so far as that is consistent with the
care that she should take of herself.

She should understand that childbearing is a normal function, but, like
other normal functions, may become abnormal if neglected; and that a
sick pregnancy is not a normal one.

In connection with the patient’s mental attitude and her anxieties, the
nurse may be of great comfort in helping to dispel superstitions and the
widely credited and depressing beliefs concerning maternal impressions.

After one has traced the development of the human body in the uterus,
and even faintly understood its growth and method of nourishment, it is
impossible to believe that the mother’s thoughts or experiences could in
any way deform or mark her child, or alter its sex. That the mother’s
“reaching up,” for example, could slip the cord around the unborn baby’s
neck is manifestly absurd, as well as the previously mentioned
superstitions about the eight-month baby’s slender chances for survival.

But superstitions are always fondly cherished, for, as Gibbon tells us,
“the practise of superstition is so congenial to the multitude, that if
they are forcibly awakened, they still regret the loss of their pleasing
vision.” We can scarcely wonder however that even intelligent and
educated people hold utterly improbable beliefs about pregnancy, for the
most fanciful of them are quite as easy to believe as the thing that we
know actually occurs—the development of a human body from a single cell.

These fanciful beliefs, however, are sometimes serious matters to the
young woman who is traveling, day by day, toward a great and mysterious
event, and they should not be laughed to scorn, but explained away
seriously and with sympathy. She may be told quite simply, that after
conception she gives her baby only nourishment; that the baby’s
connection with her body is through the cord and placenta, in neither of
which are there nerves; and that even if the blood could carry mental
and nervous impulses, which it cannot, the maternal and fetal blood
never come in actual contact with each other. A tale which she has heard
about a woman who saw something distressing and later gave birth to a
marked child may cease to worry her if she is reminded of the
innumerable babies, beautiful and unmarked, which are born to women who
have had equally shocking experiences. It is scarcely probable that any
woman lives through the ten months of pregnancy without seeing, hearing
or thinking things that would disfigure a baby if maternal impressions
could produce such results, and yet newborn babies are very rarely
blemished. Although the ultimate causes of marks and deformities of the
fetus are not definitely known, they are probably to be found in faulty
development very early in the embryonic life, and, therefore, are not
preventable.


                          HYGIENE OF PREGNANCY

In coming to the expectant mother’s personal hygiene, we find that an
understanding of the physiology of pregnancy almost of itself indicates
what this hygiene should include. We shall take it up in detail,
however, and describe what is at present considered a reasonable outline
of the routine desired for the average pregnant woman, who is found by
careful examination to be normal and free from complications, and
needing only to keep well. But, as has been said, and must be oft
repeated, the ideal routine cannot be deposited _en bloc_ upon all
expectant mothers. It must be adjusted to the individual and to her
circumstances.

EXCRETIONS. Although, as has been explained previously, the pregnant
woman does not have to eat for two, she does have to eliminate the waste
and broken-down products from two bodies, through her own excretory
organs: the kidneys, skin, lungs and bowels. True, the amount of the
baby’s ash is not great, but is of such a character that its elimination
is important and increases the strain upon the maternal excretory
apparatus.

=Kidneys.= One of the most important factors in prenatal care is
promoting the function of the kidneys and watching their output. It is
probably more true of the kidneys than of any other organs that a slight
abnormality which would not give trouble at other times may, if
neglected during pregnancy, produce very grave results. The amount of
urine passed in twenty-four hours should be measured, and a specimen
prepared, once a month during the first half of pregnancy and every two
weeks afterward. If less than three pints are passed the patient should
know, without further instruction, that she is not taking enough water
and must take more. And so it is the nurse’s duty, in this connection,
to convince her patient of the importance of drinking an abundance of
water, and periodically measuring her urine and sending specimens to the
doctor for examination.

She is very likely to follow such advice if she is told that by so doing
she will help to prevent convulsions, for most women know of this
complication and dread it.

In preparing a specimen, a covered or corked receptacle which is large
enough to hold the voidings for twenty-four hours, must be thoroughly
washed and scalded; in it should be collected the total amount of urine
voided during twenty-four hours and kept in a place that is cool enough
to prevent putrefactive changes. The additional precaution of putting a
teaspoonful of chloroform into the receptacle is wise and does not
injure the specimen. The patient should be instructed to empty her
bladder at any designated hour, and then keep all urine voided from that
time until the corresponding hour on the following day. The urine should
be shaken so as to mix thoroughly the different voidings, and six or
eight ounces poured into a bottle which has been washed and scalded,
carefully corked and labelled with the date, patient’s name, address and
the total amount for twenty-four hours.

If the nurse is called upon to test for albumen, either of the following
will serve, unless the doctor specifies a test which he prefers:

_Heat and acetic acid test_: Fill a test tube about half full of urine
and gently boil the upper part in a flame; add five drops of 2% to 5%
acetic acid and again boil gently. The presence of albumen is shown by a
white cloud in the upper part of the urine.

_Esbach’s test_: Fill a test tube half full of urine; add eight or ten
drops of Esbach’s Solution. The presence of albumen is shown by a white
flocculent precipitate in the upper part of the urine.

=Skin.= Under ordinary conditions, the skin serves as a protective
covering for the body, helps to regulate the body temperature and acts
constantly as an excretory organ. This last function is performed by the
sweat glands which open upon the surface of the body, and we are told
that there are some twenty-eight miles of these minute, tube-like
structures in the skin. These glands should be, and usually are,
constantly active and they daily pour upon the surface of the body an
oily substance that lubricates the skin and something over a pint of
water containing waste matter, that is inimical to health if retained in
the body. We are not aware of this constant excretion of fluids, which,
therefore, is termed “insensible perspiration,” but it continues even in
cold weather and must not be interrupted if health is to be preserved.
If the oil, dust, particles of dead skin and the waste material left by
dried perspiration are allowed to remain upon the surface of the body,
they will clog the pores and gland openings and thus interfere with
their functions. The removal of this material, then, is an imperative
health measure. This is done automatically, in part, for the fluid
evaporates, and much of the solid matter is rubbed off on the clothing.
But the most important aids to the skin’s activity are the drinking of
plenty of water, deep breathing, exercise and warm baths; baths serving
the double purpose of removing waste matter already on the surface, and
stimulating the glands to increased activity in giving off still more.

This explains the importance to the expectant mother of thorough and
regular bathing, and of keeping her body evenly warm. Most doctors
advise a warm, not hot, shower or tub bath every day, with soap used
freely over the entire body, followed by a brisk rub. The best time for
this warm, cleansing bath, as a rule, is just before retiring, as it is
soothing and restful and tends to induce sleep. Very hot baths are
fatiguing, particularly during pregnancy, and should never be taken
except with the doctor’s permission; but cold baths usually may be
continued throughout pregnancy if the patient is accustomed to them and
reacts well afterwards. Under these conditions the morning cold plunge,
shower or sponge is beneficial, as it stimulates the circulation and
thus promotes the activity of the skin. Some doctors forbid tub bathing
of any kind after the seventh month, on the ground that as the patient
sits in the tub her vagina is filled with water, which may contain
infective material. Should labor occur shortly afterward an infection
might result. As the patient is heavy and somewhat uncertain on her
feet, there is also the danger of her slipping and falling while getting
in or out of the tub.

Other doctors permit tub baths throughout pregnancy, up until the onset
of labor; while as to hot foot baths, there seems to be no reason for or
against them at any time during the nine months.

Bathing in a quiet stream or lake is apparently harmless, but sea
bathing, if the surf is rough, is inadvisable because of the impact of
the waves upon the abdomen and the general violence of the exercise.

The importance of keeping the body evenly warm throughout pregnancy
cannot be overemphasized, for a sudden chilling or wetting may so check
the excretory function of the skin as to throw a greater burden upon the
kidneys than they can meet, in their effort to eliminate the skin’s
share of the body waste. Accordingly, a single chilling will sometimes
be enough to precipitate an eclamptic seizure. This may be one reason
why we see eclampsia more frequently during cold weather or after a
sudden drop in the temperature after warm or mild days.

=Bowels.= The bowels, also, eliminate a certain amount of toxic material
and if they do not move thoroughly at least once a day, deleterious
substances are absorbed into the system and an extra tax is placed upon
the kidneys in an attempt to excrete them.

Unhappily, a large proportion of pregnant women suffer from
constipation, particularly during the later weeks, though women who have
always had a tendency of this kind may have trouble from the very
beginning of pregnancy. Sluggish peristalsis, due to pressure by the
enlarged uterus upon the intestines, is probably the prime cause, though
impaired tone of the stretched abdominal muscles also may be a factor.

The bowels should move regularly every day, and to this end the patient
should regularly attempt to empty them, immediately after breakfast
usually being the best time. The importance of regularity in making the
attempt cannot be overemphasized, even though the bowels do not always
move.

Exercise, the intake of an abundance of fluids, eating fresh fruit,
coarse vegetables and bulky cereals, such as bran, to stimulate
peristalsis, and drinking a glass of hot or cold water upon retiring and
arising are all laxative in their effect. As the regular use of enemata
only tends to lessen intestinal tone, they should not be employed unless
ordered by the doctor; nor should the patient take cathartics without
the doctor’s order. But she may safely increase the amount of her fluids
and the bulk of her food, in order to regulate her bowels, and may also
take senna and prunes cooked together. A simple way of preparing prunes
for this purpose is to pour a quart of boiling water over an ounce of
senna leaves and allow it to stand for about two hours. A pound of well
washed prunes should soak over-night in this infusion, which has been
strained, and the combination cooked until tender. They may be sweetened
with two tablespoons of brown sugar, and the flavor improved by adding a
stick of cinnamon or slice of lemon while they are cooking. Half a dozen
of these prunes, with some of the syrup, may be taken at the evening
meal to start with, and increased or decreased in number as necessary.

CLOTHES. The chief purpose of clothes under all conditions is to aid in
keeping the body warm, thus helping to preserve an even circulation and
the activity of the sweat glands. As has been pointed out, this is of
especial importance during pregnancy. The expectant mother’s clothes
should be not only sufficiently warm, but they should be equally warm
over the entire body. They should be light and porous, and fairly loose,
so as not to interfere with the circulation or other body functions.
There must be no pressure on chest or abdomen; no tight garters, belts,
collars or shoes.

The patient’s clothes, like every other detail in her care, will have to
be adapted to her environment and mode of living. If her house is well
and evenly heated during the cold months, she may quite safely dress
lightly while indoors; if it is not, she should be advised to wear
underwear with high neck, long sleeves and drawers, both indoors and
out, except when the weather is warm enough to induce free perspiration.
At all times, however, the warmth of her clothing must be adjusted to
the temperature of the home, the climate and to the state of the
weather.

Bearing in mind the importance of diversion and amusements, it becomes
apparent that in addition to the hygienic qualities mentioned, the
expectant mother’s clothes should be as pretty and becoming as is
consistent with her circumstances. She is much more likely to go about
and mingle with her friends if she is fortified with the consciousness
that she is becomingly and well dressed. Which, of course, is not
peculiar to pregnant women.

The expectant mother’s clothes should be so made that their weight will
hang from the shoulders instead of from the waistband.

And that brings us to the question of _corsets_, one of the most
discussed garments in her wardrobe. Women who have not been accustomed
to wearing corsets will scarcely feel the need of adopting them during
pregnancy, except perhaps during the later weeks when the heavy,
pendulous abdomen needs to be supported for the sake of comfort. This is
particularly true of women who have borne children and whose flaccid
abdominal walls give but poor support to the uterus.

Women who have been wearing comfortable, well-fitting corsets probably
will not feel the need of making a change until the third or fourth
month. By this time the uterus has pushed up out of the pelvis into the
abdomen and accordingly the corsets must be so constructed that they
will accommodate themselves to an abdomen that is steadily increasing in
size and also changing in shape; will provide support for both abdomen
and breasts and still not compress nor disguise the figure. To be
entirely satisfactory in their adjustability, the maternity corsets must
be made of very soft material and have elastic inserts and side, as well
as front or back lacings. They should extend well down in front and fit
snugly over the hips. The upper part may be fitted with adjustable
shoulder-straps that will support the breasts and help to suspend some
of the abdominal weight from the shoulders; but at the same time will
not interfere with the development of the breasts nor compress the
nipples. Many women find great comfort in wearing a short-waisted
maternity corset and a brassiere.

The front-lace corset is usually found to be the most satisfactory, for
the patient may lace it from below upward while lying on her back. This
enables her to draw it in snugly about the hips, below the abdomen, and
adjust the garment to the abdominal curve so as to really support,
without compressing the uterus. Other excellent corsets lace both front
and back and are capable of very comfortable adjustments. If the nurse
clearly understands the purpose of a maternity corset, she will be able
to explain to her patient why the same style as she ordinarily wears, no
matter how large, will not be satisfactory during pregnancy, and may be
even harmful.

Even a properly fitting maternity corset may become uncomfortable during
the last few weeks of pregnancy, and have to be replaced by an abdominal
supporter of linen or rubber. And when this stage is reached, even the
woman who has worn no corsets may be made more comfortable by adopting
such a support, particularly at night. There are many admirable binders
on the market, or the nurse and patient may fashion some such an one as
is shown in Figs. 34, 35, 36 and 37. Comfortable and inexpensive
stocking supporters, which meet all practical requirements, may be made
by the patient from tapes or strips of muslin. (Figs. 38 and 39.)

[Illustration:

  FIGS. 34, 35, AND 36.—Front, side and back views of home-made binder
    for supporting heavy, pendulous abdomen during later weeks of
    pregnancy. It is adjusted as the patient lies down, the ends being
    crossed in the back and pinned to the lower margin of the front,
    thus giving additional support.

  Also breast-binder made of a straight strip of soft cotton material,
    10 or 12 inches wide and 2 yards long. This is crossed in front and
    held with safety pins, the ends being carried over the shoulders and
    pinned to the back of the binder. It should be snug below the
    breasts but loose over the nipples. The openings over the nipples
    show how this binder may be used to support the breasts of the
    nursing mother. (From photographs taken at the Maternity Centre
    Association, New York.)
]

[Illustration:

  FIG. 37.—Abdominal binder used in Figs. 34, 35 and 36, showing darts
    at top of front to fit it over the abdomen.
]

[Illustration:

  FIGS. 38 AND 39.—Front and back view of home-made stocking supporters
    made of webbing or 1–inch strips of muslin and a pair of child’s
    side garters. The straps are sewed together in the back, but pinned
    in front to permit adjustment as the abdomen enlarges. (By courtesy
    of the Maternity Centre Association, New York.)
]

The expectant mother’s _shoes_ also merit considerable attention and
thought. Her feet are larger than usual because they are likely to be
somewhat swollen during the latter part of pregnancy, and the increased
weight of her body tends to spread them. This added weight also
increases the strain put upon the arch and flat foot is a not infrequent
result, unless the arch is well supported. Another reason for the need
of proper shoes is that, as pregnancy advances, the body’s centre of
gravity changes. The pregnant woman becomes unstable on her feet and
needs low, broad, firm heels. They need not necessarily be flat at
first, if the patient has been accustomed to wearing moderately high
ones, for the sudden lowering of the heels may injure her arches. High
French heels, of course, should be avoided because they not only
increase the difficulty and discomfort of walking but cause backache, as
well, by forcing a posture that adds to the pressure on the lower part
of the abdomen. They also increase the risk of turning the ankles,
tripping and falling.

The patient’s shoes should be an inch longer than those she ordinarily
wears; they should have broad toes and fit snugly over the instep, in
spite of being large. If her shoes are not comfortable the expectant
mother will tire easily and tend to take less exercise than she should.

DIET.—It is advisable for both nurse and patient to understand, and keep
clearly in mind, the purposes which are served by the food intake of the
expectant mother, and what foods and practices will defeat, and what
will accomplish these purposes. Her food should provide nourishment, as
under ordinary conditions; it should promote the functions of her skin,
kidneys and bowels, because of the waste from her own and her baby’s
body which she must excrete; it should be adequate to build and nourish
the baby’s body without drawing materials from the mother’s own tissues.
Moreover, proper food during pregnancy is an essential factor in
preparing the mother to nurse her baby, which is as important as
nourishing the fetus _in utero_.

In order to accomplish these various ends the patient must not only eat
suitable food, but she must digest and assimilate it. This requires that
she sedulously guard against overeating, constipation and indigestion of
any kind. Indigestion may be avoided during pregnancy exactly as it is
at other times, by eating proper food; by cultivating a happy frame of
mind; by exercise, fresh air, adequate rest and sleep.

If accustomed to a fairly simple, well-balanced, mixed diet, the average
expectant mother will need to make little or no change, excepting to
make her evening meal light if it has been a hearty one; for she uses
her nutritive material with surprising economy and does not have to “eat
for two,” as is so commonly believed. It is a safe general principle
that an amount and kind of food that keeps the expectant mother,
herself, in a state of health and good nutrition, is favorable to
satisfactory development of the fetus until the latter part of
pregnancy.

She will probably be able to understand why this is true if it is
explained that her baby gains nine-tenths of his weight after the fifth
month, and one-half of his weight during the last eight weeks of
pregnancy; also that if she takes too much food, the excess is stored up
in both her own and the baby’s tissues; if too little, the fetus is
nourished and her body deprived.

It is very unwise for the mother to diet with the idea of keeping the
child small, and thus make labor easy, unless she is so ordered by her
physician. In general, it is the size of the fetal skull that makes
labor easy or difficult, and not the amount of fat distributed over the
child’s body. And if the patient cuts down the minerals in her diet to
make the fetal bones soft, and thus increase the compressibility of the
skull, the fetus will extract lime from her bones and teeth, so that the
only effect is upon herself.

The expectant mother’s meals should be taken with clock-like regularity,
eaten slowly and masticated thoroughly. Three meals a day will usually
suffice during at least the first half of pregnancy. The possible need
for slight additional food after that may be supplied more
satisfactorily by lunches of milk, cocoa or broth and crackers or toast,
between meals and upon retiring, than by taking larger meals. But if the
patient has a tendency to nausea, early in pregnancy, she will often be
able to control it by taking a little food regularly five or six times
daily, instead of the usual three meals.

In general the expectant mother should eat an abundance of fruit and
vegetables, taking at least some uncooked fruit and a green salad,
daily, and making sure that her food contains a good deal of residue,
such as is provided by fruit and coarse vegetables. This residue
increases the bulk of the intestinal contents, which stimulates
peristaltic action and thus helps to overcome the tendency toward
constipation. As fat is less easily digested, and more likely to cause
nausea during pregnancy, than carbohydrates, it is better for the
patient to eat no more fat than usual, but to supply the additional
energy needed after about the sixth month, by taking a little more
starch. But after all, only a slight increase is needed, and this
chiefly during the last three or four weeks.

It is of the greatest importance that every pregnant woman drink an
abundance of fluid, to act as solvent for her food and waste material,
and stimulate the activity of her kidneys, skin and bowels. She needs
about three quarts daily, and most of this should be water, the
remainder consisting of milk, cocoa, soup, and other liquids.

Alcohol should not be taken under any circumstances, except upon a
doctor’s order, while tea and coffee, if taken at all, should be used
with moderation. The patient should be advised to avoid fried food,
pastry, rich desserts, rich salad-dressings and any other food which
would ordinarily disagree with her. In fact any article of food that
disagrees with her in a non-pregnant state should be avoided during
pregnancy, no matter how valuable it may be as nourishment to the
majority of people.

On the other hand, it sometimes happens that an article of food which is
likely to disagree with other people will be easily digested by the
pregnant woman, and if it adds to the pleasure of her meals should not
be taboo, for the enjoyment of one’s meals promotes digestion. So-called
“cravings” are not as common in fact as they are in rumor, but the
expectant mother may have a capricious appetite and display strange
likes and dislikes for certain dishes, possibly because of her tendency
to be nauseated.

The average pregnant woman with no symptoms of complications will be
able to supply her needs, and at the same time keep within the bounds of
safety if she selects her diet from such groups as the following:

  ANIMAL FOODS.—Milk and eggs are the most satisfactory, but for the
  sake of variety, and to tempt her appetite, she will usually be
  allowed to have fish, the various kinds of shell fish, beef, lamb,
  chicken or game rather sparingly, preferably only once a day. Pork,
  veal, and goose should be avoided as a rule, and particularly by
  women with whom they ordinarily disagree.

  SOUPS.—Thin soups and broths have little food value, but, because of
  their appetizing flavor and aroma, are an aid to digestion, and
  frequently will stimulate a flagging appetite and prompt the patient
  to eat and assimilate more than she would without them. Cream soups
  and purées obviously have a high food value, and, like thin soups
  and broths, also supply a definite amount of fluid which the patient
  must have.

  VEGETABLES.—The group of vegetables usually designated as “leafy”
  are of even greater importance to the expectant mother than they are
  to the average person. Of these, she may safely eat onions,
  asparagus, celery, string beans, spinach, and make a point of taking
  a green salad, such as lettuce, cress, or romaine, at least once
  daily. Sweet potatoes, white potatoes, rice, peas, Lima beans,
  tomatoes, beets and carrots may also be eaten with safety as a rule,
  but cabbage, cauliflower, corn, egg-plant, Brussels sprouts,
  parsnips, cucumbers, and radishes should be taken with great caution
  and avoided altogether if they cause flatulence or any kind of
  distress.

  FRESH FRUITS.—A necessary part of the diet is fresh fruit, and among
  those fruits which are both beneficial and harmless are apples,
  peaches, apricots, pears, oranges, figs, cherries, pineapple,
  grapes, plums, strawberries, raspberries, blackberries, and
  grapefruit. These are more likely to be laxative if eaten alone, as
  before breakfast and at bedtime. Cooked fruits are also valuable
  articles of diet, but are probably less laxative than raw fruit.
  Some of the citrus fruits, oranges, grapefruit and lemons, should be
  taken daily because of their antiscorbutic properties.

  CEREALS.—For their nourishing and laxative qualities, cereals are
  important, and their food value is increased by the milk and cream
  which are usually taken with them. Cooked cereals should invariably
  be cooked longer than the usual directions suggest. Bran, eaten
  alone, as a cereal or in combination with other grains, is an
  excellent laxative.

  BREADS.—Graham, cornmeal, whole wheat and bran bread are all good.
  In general the expectant mother will be on the safe side if she eats
  sparingly, if at all, of very fresh or hot breads and hot cakes.

  DESSERTS.—Desserts are very important for they add to the
  attractiveness of most people’s meals, and if wisely chosen and
  properly made, may supply a good deal of easily digested
  nourishment. They may include, in addition to fresh and cooked
  fruits and preserves, ice-cream, a wide variety of custards, creams
  and puddings made largely of milk, eggs, and some ingredient to give
  substance and firmness, such as gelatine, cornstarch, rice, tapioca,
  farina, arrow-root and similar materials.

FRESH AIR AND EXERCISE. If the nurse has become aware of the value of
promoting all of the normal physiological processes of the pregnant
woman, she already realizes how important are fresh air and exercise to
the patient and her expected baby.

The average individual uses every minute the oxygen contained in four
bushels of air, and since the pregnant woman takes in through her lungs
the oxygen for both herself and the baby, she must have an adequate
quantity of constantly changing air to supply at least this amount. She
should spend at least two hours of each day in the open air. If the
weather is so stormy or severe as to make it undesirable for her to go
out from under cover, because of the danger of getting wet or chilled,
she may wrap up well and take her airing on a protected porch or in a
room with all of the windows wide open. But this is only a part of it,
for the air in her house, or rooms, must be kept fresh all day by being
constantly changed; this requires a steady inpouring of fresh air and
outpouring of stale, vitiated air.

A very good way to accomplish this is to have one or more windows open
slightly, top and bottom, all the time. But there must be no sudden
changes of temperature, nor drafts, for fear of chilling the patient’s
skin. At night she should sleep in a room with the windows open, taking
care to be well protected by light, warm coverings.

Each detail of the expectant mother’s daily routine seems to be more
important than the last. And so when we come to the question of regular
outdoor exercise we almost think that whatever else may be neglected,
this is indispensable, since it promotes digestion, stimulates the
functions of the skin and lungs; steadies the nerves, quiets the mind
and promotes sleep. And more than that, walking, which is probably the
most satisfactory form of exercise, also strengthens some of the muscles
that are used during labor. But exercise is downright injurious if
continued to the point of fatigue, no matter how little has been taken.
Each woman must be a law unto herself in this matter, therefore, and
must be impressed with the importance of stopping before she is tired.
She should start by walking only a short distance, increasing gradually
until she is able to walk possibly as much as an hour in the morning and
an hour in the afternoon, if she can do so without fatigue.

All violent exercises and sports are of course to be avoided,
particularly swimming, horseback riding, and tennis. While motoring and
carriage riding are pleasant diversions, they cannot be classed as
exercise. They should be taken only in comfortable vehicles and over
smooth roads, so that there will be no jarring nor jolting, and the
patient should not do the driving herself.

A certain amount of exercise, in the shape of light housework, may be
taken indoors. It is distinctly beneficial, if not continued to the
point of fatigue, both because of the exercise which it provides, and
also the diversion and interest, for these promote mental and physical
health. But this indoor exercise must not interfere with, nor to any
degree replace, the daily exercise out of doors; nor must it include
heavy work, such as washing, sweeping, heavy lifting, running a sewing
machine by foot nor much running up and down stairs. However, the amount
and kind of work which a woman may comfortably and safely do are so
related to what she has been accustomed to, that it is not possible to
offer more than general suggestions, which will help in the planning for
each individual. All patients will do well to moderate their activities
at the time when they would ordinarily menstruate.

There are patients to whom massage and gymnastics are beneficial during
pregnancy, when for some reason the out-of-door activities are
contra-indicated. This might be true of a patient with heart trouble,
for example, or one who is being kept in bed to avert an abortion, and
accordingly is a matter which must be entirely in the doctor’s hands.

REST AND SLEEP. When we studied the bony structures of the female body,
we found that as the abdominal tumor of pregnancy increased in size and
weight, the body’s centre of gravity changed and the pregnant woman was
required to make a constant, though unconscious effort to stand upright.
This is probably one reason for the fatigue which expectant mothers so
often feel without apparent cause, and for the fact that they are likely
to tire rather more easily than usual.

Accordingly, the patient may have to rest frequently during the day, in
order to avoid the ill effects of fatigue. She should work and exercise
in short periods rather than long, always lying down when tired, and for
an hour or two after the noon meal. She must be particularly careful not
to be over-active, nor to overexert herself at the time when
menstruation would occur were she not pregnant, for fear of bringing on
an abortion. This precaution is particularly important during the first
four months, the period when abortions occur most frequently.

Since eight hours’ sleep is usually considered necessary to keep the
average person in good condition, the pregnant woman cannot expect to
progress satisfactorily with less. In fact, it is so important to her
general well-being that she should be taught and persuaded to do
everything in her power to secure it.

Fresh air during the day and open windows at night; prudent eating; a
comfortable bed furnished with warm but light bedding; warm baths; a hot
water bag to the feet and a hot drink upon retiring are all conducive to
sleep.

But in addition to these, and perhaps of even more import, are
cheerfulness and a tranquil, untroubled state of mind. It is well for
the nurse to make a mental note of that intangible but influential fact,
for she can usually exert a great deal of influence in shaping her
patient’s or patients’ moods.

BREASTS.—Breast feeding is the most urgent single need of the baby, for
whose coming we are making preparation, and practically every mother,
excepting those with definite physical disability, can supply this need
of her baby’s, if she gives herself proper care both before and after
its birth. It is true, that everything that promotes her general health
helps to prepare her to nurse the baby, but there is need also for care
of the breasts and nipples themselves, to make the nursing satisfactory,
and to prevent sore nipples and possibly even breast abscesses.

Briefly, this local care consists of supporting heavy breasts, but
avoiding pressure; bringing out flat or retracted nipples and toughening
the skin which covers the nipples.

After they become heavy and uncomfortable the breasts may be supported
by brassieres, which are snug below the breasts, loose over the breasts
themselves and suspended from shoulder straps; or by some such binder as
is shown in Figs. 34, 35, and 36, which answers the same purpose.

If the patient’s nipples are flat or retracted, she should begin about
the fifth month to make them more prominent in order that the baby may
grasp them easily. There are several ways of accomplishing this, all of
them in the nature of massage, but whatever is done must be done
regularly and persistently. One simple and effective method is to grasp
the nipple between the thumb and forefinger, draw it out, hold it for a
moment, then release it and allow it to retract. This should be done
over and over, two or three times daily. Or the unstoppered opening of a
warm bottle may be placed over a flat nipple and held in place until the
nipple is drawn up into the neck of the bottle as it cools and forms a
vacuum.

The toughening of the nipples should be begun eight weeks before the
baby is expected. There are two general methods which seem to give about
equally satisfactory results; one is to harden the skin with astringents
and the other is to soften it with ointments. In either case, the
nipples should first be scrubbed gently with a soft brush or cloth, warm
water and soap, for about five minutes night and morning. They may then
be rubbed with lanoline, cocoa-butter or vaseline and covered with a
piece of clean soft cloth or gauze, to protect the clothing; or they may
be bathed with a wash consisting of equal parts of a saturated solution
of boracic acid and 95% grain alcohol. Tannin, benzoin and a great
variety of astringents are also used, and with satisfactory results. But
the essential is to decide upon some method of preparation, of proved
value, and then persuade the patient to employ it with faithful
regularity.

CARE OF THE TEETH. It is important that the pregnant woman give her
teeth excellent care, for in addition to the conditions with which we
all have to cope, she must combat the effect of her tendency to have an
acid stomach. And her teeth are prone to decay and crumble, since the
fetus extracts lime salts from her bones and teeth, unless she is
careful to take in through her food a supply which is adequate to meet
the fetal needs. It is therefore advisable for her to place herself
under the care of a dentist, as soon as she knows of her pregnancy, and
have any necessary work done at that time, as delay may be serious.

Some physicians think it advisable to have an X-ray examination of the
teeth made as a routine, in order to discover any existing pockets of
pus at the apices of devitalized teeth. They feel, that because of the
somewhat unstable condition of the pregnant organism, these localized
infections are more of a menace to the expectant mother than to the
ordinary individual, and that in some cases they should be drained.

As to daily care of the teeth, the patient should use dental floss and
brush her teeth after each meal, and use an alkaline mouth wash several
times daily, particularly after vomiting and before retiring. Much
damage may be done by the acid secretions in the mouth if they are
allowed to bathe the teeth through the long night stretches. Common
cooking-soda, lime-water or milk of magnesia make excellent mouth
washes.

TRAVELING. In this day, when people travel so much and so easily, it is
common to hear discussions as to its advisability for the prospective
mother. Like many other details of prenatal care, this point cannot be
settled once for all women, nor for all stages of pregnancy. Each
patient’s general condition must be considered; her tendency to nausea;
the length of the journey and the ease with which it may be made, and
whether or not she has ever had, or been threatened with an abortion. In
general, traveling is less hazardous for the expectant mother to-day
than it was formerly, to just the extent that it causes less strain,
discomfort and fatigue. But as a rule it is considered wise for her to
avoid traveling during the first sixteen and the last four weeks of
pregnancy, and at the times when menstruation would ordinarily occur.
Obviously, then, in the interests of prevention, a journey should not be
undertaken at any time without a physician’s approval.

The _marital relation_ is usually considered inadvisable in all cases
after the eighth month of pregnancy, and among women who have had
abortions or miscarriages it is best omitted throughout the entire
period of gestation. This is particularly true of elderly primiparæ.


                  COMMON DISCOMFORTS DURING PREGNANCY

There are many minor disturbances which overtake the pregnant woman, and
though not serious in themselves, her comfort is greatly increased by
having them relieved, and this promotes her general welfare. The relief
of these discomforts, when they are slight or only temporary, sometimes
resolves itself into little more than a question of nursing. When long
continued or severe, however, they constitute complications which the
doctor treats accordingly.

=Nausea and vomiting= are probably the commonest disturbances of
pregnancy and vary from the slightest feeling of nausea when the patient
first raises her head in the morning, to persistent and frequent
vomiting which then assumes grave proportions and is termed “pernicious
vomiting.” Although it is possible that even the slightest nausea is due
to a mild toxemia, there can be no doubt that in many instances the
patient’s mental attitude is an important factor.

Dr. Slemons makes the interesting observation, that women who are
unaware of their pregnancy for several months are seldom troubled with
nausea, while those who erroneously believe themselves to be pregnant
will suffer from this well-known symptom of pregnancy, until convinced
of their mistake. The nausea then subsides.

As there is a marked tendency toward nausea during early pregnancy, it
may be brought on by slight causes which would not produce it under
ordinary conditions. Anxiety, grief, fright, shock, incessant worrying,
fits of rage, introspection, brooding, or any great emotional stress may
cause nausea when the diet is entirely satisfactory. But indiscretions
in diet, rapid or over-eating also may cause nausea and vomiting in the
expectant mother.

We seem to get back to the principles of personal hygiene as preventives
of nausea during pregnancy, for simple, light food, taken in small
quantities five or six times daily, eaten slowly and masticated
thoroughly; the cultivation of a happy frame of mind; exercise and fresh
air all tend to avert this very uncomfortable condition. Its prevention
is of great importance, as the habit of vomiting is easily acquired but
broken with difficulty. The common causes of nausea, and their
prevention, should therefore be explained to the average patient, for
she will then be able to help herself in warding it off.

Should “morning sickness” occur, however, it may be relieved in many
cases, by eating two or three hard, unsweetened crackers or pieces of
toast, with nothing to drink, immediately upon awakening and then lying
still afterwards for half or three quarters of an hour. The sufferer
should then dress slowly, sitting down as much as possible while doing
so, and eat her regular breakfast. Lying flat, without a pillow, and
keeping very quiet for a little while after meals, or whenever feeling
the slightest premonitory symptom, will frequently prevent, and also
relieve nausea, and sometimes comfort is derived from the use of either
hot or cold applications to the abdomen. Some patients are relieved by
having hot coffee or even a full breakfast before arising.

=Heartburn=, so called, which is experienced by many pregnant women, has
nothing to do with the heart. It is caused solely by an excess of
hydrochloric acid in the stomach, and is usually described as a burning
sensation first in the stomach, then rising into the throat. It may be
prevented, as a rule, by taking a tablespoonful of olive oil, or a
cupful of cream or rich milk, fifteen or twenty minutes before meals,
and avoiding fat and fried food at the meals immediately following.

This apparent inconsistency in treatment is due to the facts that fat
taken into the empty stomach tends to inhibit the secretion of acid,
while fat and fatty foods taken with meals tend to prolong their stay in
the stomach and this in turn stimulates the secretion of hydrochloric
acid, the thing to be avoided.

A patient with a tendency to heartburn will be wise, therefore, if she
generally eliminates oils, fats and fatty foods from her meals, and
definitely avoids them when the burning occurs. Since the painful,
burning sensation is directly due to an excess of acid in the stomach,
the obvious step toward relief is to take an alkali at once. A
tablespoonful of lime-water is often satisfactory; a teaspoonful of
sodium bicarbonate in water; a small piece of magnesium carbonate may be
nibbled by itself, or any alkaline water that the patient fancies may be
taken.

=Distress.= There is another form of discomfort, often vague and
ill-defined, commonly called “distress” and occurring after eating. It
may be neither heartburn nor pain, but resemble both and make the
patient very miserable. It is usually seen in women who eat rapidly, do
not chew their food thoroughly or eat more at one time than the stomach
can hold comfortably. The prevention, naturally, lies in taking small
amounts of food slowly and masticating thoroughly.

=Flatulence= may or may not be associated with heartburn, but it is
fairly common and rather uncomfortable. It is usually due to bacterial
action in the intestines, which results in the formation of gas. As has
been previously explained, the pressure of the enlarged uterus upon the
intestines and absence of pressure by the abdominal muscles, retards
normal peristalsis, with the result that gas sometimes accumulates to a
very uncomfortable extent. It is clear, therefore, that a daily bowel
movement is of prime importance in preventing and relieving flatulence,
and also that foods which form gas should be carefully excluded from the
diet. The chief offenders are parsnips, beans, corn, fried foods, sweets
of all kinds, pastry and very sweet desserts. Various intestinal
disinfectants are employed, as in non-pregnant states, and also yeast
cakes, cultures of Bulgarian bacilli and artificially fermented milk
containing bacteria that are antagonistic to the gas-producing forms.

In the opinion of some doctors, flatulence is sometimes an early symptom
of toxemia.

=Diarrhea.= Although diarrhea is not one of the commonest disturbances
of pregnancy, neither is it infrequent, and must be borne in mind in
connection with digestive troubles. Of course, a pregnant woman may have
an attack of diarrhea from the same causes that produce it in any one
else, and its relief would be obtained by the usual methods, chiefly the
correction of dietetic errors. But on the other hand, it may be due
entirely to the uterine pressure on irritable intestines. Like
flatulence, it is regarded by some doctors as a possible symptom of
toxemia.

PRESSURE SYMPTOMS. Under the general heading of pressure symptoms are
several forms of discomfort resulting from pressure of the enlarged
uterus on the veins returning from the lower part of the body, thus
interfering with the flow of blood back to the heart. As both the cause
and relief of these symptoms are associated with the force of gravity,
the nurse will usually know what to do in mild cases without further
explanation. In general the heavy abdomen should be supported by a
binder or properly fitting corset, the patient should keep off her feet
as much as possible and elevate the swollen part.

The commonest pressure symptoms are swollen feet, varicose veins,
hemorrhoids, cramps in the legs and shortness of breath, and though they
may appear at any time during the last half, of pregnancy, they grow
progressively worse as pregnancy advances.

=Swelling of the feet= is very common, and when very slight may not be
serious nor particularly uncomfortable. The edema may be confined to the
back of the ankle, which grows white and shining, or it may extend all
the way up the legs to the thighs and include the vulva. Sitting down,
with the feet resting on a chair, or lying down with the feet elevated
on a pillow will naturally give a certain amount of relief. If the
swelling and discomfort are extreme the patient may have to go to bed
until they subside, but very often she will secure adequate relief by
elevating her feet for even a little while, several times a day. But
while employing these harmless, and clearly indicated measures, to make
her patient comfortable, the nurse must be keenly alive to the fact that
while edema of the feet, legs and vulva may be of solely mechanical
origin, they are also symptoms of toxemia, about the most dreaded
complication of pregnancy. And as recognition of the earliest signs of
toxemia is among the triumphs of prenatal nursing, even the slightest
swelling must be reported to the doctor and immediate steps taken to
have the urine measured and examined.

[Illustration:

  FIG. 40.—Right angled position, to relieve edema or varicose veins of
    feet and legs. (By courtesy of The Maternity Centre Association.)
]

=Varicose veins= are not peculiar to pregnancy, but are among the
pressure symptoms which frequently accompany this condition during the
later months, particularly among women who have borne children. The
superficial veins in the legs will often be equal to the tension put
upon them the first time, but will give way as the strain is repeated
during subsequent pregnancies. The distension of the veins is not
serious as a rule, but may be very uncomfortable; this, coupled with the
unsightly appearance, sometimes has a bad mental effect. Varicose veins
may occur in the vulva, but they are usually confined to the legs, and
both legs are about equally affected. But as the position of the child
_in utero_ may exert greater pressure on the right than on the left
side, the veins on that side may be more distended; or the right side
alone may be affected.

Relief is obtained by keeping off the feet, and particularly by
elevating them and also by the use of elastic bandages. When a woman
finds it difficult or nearly impossible to sit or lie down for any
length of time, she may accomplish a great deal in a few moments by
lying flat on the bed with her legs extended straight into the air, at
right angles to her body, resting against the wall or head board, as
shown in Fig. 40. This right-angled position for five minutes, three or
four times a day will accomplish wonders in reducing varicose veins.

In addition to posture, a spiral elastic bandage will give relief and
help to prevent the veins from growing larger, if applied freshly after
each time that the leg is elevated. The most satisfactory bandages, from
the standpoint of expense, comfort and cleanliness, are of stockinette
or of flannel cut on the bias, measuring three or four inches wide and
eight or nine yards long. If made of flannel, the selvedges should be
whipped together smoothly so that there is neither ridge nor pucker at
the seam. The bandage should be applied spirally with firm, even
pressure, starting with a few turns over the foot to secure it, and
leaving the heel uncovered, carried up the leg to a point above the
highest swollen vessels. As a rule, it may be left off at night.

There are satisfactory elastic stockings on the market, but they are
expensive, often cannot be washed and seem to offer no advantage over
the bandages.

Engorged veins in the vulva may be relieved by lying flat and elevating
the hips, or by adopting the elevated Sims’ position for a few moments,
several times a day. (Fig. 41).

[Illustration:

  FIG. 41.—Elevated Sims’ position to relieve varicose veins of the
    vulva. (By courtesy of The Maternity Centre Association.)
]

=Hemorrhoids= are virtually varicose veins which protrude from the
rectum, but, unlike those in the legs, are extremely painful. As it is
the straining incident to constipation that causes these engorged veins
to prolapse, this condition constitutes one more reason for preventing
constipation. A pregnant woman whose bowels move freely every day rarely
has hemorrhoids.

Should hemorrhoids appear, the first step is to have them gently pushed
back into the rectum. The patient can usually do this for herself, quite
satisfactorily, after lubricating her fingers with vaseline or cold
cream. Lying down, with the hips elevated on a pillow; the application
of an ice bag, cold cloths or witch-hazel compresses to the anus will
almost always give relief. When the condition is severe, the physician
may prescribe medicated ointments, lotions or suppositories, but
operation is seldom resorted to during pregnancy, for fear of bringing
on labor prematurely. Sometimes the hemorrhoids are worse during the
first few days after labor, but as a rule they disappear with the
removal of the cause, which in this case is pressure made by the
enlarged uterus.

=Cramps in the legs=, numbness or tingling may be caused by the pressure
of the large, heavy uterus upon nerve trunks supplying the lower
extremities. The recumbent position; applying heat and rubbing the
painful areas will often give comfort.

=Shortness of breath= is sometimes very troublesome toward the end of
pregnancy, and, as may be easily seen, is due to the upward, and not
downward pressure of the uterus. For this reason it is aggravated by the
patient’s lying down and relieved by her sitting up or being well
propped up on pillows, or a back rest.

=Vaginal discharge.= The normal vaginal discharge is greatly increased
during the latter months of pregnancy, as was pointed out in Chapter V,
so that ordinarily the moderately profuse yellowish or white discharge
at this time has no particular significance. Its existence should be
noted, however, and brought to the doctor’s attention, for a very
profuse discharge is likely to be regarded as a possible evidence of
gonorrhea. For this reason a smear is usually made, when the discharge
is excessive, to establish or eliminate this diagnosis; if it is
positive, it indicates the necessity for treatment to safeguard both
mother and baby.

As the normal vaginal discharge has antiseptic properties, it should not
be removed by douches, which many patients are eager to take; but if it
is irritating and causes itching or burning the patient may be made
entirely comfortable by avoiding the use of soap and by bathing the
vulva with a solution of sodium bicarbonate or with olive oil.

=Itching of the skin= is a fairly common discomfort, and is possibly a
result of irritating material being excreted by the skin glands and
deposited upon the surface of the body. The local irritation usually may
be allayed, if not very severe, by bathing the uncomfortable areas with
a solution of sodium bicarbonate, or a lotion consisting of a pint of
lime-water, half an ounce of glycerine and thirty drops of carbolic
acid. It is a good plan, also, for the patient to increase the amount of
fluids which she is taking, in order to promote the activity of the
skin, kidneys and bowels, and thus dilute the material that may be
responsible for the itching and increase its elimination through all
channels. In other words the itching may be due to a mild toxemia.

Some women complain of discomfort caused by the stretching of the skin
over the enlarged abdomen, which becomes so tense it feels as though it
might tear apart. There is a very old and widely current belief that
this sensation may be relieved by rubbing the abdomen with some kind of
an oil or ointment. And, moreover, that such oiling will not only
increase the elasticity of the superficial layers of the skin, but the
deeper layers as well, and that by this means striæ may be prevented.
There seems to be little foundation for the fear that the skin will
tear, or belief in the efficacy of the oiling, but if a woman fancies
that she is safer and more comfortable after oiling her abdomen, there
is certainly no reason why she should not do so.


               EARLY SIGNS OF COMPLICATIONS OF PREGNANCY

It is evident that by teaching the principles of personal hygiene to the
expectant mother so convincingly that she will adopt them, and
sometimes, by employing simple nursing procedures to relieve the various
discomforts of pregnancy, much will be accomplished toward promoting the
welfare of both the patient and the expected baby. But this is not
enough. The nurse must also be on the alert to detect and report the
early symptoms of complications, for there may be times when she will be
the first one to see the patient after a symptom has developed.

The principal complications of pregnancy which are amenable to
preventive or early treatment are the toxemias, premature terminations
of pregnancy and hemorrhage.

The causes of these conditions and the details of treatment and nursing
care are so inextricably associated with each other that they are
discussed together and at some length in another chapter. But their most
conspicuous, early signs are briefly noted here, since watching for them
constitutes a part of routine prenatal care.

The =toxemias= are apparently caused by disturbed metabolism and
impaired or inadequate excretory processes. Their prevention is to be
accomplished largely by observing the principles of personal hygiene
previously described, and in quickly treating early symptoms. One of the
commonest of these symptoms is headache, sometimes persistent and very
severe. Others are disturbed vision, dizziness and more persistent or
severe vomiting than could reasonably be called “morning sickness”;
puffiness under the eyes, or elsewhere about the face, or of the hands;
anything more than very slight swelling of the feet and ankles; high or
increasing blood pressure; mental depression; albumen in the urine,
amounting to more than a trace, and epigastric pain, are all possible
symptoms of toxemia. A patient in whom even one of these symptoms
appears is usually placed under close observation; frequently put to bed
and her diet restricted to milk, or even water, until the symptoms
subside.

The common symptoms of =premature termination of pregnancy=, (an
abortion, miscarriage or premature labor) are bleeding, with or without
pain in the small of the back, followed by cramp-like pains in the
abdomen. Bleeding or a bloody discharge, therefore, irrespective of pain
should be regarded as a symptom of pending labor and the patient should
be put to bed promptly, and kept quiet. Preventive treatment, after
pregnancy has begun, consists largely of rest, particularly at the time
when menstruation would ordinarily occur; avoidance of physical shocks
and of overwork during the later weeks. Prolonged failure on the part of
the patient to feel fetal movements or of the nurse or doctor to hear
the fetal heartbeat after they have once been manifest usually indicates
the death of the child and precedes its expulsion.

=Bleeding=, or a sudden increase in the size of the uterus with a rapid
pulse or general symptoms of shock, may be the symptoms of hemorrhage
caused by placenta prævia or premature separation of a normally
implanted placenta; upon the appearance of any one of these signs the
patient should be put to bed and kept absolutely quiet.

To sum up, we find that the following symptoms may be forerunners of
serious complications, and therefore should be watched for and reported
to the doctor immediately upon their discovery:

  1. Persistent or severe vomiting.

  2. Persistent or severe headache.

  3. Dizziness.

  4. Disturbed vision or the appearance of black spots before the eyes.

  5. Puffiness under the eyes, or elsewhere about the face.

  6. Swelling of the feet, ankles or hands.

  7. Sharp pains, particularly in the epigastric region.

  8. Prolonged failure to feel fetal movements after they have once been
       felt.

  9. Cessation of the fetal heartbeat, or a marked change in its rate or
       rhythm.

 10. Bleeding, or a bloody discharge.

 11. Pain in the lumbar region, followed by cramp-like pains in the
       abdomen, before the expected date of confinement.

 12. Albumen in the urine.

 13. High, or increasing blood pressure.

 14. Unwarranted mental depression, anxiety or apprehension.

These are generally accepted as the cardinal danger signs of pregnancy,
any one of which, alone or in combination with one or more of the
others, is of significance and should be reported to the doctor at once.

When all is said and done, our wish for the expectant mother is for
little more than that she shall live a normal, wholesome life; that she
shall be willing, and also be able to weave into her every day life the
principles of personal hygiene which every one should adopt; that she
shall be carefully watched for complications throughout the entire
period of pregnancy, and that these complications shall be speedily
treated.

Adoption of personal hygiene, then, and prevention of complications by
their early detection and treatment—these we want for every woman who is
looking forward to motherhood.

For lack of these things there are sick and blind and maimed babies and
invalid women; there are lonely, motherless children and bereaved
mothers in every corner of our land.



                              CHAPTER VII
                 MENTAL HYGIENE OF THE EXPECTANT MOTHER


It is only once in a long time that the obstetrical nurse has a patient
who is suffering from such a marked mental disturbance that her
condition is diagnosed and treated as a psychosis. But more often than
not she has a patient who is secretly suffering a good deal of mental
stress and pain, which is not recognized and not treated.

In fact, by virtue of the deep significance of the states of pregnancy
and motherhood, and the long period of time through which they continue,
it is scarcely possible for them not to produce a mental effect of some
sort upon the average woman. Sometimes this effect is a very happy one;
but all too often it is quite the reverse. It is safe to say that the
majority of maternity patients are passing through deep waters, and the
nurse’s usefulness to these charges will be greatly broadened if she has
at least some understanding of the cause and character of these mental
sufferings.

In the ordinary course of events, from birth to death, we all of us are
being called upon continuously to adjust ourselves to all sorts of
experiences, situations and emotional strains peculiar first to early
childhood, then the school epoch, the period of emancipation from home
and finally to the life work. And as we take our way, we develop habits
of meeting the sorrow and disappointments that come; the anxiety,
criticism, success, failure, illness, poverty and what not.

Some individuals habitually face the issues of life, whether large or
small, and habitually overcome difficulties for themselves and for other
people. They are described by the psychiatrists as being grown up, or
psychologically evolved.

Others follow the course of least resistance; never face their problems;
are thoughtless and inconsiderate in their demands; are unable to make
decisions and accordingly live upon the mental and moral strength of
others. Such people are referred to as being infantile, or
psychologically undeveloped. They are not unlike the baby who gets “what
he wants when he wants it” by the unreasoning method of screaming and
pounding upon his high chair with a spoon. He is scarcely more
irresponsible than the hysterical adult who gains her point by
developing a headache or fainting, flying into a rage or tearing her
clothes and smashing china. Such people make little or no adjustment to
unsatisfactory conditions and have poor capacity for endurance or
sacrifice.

With not a few women this poor capacity is a result of lifelong
indulgence or protection by unwise parents, and they never reason out
the question of obligation or responsibility because they never have to.
Everything is done for them. All rough places are so consistently
smoothed out that they never entertain the idea that effort or
adaptation on their part could possibly be in order.

There are others who cherish trouble, make difficulty where there need
be none and steadfastly refuse to acknowledge good fortune or see the
silver lining. This is their method of securing attention, much as the
baby cries or screams to the same end.

Between these extreme types are ranged people who display innumerable
shadings and degrees of psychological development. Some cope
satisfactorily with their life situation because that situation is
neither difficult nor beyond their capacity for adjustment. Others need
a little bolstering up now and then to bridge over the gap between the
demands made upon them and their ability to meet these demands. Still
others have to be literally carried when disaster overtakes them, or
they break down.

As might be expected, our ability to stand the big tests or strains that
may come to us; our manner of meeting them and their effect upon us
depend very largely upon how we have habitually met the lesser trials
that have come to us previously, how we have habitually adjusted
ourselves to the experiences of life. For after all the test of life is
a measure of one’s capacity for adaptation to these experiences and to
surroundings.

The strain that measures our ability to adapt ourselves may be one big
stroke or it may be a long drawn out trial which would be of small
consequence were it of short duration. It is the persistency and the
monotony of a lesser care that so often wears away the rock of our
endurance.

If a strain proves to be too much for our adaptive capacity, and we
break down under it, our manner of breaking will be characteristic of
us, or an accentuation of what might have been called our bendings under
lesser difficulties in the past.

The expectant mother is no exception to these general principles. She
does not develop nervous breakdowns either more or less frequently than
the non-pregnant woman who is under an equal strain. She is merely a
human being whose adaptive capacity is being tested. But the test is
severe for there is, perhaps, no greater strain upon the adaptive
capacity of a human being than that to which a woman is subjected during
pregnancy, confinement and the months directly following the birth of a
child. She may be expected to meet this strain just as she would meet
another equally great demand upon her adaptive capacity.

Otherwise, pregnancy of itself does not affect the brain or the mind,
any more than it affects the kidneys, for example. But like the kidneys,
the brain or the mentality may have difficulty in coping with the
additional strain that is put upon it during pregnancy, and if the
strain is greater than the ability to function in either case there is
likely to be a breakdown.

It is now generally believed, therefore, that there is no psychosis
which is typical of pregnancy. But that during pregnancy one may see all
types of neuroses and psychoses which are frequently associated with
other severe strains upon the individual. We see depressions,
excitement, paranoid trends, delusional and hallucination states,
hypochondriasis, obsessive fears, anxiety attacks, hysterical
manifestations as well as the so-called “neurotic vomiting.”

Aside from the delirium-like experiences often associated with the
toxemias of pregnancy, none of the above mentioned conditions are
referable to any disturbance of the physiologic or metabolic functioning
of the patient, so far as science can demonstrate. They are merely
accentuations of poor habits of adjustment to difficulties, which the
patient has betrayed all her life.

The psychoses of pregnancy and the puerperium require skilful handling
and the nurse is not called upon to care for them except under the
constant supervision of a physician.

She is, however, constantly brought face to face with facts of fear and
worry and conflicting desires which play a tremendous rôle in the
well-being of the patient during the months of pregnancy and
confinement. The chief source of happiness and of unrest is the mother’s
attitude toward the coming of the baby.

Just here it may be helpful to have a word about what is meant by
“conflict” and the “mechanism” which produces it. As a starting point
there must be a recognition of the fact that the deepest and most
influential feminine instinct is maternal—the desire to have and care
for a child. It is primal. It has been in women since the dawn of
Creation and although in many women it is put down, stifled or
complicated by other desires, it cannot be destroyed. Not a few women
deny this instinct, but back of their denial is some reason, conscious
or unconscious, which is not harmonious with the idea of motherhood. The
woman may be selfish, for example; she may be vain and not want to lose
her grace and charm through pregnancy.

When some such feeling is strong it conflicts with the deeper one of
maternalism and there is a lack of harmony or a “conflict.” It is just
that—a conflict or struggle between two emotions and the result is a
state of mental unrest. A homely comparison might be found in the
digestive disturbance which may follow an effort to cope with two
incompatible articles of food at the same time. The patient may have
nausea, vomiting, pain or even more severe symptoms. The severity of the
symptoms and their effect upon the patient depend somewhat upon the
average vigor or stability ordinarily displayed by the digestive tract
under a lesser strain. People with so-called delicate digestions may be
greatly upset by combinations of food which others are able to cope with
and suffer little or no inconvenience.

When a well evolved individual has a desire which results from our
culture or civilization (a wish to preserve her grace or her luxuries,
for example), that is in conflict with a deeper primal instinct, she
will often be able to reason out the situation, and in the case of
approaching motherhood, decide that the baby is worth any sacrifice, any
inconvenience, and go joyfully through her period of expectancy. She
will glory in the consciousness of her ability to realize the supreme
purpose of a woman’s creation. In other words she adjusts herself to the
situation, harmonizes the discordant desires and is mentally
undisturbed.

A less well evolved woman, like a person with a delicate, easily upset
digestive tract, will have difficulty in making an adjustment—in
harmonizing her instinctive desire for motherhood and her acquired
desire for comfort, attention and the things demanded by convention. The
conflict may be violent enough to greatly upset her. This is
particularly true if the demands of our cultural state make it necessary
for the patient to keep this turmoil below the surface with no safety
valve to relieve the pressure.

This problem of the mother’s attitude toward the coming of the baby is
very general and varied as well. The mothers of families already large
and poverty stricken are usually quite frank in expressing their dismay
over the expected birth and lament the prospect of this extra burden,
but at the same time they decide to make the best of it and they succeed
in making a pretty satisfactory adjustment. Moreover, they do not feel
the necessity for concealing their feelings or do not “repress” them,
and accordingly find some relief in being candid.

The mothers of the middle and upper classes, however, are often
surrounded by an atmosphere of conventional codes that are stifling to
mental honesty. Accordingly they are less genuine in expressing their
true attitude toward the coming child. To many of them—the selfish,
self-centered type—the new baby will bring inconvenience rather than
hardship. The importance of their ego will be dimmed. There will be a
cutting down of luxuries and of freedom for social activities, and
increased responsibility with closer confinement to the home. And while
they give utterance to joy and pleasure over the prospect of having a
baby, this does not quite reflect their inmost feelings.

Not a few women find an outlet for the tension caused by their conflict
by being fretful and irritable or through conduct which they would have
displayed if annoyed or chagrined about something other than the
approaching birth of a child. Because of this outlet they are not so
likely to break down.

It is by no means the rôle of the nurse to pry into the affairs of her
patients, but she can often become the avenue of ventilation for a
patient suffering from a mental conflict, and with very happy results.
For one of the most helpful things that such a person can do is to talk,
and little by little bring out and put into words the buried thoughts,
dreads or shame that may be causing the conflict. Very often the
listener will say surprisingly little and will express no definite
opinions, but by a sympathetic, responsive attitude encourage the
worried person to pour out the content of her mind.

Another source of unrest in the mind of the expectant mother, especially
during her first pregnancy, is the fear of death during labor, or the
development of complications. She is reluctant to speak of these things
to her husband, family or friends, lest they laugh at her or regard her
as a coward at the prospect of pain. Or she may be unwilling to distress
those who love her by admitting her fear.

Fear of death and disease are very common traits and equally common is
the hesitancy we all have in acknowledging them. And so the patient
keeps these things to herself and turns them over and over in her mind;
buries them and tries to put them out of her thoughts. But they stick.
Her fear and her dread color everything that she hears, and very often
and unwittingly her friends and relatives make matters worse by
recounting the unhappy experiences of other mothers that they have
known. At the same time these communicative friends do not tell of the
immeasurably greater number of women who have come through safely, nor
does the patient dwell upon these in her mind. She remembers the women
who had convulsions or fever or a hemorrhage, or the one who died.

The nurse who sees the human being beyond the obstetrical case will
appreciate the pain which such a conflict causes and by being
sympathetic and responsive will try to make it easy for her patient to
talk it over. The patient should invariably find her nurse ready to
listen and to give assurances of the proved value of the precautions
that are being taken to safeguard her and her baby. For not a few women
are torn, not alone by the fear that things will go wrong with
themselves, but with the fear that harm may come to the baby that they
long to take into their arms and keep.

Other women are upset because of a habitual inability to make decisions
that will bring about a marked change in their lives. They find it
difficult to accept pregnancy because its consummation will definitely
alter their state. Life may prove to be more satisfactory because of the
baby, or it may be less so. But in any event it cannot be the same and
they dread making an irrevokable change.

Still another cause of distress is the current belief as to hereditary
influence, and the possible effect upon the unborn child of unsuccessful
attempts at abortion which the patient has made early in her pregnancy.
Every family has its skeleton of a relative who is “queer,”
feeble-minded, epileptic or who has died in a sanitarium or state
hospital for the insane. The fear that the child may “strike back” to
one of these individuals, and suffer retardation in his mental
development, often amounts to little less than an obsession.

The nurse may often dispel such an anxiety by drawing upon even her
slender knowledge of embryology and reassure her patient that we know
very little about inheritance, but that the evidence is that environment
and early training are such important determining factors, that a child
is more likely to be affected by the example and guidance of his parents
during his first few years than through transmission from their blood.

Attempted abortions during the early months of pregnancy are more common
than is generally supposed. Of their effect upon the offspring we know
very little. We do know, however, that an attempt to produce an abortion
often gives rise to a good deal of secret worry on the part of the
expectant mother. It is the nucleus of many a vague depression during
pregnancy, not only because of remorse over wrong-doing, but also
because of fear that the child who is coming, in spite of the attempt to
destroy him, may suffer the consequences. This is another of the
anxieties which the patient can seldom bring herself to discuss with her
family or even with her physician. But it so occupies her mind that she
may allude to it, in a roundabout way, to the nurse who becomes her
constant companion, as though describing the act of a friend. The nurse
who reads between the lines may often relieve a serious tension caused
in this way by discussing the matter casually and impersonally. Above
all she must not assume an attitude of disapproval, for it is not within
her province to go into the ethics or morality of the act. Her function
at this time is solely to give the patient an opportunity to ventilate
her thoughts.

Another real cause of worry during pregnancy is the patient’s fear of
her own inadequacy to care for and to rear a child in the best possible
manner. The idea of assuming the physical care and the moral guidance of
another human being is often little less than terrifying to a young
woman whose responsibilities in the past have been shared or carried by
some one else. Or to the one who has gone through life hunting for, and
exaggerating, the difficulties in a situation, before attempting to meet
it; and perhaps to the one who is habitually conscientious in all of her
relations with other people.

Still another type, and one which presents a much simpler situation, is
the expectant or young mother who is scarcely suffering from a mental
strain, but has a little let-down in her customary poise and
self-control, such as we so often see in convalescents and chronic
invalids.

Pregnancy, labor, and the puerperium are normal physiological processes,
it is true, but they impose a physical tax and the patient is sometimes
physically tired and after labor may suffer something akin to surgical
shock.

The physical weariness may be due to an insufficiency on the part of
some one of the internal secretions. But in any event the patient feels
tired and may show the same sensitiveness or irritability that any of us
show when tired and exhausted and she will merit considerable
forbearance on the part of those who surround her.

But when we understand, even faintly, the conflicts which are possible
in the mental life of the expectant mother—the incompatibility of her
age-old maternal instinct and the desires born of our culture and
civilization, it is not difficult to see that her adaptive capacity may
be sorely tested.

The cause of her trouble is not apparent to the patient’s associates but
they are aware of its manifestations in the shape of moods, temper
tantrums, strange conduct and all sorts of nervous and mental symptoms.
If such a patient does not get relief through talking things over, but
continues to brood and worry alone—to repress the cause of the
conflict—she may not be sufficiently adaptive to endure its ravaging
effects, and have a nervous or mental breakdown as a result.

It is hoped that the nurse may understand from this discussion that the
conflicting thoughts which her patient does not discuss, but buries and
keeps below the surface of her mind, are the factor that works harm in
her mental life. If the nurse can get her patient to ventilate these
thoughts, they will be robbed of much of their power to injure. But this
patient, like any one else, will talk freely only when she talks
spontaneously and she will do this only when she senses in her nurse a
sympathy and a sincere concern over her troubles.

Accordingly, the nurse should try to so attune herself as to be
receptive to evidences of the patient’s moods and impulses, and possibly
from a chance remark get a clue to the repressed desires which are
working harm. She will then be able to meet the patient on that ground.

It is not that the relief of the patient by means of mental catharsis is
necessarily a nurse’s function. It is simply that a patient suffering
from a conflict should talk freely to some one, it does not matter who,
and by virtue of the long hours which they spend together, the nurse
very often happens to be that some one. People do not ordinarily find it
easy to lay bare their inmost thoughts before the members of their
family and the patient may not discuss her conflict with her physician,
which of course is the ideal, because his visits are relatively short
and do not favor the ambling, desultory conversation into which the
nurse and patient may so easily drift.

On the other hand, the nurse must not look for trouble, in order to be
useful, nor by the slightest intimation give her patient an idea that it
is a common practice among expectant mothers to worry, be fearful or
alarmed. If the patient displays these emotions the nurse must be ready,
but she must not be suggestive. Her attitude must be entirely passive
for she is simply a receptacle into which the patient may pour her
conflicting thoughts. But the receptacle must be always available.

The positive course which the nurse may take is to be unfailingly
hopeful and courageous and take it for granted that her patient is
filled with joy and pride over her pregnancy. The gratification is there
by instinct, but it may be so buried and complicated by other emotions
that the patient is not wholly aware of it. It may be surprisingly
clarifying for the nurse to say quite simply, “But, after all, it is a
wonderful thing to have a baby and you are proud and glad that he is
coming. He will be worth any sacrifice.”

If the nurse will so far put herself in the patient’s place that she is
glad, sincerely glad, that the baby is coming, this attitude will
communicate itself to the expectant mother. Happiness and enthusiasm are
very infectious.

To sum it all up: The expectant mother who habitually has not made
satisfactory adjustments during her life may be bending under a mental
burden that is a little heavier than her slender, unevolved powers can
bear. The nurse’s part is to recognize this possibility and realize that
while she cannot attempt to correct the difficulty she can be a prop by
simply being optimistic and reassuring. A patient who may be suffering
from a mental conflict is often saved from a breakdown by little more
than a ready sympathy which is born of understanding.



                              CHAPTER VIII
   THE PREPARATION OF ROOM, DRESSINGS AND EQUIPMENT FOR HOME DELIVERY


It sometimes devolves upon the nurse to give advice in selecting and
preparing the room to be used for a home confinement, and very often to
help the prospective mother in preparing and assembling adequate
equipments for the delivery and for the care of herself and the baby
afterwards.

Under such circumstances the nurse must feel under compulsion to do all
in her power to make the home delivery satisfactory, from the standpoint
of the patient’s happiness and contentment and from the standpoint of
surgical cleanliness and efficiency as well, so that normal cases, at
least, may be attended with reasonable safety at home.

We know that the deaths, incident to childbirth, throughout this country
at large, have not declined during the past decade, in spite of improved
obstetrical methods and skill and the large percentage of recoveries in
hospitals where they are applied. In the homes, in general, young
mothers continue to die in distressingly large numbers, chiefly from
infection, which we know is largely preventable. Apparently, then, in
some important particulars the conditions surrounding the majority of
home deliveries are still such as to be almost a menace to life and
health. And as it is manifestly impossible for all obstetrical patients
to be cared for in hospitals, home deliveries need to be made safer,
which virtually means, made _cleaner_.

This grave need cannot be dismissed by the nurse as something outside of
her province. She may aid greatly, and therefore is under obligation to
do so, in making home confinements surgically clean, by being
conscientious and thoughtful and thorough in her preparations and
assistance.

A relatively small percentage of obstetrical patients require operative
assistance, but without a single exception they all require cleanliness;
cleanliness of appliances and cleanliness of methods.

As the first labor is usually longer and more difficult than later ones,
and the percentage of lacerations and operative interference is higher,
primiparæ should be delivered in hospitals when possible, as well as all
cases presenting any complication or abnormality. But women who are
normal, particularly multiparæ, and these constitute the vast majority
of obstetrical patients, should be able to remain at home in safety.

In most instances the patient who is to be delivered at home will have
to occupy her accustomed room and there is no alternative. Should there
be a choice of rooms, however, one should be selected that is cool and
shady, if the confinement takes place during the summer, but bright and
sunny for occupancy during most of the year; it should be conveniently
near a bathroom if possible, and have an adjoining room for the nurse
and baby to occupy.

The arrangement and furnishings of the room will not of necessity vary
greatly from those of a room which is to be occupied by any patient.
Carpets, upholstered furniture, heavy draperies and curtains are no more
suitable in this than in any patient’s room.

The ideal is: A room with a washable floor with small, light rugs;
freshly laundered curtains at the windows; a single, brass or iron
bedstead, about 30 inches high, with a firm mattress, and so placed as
to be accessible from both sides and with the foot in a good light,
either by day or by night; a bedside table and two others (folding card
tables are a great convenience); a bureau; a washstand, unless there is
a bathroom on the same floor; one or two comfortable chairs, two or
three straight chairs and a couch or _chaise longue_, all of which
should be of wood or wicker or covered with freshly laundered chintzes.

Barrenness is not only unnecessary but is to be avoided, for the room
should be as cheerful and pretty as is compatible with cleanliness.
There is usually no objection to pictures on the wall, but the room
should be free from useless, small articles which are dust catchers,
give the nurse unnecessary work, and occupy space needed for other
things. Between such a room as this and the one which the nurse finds
must be used, there may be a dismaying difference, and so once more she
must exercise her ingenuity and resourcefulness; change and improve
where it is possible and make the best of conditions that cannot be
altered, for the baby is coming and the mother must be safeguarded from
infection and other disaster, no matter what the room is like.

Much as we should like ideally to equip and prepare every room to be
used for a home confinement, we cannot overlook the importance of having
preparations made with as little disturbance as possible to the patient
and her household. Preparations made with bustle and ostentation are
suggestive of inefficiency; are bad for the patient, frequently causing
her great alarm, and in the main had better be omitted. The nurse who is
able to go into a home quietly and unobtrusively and accept what she
finds, even carpets and draperies, and still do clean work, is doing
better nursing than the one who arranges a faultless room but upsets her
patient and disrupts the household in the process.

Common sense, judgment and tact, then, will sometimes be as important in
preparing a room for home delivery as are washable floors, curtains and
furniture.

While we do not advise nor elect to have carpets, draperies and
upholstery in a delivery room, we know that they need not menace the
patient’s welfare if all details of the work about the patient, herself,
are scrupulously clean. That is the one point which the nurse must bear
constantly in mind, the paramount importance of clean work about the
patient.

The room should be given a thorough housecleaning about two weeks before
the expected date of delivery. If there is carpet on the floor, there
should be a large canvas or rubber, or an abundance of newspapers
available to protect it, about, and under the bed; and if the bed is of
wood, the sideboards and foot should be covered to protect them from
injury by soap, water and solutions which may be spattered or spilled
during labor. If the bed is low, there should be four solid blocks of
wood prepared, upon which to elevate it, after removing the casters, and
it is also a good plan to have a large board, or table leaves, in
readiness to slip under the mattress to make it firm, particularly if
the bed is soft or sinks in the middle.

So much for the room.

In preparing the dressings and assembling the various articles to be
used the nurse will do well to remember that, although it is possible to
use a number of things during labor, it is also possible to do excellent
work with a meagre equipment supplemented with a cool head and ingenuity
and training and above all, an exacting conscience. The average nurse
will wish, usually, to follow a median course in her preparations,
having everything at hand that will facilitate the work; be adequately
equipped for emergencies but not burdened with non-essentials.

As the wishes and methods of different doctors vary, the articles needed
in assisting them must of necessity vary also. But in addition to the
instruments which will be used, the following articles will meet the
ordinary requirements during a home confinement, and many of them, or
adequate substitutes, are to be found in the average household.

=For the Mother and the Delivery=:

 Plenty of sheets, pillow cases, towels and night gowns.
 4 or 6 T. binders or sanitary belts.
 1 piece rubber sheeting or oilcloth, 1 × 1½ yards.
 1 piece rubber sheeting or oilcloth, 2 × 1½ yards.
 Two or three dozen safety pins.
 Hot water bag with flannel cover.
 1 two-quart fountain syringe.
 1 douche pan.
 1 bed pan.
 2 covered slop jars or covered pails.
 3 basins, about 16, 14 and 12 inches in diameter.
 2 stiff nail brushes, nail scissors and file or orange stick.
 3 agate or enamel pitchers, holding at least one quart each.
 Medicine glass.
 Medicine dropper.
 2 bent glass drinking tubes.
 100 bichloride tablets.
 4 oz. chloroform.
 4 oz. boric acid powder.
 4 oz. green soap.
 1 pint grain alcohol.
 Small jar of vaseline to be sterilized.
 Lard, olive oil, vaseline or albolene to oil baby.
 Roll adhesive plaster 1 inch wide.
 1 pkg. absorbent cotton.
 1 thermometer.

In addition to these, a certain supply of sterile dressings will be
needed. Complete outfits of such dressings, sterilized and ready for
use, may be obtained from any one of a number of firms, or the following
may be prepared by the nurse or by the patient, under the nurse’s
direction:

=Dressings=:

 1 doz. sterile towels.
 5 or 6 doz. perineal pads.
 2 or 4 delivery pads, made of gauze and common cotton with top layer of
    absorbent cotton, or newspapers covered with muslin.
 5 or 6 doz. gauze sponges.
 2 or 3 doz. gauze squares, 4 inches square.
 4 or 5 doz. cotton pledgets.
 1 pr. leggings, made of canton or outing flannel, either loose fitting
    hose or a yard square folded diagonally and stitched. (See Fig.
    110.)
 3 sheets.
 6 pieces cord-tie of bobbin or narrow tape, 9 inches long.

These may be put up into packages in the usual manner, using muslin for
wrapping, and sterilized in the patient’s home as follows: Fill a wash
boiler about ¼ full of water and fashion a hammock from a towel or
strong piece of muslin, tied securely with strings at each end and hung
from the handles so that the bottom of the hammock in about half way
down in the boiler. As the weight of the dressings makes the hammock sag
low, in the middle, it is usually necessary to place a rack, or support
of some kind, in the bottom of the boiler to hold the dressings well
above the bubbling water, at the point where they hang lowest. Pile the
dressings into the hammock, cover the boiler tightly and keep the water
boiling vigorously for one hour; dry the packages in the sun or by
placing them in the oven for a few moments, and at the end of
twenty-four hours repeat the steaming and drying process, wrap the
packages in a clean sheet or paper and put them away in a drawer or
covered box where they should remain until time to prepare for the
delivery. The brushes, douche pan, irrigation-bag, and other articles
which must be surgically clean may be sterilized in the same way. The
gloves may be sterilized in this way or boiled immediately before
delivery. If sterilized by steam, the gloves should be thoroughly dried,
dusted with talcum inside and out to prevent them from sticking
together, and may be wrapped in packages or placed in individual cases
(Fig. 42). A small towel or piece of soft muslin and a ball of gauze
containing talcum powder, if placed in the case and sterilized with the
gloves, are often a convenience to the doctor in putting on the gloves.

[Illustration:

  FIG. 42.—Gloves with cuffs turned up, lying with small towel and
    powder puff of gauze and talcum, on double envelope case in which
    they may be dry-sterilized. (From photograph taken at the Brooklyn
    Hospital.)
]

The newspaper delivery pads offer excellent protection and are made of
six thicknesses of paper covered with a piece of freshly laundered
muslin, which is folded over the edges and basted in place. (Fig. 43).
These pads may be made virtually sterile by ironing them on the muslin
side with a very hot iron, folding the ironed surface inside without
touching it; again ironing on the outside and wrapping in a clean muslin
or sheet, also recently ironed, and putting away in a place protected
from dust.

The nurse herself should have:

 A hypodermic syringe and 4 or 6 needles.
 1 pr. long forceps to use as dressing forceps.
 1 pr. short forceps.
 1 pr. blunt pointed scissors.
 2 artery clamps.

[Illustration:

  FIG. 43.—Reverse side of pad made of newspapers and old muslin to
    protect bed during a home confinement. If muslin is held in place
    with safety pins it may be removed easily, washed and used for
    another pad. (Courtesy of The Maternity Centre Association.)
]

The doctor will usually supply himself with any articles needed beyond
those which have been enumerated, but the nurse should be sure about the
following in order that she may prepare whatever he may lack:

 Instruments and sutures.
 Hypodermic tablets.
 Pituitrin and ergot, or ergotole.
 Gauze packs.
 Gloves and sterile gown.
 Rubber apron.
 Filtered, sterilized salt solution and infusion needles.
 Chloroform inhaler.

In planning the baby clothes, there are a few important factors to bear
in mind. The clothes should be simple; not more than twenty-seven inches
long; warm, but light in weight, and large enough to fit loosely. Like
the dressings, complete layettes may be bought outright, but if the
mother wishes to make the little garments herself, the following list
will be found to provide an adequate supply of clothing for the new
baby. (See also Fig. 159.)

=For the Baby, Layette=:

 2 to 4 doz. diapers, preferably 18 in. square.
 3 flannel bands, 6 or 8 inches wide and 27 in. long unhemmed.
 3 shirts, size No. 2, of cotton and wool, silk and wool but not all
    wool.
 4 flannel petticoats, Gertrude style.
 4 flannel nightgowns or slips.
 6 white slips.
 3 knitted bands with shoulder straps, to use after the cord separates.
 Flannel kimono or square, one yard, to be used as extra wrap in cool
    room.
 Cloak and cap or other wrap for out-door use.

=Additional Articles Which Are Needed or Useful in the Care of the
Baby=:

 Bath tub, tin, enamel, agate or rubber.
 Drying frames for shirts and stockings.
 Rubber bath apron.
 Flannel, or Turkish toweling bath apron.
 Low chair without arms.
 Low table.
 Screen to protect baby during bath.
 Rack upon which to hang clothes to warm during bath.
 Scales, with beam and basket and scoop, not the spring variety.
 Hot water bag and cover.
 Crib, basket or box, to be used as bed.
 Folded felt pad, blanket or hair pillow for mattress.
 Rubber or oilcloth to cover mattress.
 6 crib sheets.
 1 thermometer.
 2 crib blankets.
 Soft towels and wash cloths.
 An old blanket to be used for bath blanket.
 3 or 4 dozen safety pins, assorted sizes.
 Castile soap.
 Boric acid powder.
 Olive oil or albolene.
 Absorbent cotton pledgets, preferably sterile.
 Enamel pail and cover.

The above lists of dressings and articles for the baby can be
considerably modified and still be satisfactory. The leaflet of “Advice
for Mothers” issued by the Maternity Centre Association, New York City
(see p. 429), gives a somewhat curtailed list of equipment which proves
to be adequate and within the means of most of the patients with whom
the Association works.

It is usually a good plan for the nurse to advise the patient to have
her dressings ready by about the end of the seventh calendar month, and
the layette by the end of the eighth month. A baby born before this time
would probably be so frail that it would be wrapped in cotton and not
require the clothes ordinarily prepared for a full-term baby.



                               CHAPTER IX
                COMPLICATIONS AND ACCIDENTS OF PREGNANCY


The prenatal care which was outlined in an earlier chapter becomes more
impressive when one considers the disasters which it is designed to
prevent. And the nurse will be more eager and able to watch her patient
intelligently, and instruct her convincingly, if she appreciates and
understands something of the conditions which she is helping to avert.
She will give more effective nursing care, too, when complications do
occur, if she gives it understandingly. In the toxemias, particularly,
the importance of the nursing care looms large, for it is painstaking
attention to details that makes this care so nearly a matter of life or
death to the patient.

In considering the complications of pregnancy, the nurse in training
needs a reminder that hospital experience is likely to give her an
exaggerated idea of the relative frequency with which they occur. This
is due to the fact that most maternity patients in hospitals are there
because they are known to be abnormal in some way, or because they are
pregnant for the first time, and first pregnancies are more likely to
end in difficult and complicated labors than later ones. The vast
majority of cases run practically uncomplicated courses, for pregnancy,
labor and the puerperium are normal physiological processes. It is
extremely serious, however, to allow them to become abnormal.

Watchfulness throughout pregnancy, then, in the interest of preventing
disaster, cannot be too insistently advocated.

Some complications that are watched for during pregnancy are peculiar to
that condition alone, and these may be divided into three general
groups:

  =1. The premature terminations of pregnancy=, which are designated
  as abortions, miscarriages and premature labors.

  =2. Ante-partum hemorrhages=, due to either a placenta prævia or a
  premature separation of a normally implanted placenta, the latter
  being termed “accidental hemorrhage.”

  =3. The toxemias=, including pernicious vomiting, pre-eclamptic
  toxemia, eclampsia and possibly nephritic toxemia, though this
  condition is not invariably associated with pregnancy.

There are other conditions, not necessarily inherent to the state of
pregnancy, but which should be detected and treated early, since their
development coincidently with expectant motherhood may threaten the
safety of the patient or the child, or both. Probably the most serious
of these is syphilis, though gonorrhea, impaired kidneys, heart lesions,
tuberculosis or a general state of poor nutrition also may prove to be
grave.

Any chronic, organic disease is likely to be increased in severity by
the strain which pregnancy puts upon the impaired organs, in common with
the rest of the maternal body. But acute diseases usually run about the
same course in pregnant, as in non-pregnant women, except when an
infection causes an abortion, the shock of which, in turn, reduces the
patient’s resistance against the complicating disease.

As we consider these various, dreaded complications which may arise
during pregnancy, infrequent though they be, we feel that no amount of
effort is too much to make, if we can, thereby, save one mother or one
baby from their destructive effects. We are stirred by the urgency of
preventing a premature ending of pregnancy, for example, when we see it,
not so much as simply another obstetrical emergency, but in its true,
tragic light as the loss of an infant life and the bereavement of an
expectant mother.


                  PREMATURE TERMINATIONS OF PREGNANCY

The termination of pregnancy before the expected time is termed an
abortion, miscarriage, or a premature labor or birth, according to the
stage to which the pregnancy has advanced, but there are wide variations
in the accepted meanings of these terms, among both lay and medical
people.

In the lay mind, abortions are usually associated with criminal practice
and the term is seldom used, while miscarriage is a term which is
loosely applied to all deliveries occurring before the child is viable,
or before the seventh month. It is not uncommon, however, to hear the
term abortion used to designate the termination of a pregnancy before
the end of the fourth month; miscarriage, one which occurs between the
end of the fourth and seventh months, and premature labor as one which
takes place any time after the seventh month, but before the expected
date of confinement.

Medical people, on the other hand, seldom use the term miscarriage, but
designate as abortions all terminations of pregnancy which occur before
the end of the seventh month; and premature labor, those occurring from
that time until the estimated date of confinement. It is these meanings
which will be intended when the terms abortion and premature labor are
used in the following pages.

ABORTIONS. In the nature of things, it is impossible to say how often
abortions occur. They sometimes happen so early in pregnancy that the
patient is unaware of the accident; or, if she does know of it, she may
take no notice of it or regard it of so little consequence that she does
not consult a doctor; while in many cases it is intentionally concealed
because of having been criminally induced. But such information as is
available suggests that at least one out of every five pregnancies ends
in an abortion.

Since the ovum is insecurely attached to the uterus until the sixteenth
or eighteenth week, an abortion is more likely to occur during this time
than later, while of this period, the second and third months seem to be
the most perilous.

Abortions are less likely to happen during first pregnancies than
succeeding ones; they occur more often among women over thirty-five
years old than in younger ones, and in all cases are most likely to take
place at the time when the menstrual period would fall due were the
woman not pregnant. Their frequency probably increases with the number
of pregnancies, because of the tendency of multiparous women to have
endometritis, which, as we shall see later, is a causative factor.

=Causes.= There is a variety of causes of abortions and miscarriages,
some entirely unavoidable, but many which are preventable, and it is
well for the nurse to be familiar with those which operate most
frequently, as follows:

  =1. Certain abnormalities of the developing fetus= are inconsistent
  with life, and are, therefore, a frequent cause of abortion. Dr.
  Mall, of Johns Hopkins University, showed after years of
  investigation that at least one-third of the embryos obtained from
  abortions were malformed and would have developed into monstrosities
  had they lived to term. It is often a great comfort to the expectant
  mother who loses her baby early in pregnancy to realize that had she
  carried her baby to term it might have been a monster, and that,
  therefore, she has not lost a beautiful, normal child. Just why
  these abnormalities occur is not known, nor is there any known
  method of preventing or correcting them. There also may be such
  defects in the placental development, that the fetus does not derive
  sufficient nourishment to continue its development, and dies very
  early as a result.

  =2. Abnormalities in the generative tract= may cause abortions, the
  most common of these being inflammation of the uterine lining and a
  malposition of the uterus itself. Gonorrheal infection is a frequent
  cause of such an inflammation, which so alters the decidua that a
  satisfactory implantation of the ovum is impossible, and it perishes
  from lack of nourishment. Uterine misplacements, particularly
  retroflexion and prolapse, are important causative factors in
  abortions. This is because the malposition interferes with the blood
  supply and lesions in the endometrium result. This also presents an
  unsatisfactory lodgement for the ovum and it cannot survive for
  long.

  =3. Acute infectious diseases= all tend to cause the death of the
  fetus and thus cause abortions. Fetal death in these cases is
  believed to be due to the transmission of toxic material from mother
  to child, as may occur also in such poisoning as phosphorus, lead
  and illuminating gas.

  =4. Mental or emotional= stress may be the cause of an abortion, but
  less importance is attached to these factors to-day than formerly.
  There is an occasional case, however, which can be explained on no
  other grounds.

  =5. Physical shocks=, such as falls, blows upon the abdomen,
  jumping, tripping over carpets, jars, jolting or overexertion, may
  be the exciting cause of an abortion where there is a marked
  irritability of the uterine muscles. This factor is largely
  influenced by individual stability, however, as a slight jar will
  cause an abortion in one woman, and violent experiences will have no
  effect upon another, at the same stage of pregnancy.

=Symptoms.= For purposes of differentiation in treatment, abortions are
usually divided into three groups and designated as threatened, complete
and incomplete, but the premonitory symptoms of all of the varieties are
the same. They are bleeding, with pain that is usually intermittent,
beginning in the small of the back and finally felt as cramps in the
lower part of the abdomen. Since menstruation is suspended during
pregnancy, it is a safe precaution to regard any bleeding during this
period, with or without pain, as a symptom of pending delivery.

=Prevention= of abortions is of course more satisfactory than remedial
treatment, and a nurse may be very helpful in this respect, by
explaining the underlying causes to the patients in her care, and
winning their cooperation in preventing a deplorable accident.

Preventive treatment really begins very early. In the chapter on
menstruation we referred to the importance of a young woman’s
ascertaining the cause of painful menses, in the interest of good
obstetrics, since inflammation of the uterine lining or a uterine
misplacement might be responsible not only for the dysmenorrhea, but if
neglected might, later, be factors in causing interrupted pregnancies.
The correction of such physical defects, then, no matter when they are
discovered, is an important step in preventing abortions.

A misplacement may be corrected, frequently, by means of a pessary,
though suspension is done in some cases; an inflamed lining, which
provides unsatisfactory lodgement for the ovum, may be removed by
curettage. The new lining which replaces the old one is sometimes
capable of receiving and holding the ovum.

There are also some more immediate preventive measures. A woman who is
pregnant for the first time, and who, therefore, does not know whether
or not she is likely to abort, should avoid such risks as fatigue,
sweeping, lifting or moving heavy objects, running a sewing machine by
foot, running, jumping, dancing, traveling or any action which might jar
or jolt her during the first sixteen or eighteen weeks of pregnancy.

On the other hand, there are many groundless beliefs concerning the
causes of abortions which the nurse may well dispel. Purgatives and
other drugs have much less effect in causing abortions under normal
conditions than is generally believed. But with a patient who has very
irritable uterine muscles, such a drug as quinine, for example, may act
as the last straw in producing an abortion which would almost certainly
have been brought on by some other slight stimulation had the drug not
been taken. Nor can reaching up, or sleeping with the arms over the
head, possibly separate the embryo from the uterine lining, yet many
women believe that they can.

In the case of an expectant mother who has had an abortion, even more
precautions than I have suggested will have to be taken, for she is in
greater danger of aborting than is a woman who has not had this
experience. It is of prime importance that she have the cause of her
previous abortion discovered, and if possible, corrected. In addition to
this, she should be particularly careful to observe precautionary
measures as she approaches the stage of her pregnancy at which the
previous abortion occurred. The accident is most likely to be repeated
at about the same time, or a little earlier, in each succeeding
pregnancy. The patient should remain quietly in bed for at least a week
before and after the time when an abortion is feared.

Complete rest and physical relaxation are such effective preventive
measures that patients with a tendency to have abortions, who have been
willing to stay in bed throughout practically the entire period of
gestation, have gone through pregnancy without interruption, and been
delivered of normal babies at term. As out-of-door exercise is clearly
impossible in such cases, it is imperative that the patient keep her
room particularly well-ventilated all of the time, and, under the
doctor’s direction, have massage or bed exercises.

Since abortion seems to be due, so often, to excessively irritable
uterine muscle fibres that respond to even slight stimulation, a patient
who is known to have difficulty in carrying a child to term is usually
advised to avoid the marital relation throughout pregnancy.

Some patients with defective uterine lining will have slight bleeding
for a long time, possibly throughout the entire period of pregnancy,
because a small area of the placenta has separated, leaving, however, a
sufficiently large attached area to nourish the fetus. Such women
should, of course, be under a doctor’s care and sedulously avoid all
shocks to the uterine musculature, for the separated area may very
easily be increased to such a size that the fetus will be unable to
secure adequate nourishment, and die as a result. And the mother’s life,
too, may be endangered by hemorrhage from the separated surfaces.

To sum up in a word, we may almost say that, after pregnancy has begun,
preventive treatment consists of rest and avoiding physical shocks,
particularly during the first sixteen or eighteen weeks and at the time
when menstruation would occur were the woman not pregnant.

=Treatment=, in the different degrees of abortion, employed by most
physicians, is usually along some such lines as the following:

  =1. Threatened.= A threatened abortion is one in which there is some
  loss of blood, associated with pain in the back and lower abdomen,
  but without expulsion of the products of conception. The treatment,
  as a rule, is absolute rest in bed and the administration of
  powerful sedatives.

  =2. Incomplete.= An incomplete abortion is one in which the fetus is
  expelled but the placenta and membranes remain in the uterine
  cavity. The treatment is removal of the retained tissues, followed
  by the same care that is given during the normal puerperium. Prompt
  action in completing the delivery is important because of the
  hemorrhage that usually persists until the uterus is entirely
  emptied of its contents. Since the pregnant uterus is very soft, the
  retained membranes are more often removed manually than
  instrumentally, for a curette may be very easily pushed through the
  uterine wall, and peritonitis would be likely to follow.

  =3. Complete.= A complete abortion, as the term suggests, is one in
  which all the products of conception are expelled. The treatment and
  care are exactly the same as are given after a normal delivery. This
  point cannot be stressed too strongly, for it is because so many
  women fail to appreciate the necessity for adequate post-partum
  care, that abortions are so often followed by ill health and
  invalidism.

Many doctors follow these various remedial measures with a search for
the cause of the abortion just past, in order that it may be corrected
if possible and recurrent abortions prevented.

=A missed abortion= occurs but rarely, and is one in which the embryo,
or fetus dies, and is retained within the uterine cavity for months, or
even years, sometimes without any unfavorable results to the mother. In
these cases, symptoms of abortion sometimes appear and then subside
without any part of the uterine contents being expelled. In other cases
there are no signs except that the abdomen stops growing. There are
cases on record in which the fetus has become mummified and others in
which it has been partly absorbed by the maternal organism.

In addition to abortions which occur spontaneously there are also
induced abortions, and these are designated as therapeutic or criminal,
according to the motive for the induction.

=Therapeutic abortions= are resorted to when the patient’s condition is
so grave that it is apparently necessary to empty the uterus in order to
save her life. Such a condition may exist, for example, when pregnancy
is complicated by pulmonary tuberculosis, heart disease, toxemia,
hemorrhage or some condition which is inherent to pregnancy. An abortion
induced under these circumstances is countenanced by law, as it is
performed to prevent the loss of life from disease; but an abortion is
not legal if brought on to save the woman from suicide, because of her
unwillingness to become a mother.

The Catholic Church, however, teaches that it is never permissible to
take the life of the child in order to save the life of the mother. It
teaches that, even according to natural law, the child is not an unjust
aggressor: and that both child and mother have an equal right to life.

There is apparently no reason why a therapeutic abortion should be
followed by ill health, for, since it is performed openly, it is done
under clean, and otherwise favorable conditions, and the patient is
given adequate after-care. It is only because the reverse conditions
frequently prevail: the unclean delivery and subsequent neglect which go
hand in hand with the secrecy of illegal performance that abortions are
followed so often by disaster.

As to the legal aspect of the matter, the laws relating to therapeutic
abortion vary in the different states. But they are fairly uniform in
their intent, and make quite clear the difference between this procedure
and the induction of abortion for any reason other than medical
necessity.

Dr. Slemons writes of the seriousness of criminal abortion in no
uncertain terms, in “The Prospective Mother.” “At Common Law” (an
inheritance from England) he tells us, “abortion is punishable as
_homicide_ when the woman dies or when the operation results fatally to
the infant, after it has been born alive. If performed for the purpose
of killing the child, the crime is _murder_; in the absence of such
intent, it is manslaughter. The woman who commits an abortion upon
herself is likewise guilty of the crime.”

PREMATURE LABOR is the termination of pregnancy after the seventh month,
but before term. Premature births are much less frequent than abortions
or miscarriages. They usually occur spontaneously, but are sometimes
induced for therapeutic purposes, or from criminal motives.

The premature baby’s chances of living are directly proportionate to the
length of its uterine life. This has already been stated, but will bear
repetition in view of the widely current fallacy that a seven-months’
baby is more likely to live than one born after eight months of
pregnancy. The facts are that as a rule, the nearer pregnancy approaches
term, the more likely is the baby to survive, provided it weighs four
pounds or more, and is forty centimeters or more in length. A smaller
baby than this has but a slender chance to live.

We ordinarily designate as premature any baby that weighs between 1500
and 2500 grams, or measures between thirty-six and forty-five
centimeters in length, and consider such a baby has a favorable outlook
if given special care. This special care of premature babies will be
described in connection with the care of the baby.

=Causes.= Syphilis was formerly thought to be a common cause of
abortion, but although this has been disproved by recent investigations,
the disease is still regarded as a frequent cause of spontaneous
premature labor. In fact, Dr. Williams considers syphilis the most
frequent single cause of premature births, and regards the birth of a
dead, macerated fetus, or a history of repeated premature labors, or
stillbirths, as strongly suggestive of syphilis.

“In my experience,” he says, “the recognition and treatment of this
disease is the most important matter in connection with the prophylaxis
of premature labor.... Some idea of the importance may be gained from
the fact that in a series of 334 premature labors, I found that syphilis
was the etiological factor in over 40 per cent., while toxemia, placenta
prævia and fetal deformity were concerned in 8.6 and 3.3 per cent.,
respectively. Sentex, who studied 485 cases in Pinard’s clinic arrived
at similar conclusions and found the underlying cause to be syphilis in
42.7 per cent., albuminuria in 10.8 per cent., and abnormalities of the
fetus in 11.1 per cent.”[3]

Other causes of premature births are the toxemias of pregnancy, chronic
nephritis, diabetes, pneumonia, typhoid fever, organic heart disease,
continuous overwork during the latter part of pregnancy, and such
poisoning as lead and illuminating gas, while of alcoholism, Dr.
Ballantyne says, “prematurity of birth is an undoubted result.”

Another important cause of premature births, of comparatively recent
recognition, is previous operation upon the cervix, particularly high
amputations; while placenta prævia and malformations of the fetus, or
monsters, are also reckoned with as causative factors. Hydramnios
sometimes brings on a premature labor by so distending the uterus as to
stimulate contractions.

Labor is sometimes induced prematurely when this procedure may be
expected to relieve an abnormality or complication which threatens the
life of the mother or baby, or both. Some of the indications for this
course are: seriously overtaxed heart or kidneys; a marked disproportion
between the size of the child’s head and the mother’s pelvis, or a fetus
that has been dead for two weeks or more. However, the reasons for it
and the methods employed in inducing labor will be discussed more at
length in the chapter on obstetric operations.

A therapeutic induction of premature labor, like a therapeutic abortion,
is not of itself usually considered any more serious for the mother than
a normal delivery, since it can be performed with care and cleanliness,
qualities not usually associated with the work of practitioners who are
willing to do criminal operations.

=Treatment.= The nursing care of the patient after a premature labor is
the same as that given after a normal delivery. Much invalidism would be
avoided if all women could be convinced of the importance of staying in
bed just as long, and having just as good care after a premature as
after a full-term labor. The difficulty of so convincing her is perhaps
due to the fact that the small, premature child is expelled more quickly
and less painfully than a baby at term and there is comparatively little
blood lost in the course of its birth.


                         ANTE-PARTUM HEMORRHAGE

[Illustration:

  FIG. 44.—Diagram of centrally implanted placenta prævia.
]

Ante-partum hemorrhage, which is a hemorrhage occurring before delivery,
is another serious complication of pregnancy. During the early months,
hemorrhages are usually due to abortion, menstruation or lesions of the
cervix and are not severe as a rule. But during the last three months
hemorrhages are almost invariably due to placenta prævia or premature
separation of a normally implanted placenta, and are often profuse.

PLACENTA PRÆVIA is one of the most serious conditions met with in
obstetrics, the maternal mortality being about 40 per cent. and the baby
death rate about 66 per cent. The frequency with which it occurs is
variously estimated as from one in 250 cases to one in every 1000.

In order to understand what is happening to the patient in this
condition, we must go back to the question of the implantation of the
ovum. We learned that, as a rule, after the ovum entered the uterus it
attached itself to a point in the uterine lining high up on the anterior
or posterior wall. Unhappily, the position of this point of attachment
is a mere matter of chance, and the ovum sometimes, but not often, is
implanted so far down toward the cervix that as the placenta develops at
that site it partially or completely overlaps the internal os. It is the
extent to which the placenta grows over the cervical opening that
determines whether it is of the central, partial or marginal variety.

[Illustration:

  FIG. 45.—Partial placenta prævia. Section of uterine wall and cervix
    showing that part of the maternal surface of the placenta which
    extends over the cervical opening and is exposed by dilation of the
    internal os, with an escape of blood from the open vessels as a
    result. Drawn by Max Brodel. (From “The Treatment of Placenta
    Praevia,” by William B. Thompson, M.D.—Johns Hopkins Hospital
    Bulletin, July, 1921.)
]

_A centrally implanted placenta prævia_ (Fig. 44) is one which entirely
covers the os; _a partial placenta prævia_ (Fig. 45), as the name
suggests, only partially covers the opening, while if it is implanted so
high up that only its margin overlaps the os, it is designated as
_marginal placenta prævia_. (Fig. 46.)

[Illustration:

  FIG. 46.—Diagram of marginal placenta prævia.
]

Another classification groups all placenta prævia as complete or
incomplete, the latter comprising the partial and marginal varieties, as
well as the lateral which is so attached that it does not quite reach
the edge of the internal os. However, as these terms do not differ
widely and are clearly descriptive, the differences are of no great
moment to the nurse, as the treatment is practically the same and the
nurse’s duties quite the same for all varieties.

=Cause.= Not much is definitely known about the cause of placenta
prævia, but it is evident that multiparity is a factor, since the
condition is found about six times as frequently among women who have
borne children, as it is among those who are pregnant for the first
time. A diseased uterine lining is probably the fundamental cause, and
this may explain why the trouble is found more frequently among the
poorer classes, since such women as a class have less skilled medical
attention than those in better circumstance.

One theory is that an old endometritis results in a very unfertile soil
for the implantation of the ovum and as a result the ovum migrates to
other parts of the uterine cavity in its search for a more favorable
site, and comes to lodge near the lower segment.

=Symptoms.= The symptom of placenta prævia is hemorrhage, occurring
during the latter part of pregnancy or at the onset of labor. The cause
of the hemorrhage is the separation of that part of the placenta
covering the internal os, when the latter dilates, thus presenting an
exposed, bleeding surface. The hemorrhage is usually so profuse that
unless it is controlled, both mother and child may bleed to death.

=Treatment.= Unhappily there is no preventive treatment for placenta
prævia, beyond that which is included in treatment for endometritis, and
good care during the preceding puerperium.

[Illustration:

  FIG. 47.—Position of Champetier de Ribes’ bag to stop hemorrhage, from
    placenta prævia, by pressure.
]

Since the great danger in this complication is from hemorrhage the
doctor’s principal effort is directed toward its control. Infection and
shock are also feared but the first step is to stop the bleeding. A
common method is to stimulate the uterus to contract; that necessitates
the removal of its contents, or the induction of labor.

The separation of the placenta leaves open, bleeding vessels in the
uterine wall and placenta, which can only be closed by pressure, until
the uterus contracts on its own vessels. The doctor sometimes makes
pressure with tampons of gauze, by rupturing the membranes and bringing
down the presenting part of the child to press against the bleeding
surface, or by introducing a rubber bag into the cervix and pumping it
full of sterile water. (Fig. 47.) By means of its weight and downward
traction, this bag presses against the bleeding areas and thus checks
the hemorrhage. It also tends to dilate the cervix, after which the baby
is sometimes born spontaneously and sometimes delivered artificially.

PREMATURE SEPARATION OF A NORMALLY IMPLANTED PLACENTA. A placenta
prævia, as has been explained, is abnormally situated. But it sometimes
happens that a placenta that is normally placed will separate
prematurely, with hemorrhage as the inevitable result. Such a hemorrhage
is termed “accidental” to distinguish it from the unavoidable bleeding
caused by a placenta prævia. If the blood escapes from the vagina, the
hemorrhage is called “frank,” but if it is retained within the uterine
cavity it is called a “concealed” hemorrhage.

=Causes.= Endometritis is probably an underlying cause, though very
little is definitely known on the subject. Previous pregnancies are
believed to be a factor, as this accident occurs less often among women
who are pregnant for the first time than among those who have borne
children, and also as the frequency of the hemorrhages apparently
increases with the number of previous pregnancies. Nephritis is believed
to be a possible cause, as well as anemia, general ill-health, toxemia,
physical shocks, and frequently recurring pregnancies.

=Symptoms.= In a frank hemorrhage, the chief symptom is an escape of
blood from the vagina, occasionally accompanied by pain. A frank
accidental hemorrhage occurs once in about every two hundred cases,
according to Dr. Edgar’s estimate, but, although more frequent than
placenta prævia, it is much less serious.

A concealed accidental hemorrhage, on the other hand, is an extremely
grave complication for both mother and child, for according to
observations made by Dr. Goodell, the death rate is 51 per cent. among
mothers and 94 per cent. among babies.[4] The symptoms are acute anemia,
abdominal pain, a general state of shock, and usually an increased
enlargement of the uterus. The blood may be retained between the uterine
wall and the placenta or membranes, or its escape from the vagina may be
prevented by the child’s presenting part fitting tightly into the outlet
and acting as a plug.

=Treatment.= The treatment of a frank hemorrhage depends upon its
severity. If the bleeding is only moderate, labor is ordinarily allowed
to proceed normally and unassisted. If the bleeding is profuse, however,
the patient is usually delivered promptly.

The treatment for a concealed hemorrhage consists of emptying the uterus
speedily in order that the muscles may contract and stop the bleeding by
closing the uterine vessels; and of treating the accompanying shock
which may be almost, if not quite, as serious as the hemorrhage itself.

It is very disappointing to have to realize that there is very little
that a nurse may do, before the arrival of the doctor, for a patient who
is having an ante-partum hemorrhage. As has been explained, it is often
necessary to pack the cervix or introduce a bag, for the purpose of
stopping the bleeding by pressure, and of stimulating the uterine
contractions which will expel the child and empty the uterus. These
measures are surgical operations and quite evidently the nurse cannot
attempt to perform them. She can, however, put the patient to bed and
have her lie flat, without a pillow, and, partly for the mental effect
upon the patient, apply ice-bags or compresses to her abdomen. As
nervousness and excitement only tend to increase the bleeding, the nurse
has an excellent opportunity to try to soothe and quiet a frightened
woman, and convince her that she can help herself, in this emergency, by
quieting her mind and body.

Pending the doctor’s arrival, the nurse should have a large receptacle
of water, boiling, to sterilize the instruments and bags that he may
want to use; clean towels and sheets, a nail brush, hot water, soap, and
a basin of an antiseptic solution for his hands.


                         TOXEMIAS OF PREGNANCY

There is probably no group of complications which prove to be more
baffling to the obstetrician than the toxemias of pregnancy. Certainly
they are challenging the best efforts of many earnest investigators, for
it is known that the toxemias cause some of the gravest conditions that
arise during pregnancy, and they are suspected of being the underlying
cause of still others which are as yet unaccounted for.

Comparatively little is known of the origin of the toxemias, except that
they are due to pregnancy. But happily, a good deal is known about
preventing them, and also about relieving them, particularly in the
early stages; accordingly many mothers and babies are saved who
otherwise would perish.

The entire subject of the prevention and treatment of these disorders
will be somewhat simplified for the nurse if she will recall the general
question of the adaptations of the mother’s physiology during pregnancy.
She will then remember that there were certain alterations of function
which were necessary to keep the maternal organism normal, while it bore
the strain of supplying nourishment to the fetus from its own blood
stream, and received in turn the broken-down products of fetal activity.
If these adaptations are insufficient to meet the demands made upon the
maternal organism, a serious toxic condition may result.

To put the matter briefly, there is in the toxemias of pregnancy a
disturbance of the mother’s metabolism, involving the liver and kidneys,
and a resulting retention within her body of something which should be
excreted. The retention of this material, which may be of fetal or
maternal origin, or both, may give rise to symptoms which range anywhere
from slight headache or nausea to coma, convulsions and death.

Beyond these general facts, there seems to be deep obscurity concerning
the cause of this group of complications, of which _pernicious
vomiting_, _pre-eclamptic toxemia_ and _eclampsia_ are the most widely
and generally recognized.

While _nephritic toxemia_ and _acute yellow atrophy_ of the liver cannot
be designated, quite accurately, as toxemias due to pregnancy, they are
usually included in this group. This may be because they are toxemias
which have many features in common with those of pregnancy, as to
symptoms and treatment, and because of the frequency with which they
appear coincidently with pregnancy, although not always due primarily to
that state.

From the nurse’s standpoint, it will perhaps be as well to regard all of
the toxemias of pregnancy as manifestations of the same general
disturbance, which vary according to the stage of pregnancy at which
they appear, and which differ from each other chiefly in severity, or
degree, rather than in kind.

In all cases the patients need to have their toxicity lessened by
dilution, and this is accomplished by giving fluids, copiously, and by
increasing elimination by promoting the activity of the skin, kidneys
and bowels. And since the nervous system is irritated by the toxins,
sometimes slightly and sometimes profoundly, the patient must be
protected from outside irritation and stimulation. This means quiet; a
soft light, or even darkness in the room; gentle handling; and with
mildly toxic, conscious patients, a pleasant, reassuring and encouraging
manner. With those who are unconscious, each touch must be the lightest
and gentlest possible.

These are the main features of the nursing care: forcing fluids and
keeping the patient warm and quiet. They offer the nurse wide scope in
adjustment and adaptation to each patient, according to her immediate
condition and to the methods of the physician in charge. There is a
difference of opinion among doctors as to details of treatment, but the
fundamentals of the care are the same. In taking up, in turn, these
manifestations of disturbed metabolism during pregnancy, we find that
vomiting is the first to appear.

PERNICIOUS VOMITING OF PREGNANCY usually occurs during the first three
months. We learned in the preceding chapter that a milder form of the
malady, known as “morning sickness,” is present in about half of all
pregnancies. This mild type ordinarily consists of a feeling of nausea,
possibly accompanied by vomiting, immediately upon raising the head in
the morning, and a capricious appetite. It appears at about the fourth
or sixth week and subsides in the course of a few weeks, sometimes after
no more care than the nursing which was described, leaving the patient
none the worse as a result of the attack.

With some women, however, the distress does not disappear in this prompt
and satisfactory manner, in which case it is described as “pernicious
vomiting.” The nausea in the morning may then persist for hours; it may
occur later in the day, or even at night; it may come on during a meal
and consist of a single attack of vomiting, after which food is taken
and retained; or it may be so persistent that the patient will be unable
to retain anything taken by mouth at any time of the day or night. Such
a condition, is, of course, serious, and may terminate fatally. The
patient may become exhausted from lack of food or because of the toxic
condition which is responsible for the vomiting, or both.

There seem to be three possible classifications of pernicious vomiting:
(1) One of _reflex_ origin, (2) one of _neurotic_ origin, and (3) one
due to a _toxemia_, resulting from disturbed metabolism. Not all
physicians accept the possibility of all of these factors, however, for
while some recognize both toxemia and neuroses as causes, they question
the possibility of a reflex cause. Others believe that all nausea of
pregnancy, from the mildest to the most severe form, is of toxic origin,
while still others contend that even the severest pernicious vomiting is
always neurotic. However, as toxicity under any conditions is very
likely to give rise to nervous symptoms, and as a nervous, unstable
woman may be made very ill by a slight degree of toxicity, it may be
that both factors sometimes enter into the causation of this disorder.

=Reflex vomiting.= Those who subscribe to the theory of reflex vomiting
believe that it may result from the irritation caused by a retroverted
uterus, or occasionally by an ovarian cyst, an erosion on the cervix or
by adhesions.

The treatment for reflex vomiting, quite obviously, consists of
correcting the disturbing condition, whatever it may be, after which the
nausea usually subsides in a short time. The nurse should take care that
her patient resumes a regular diet very gradually, even after the cause
of the nausea has been removed, for the stomach has become irritable and
the vomiting habit, both mental and physical, though easily established,
is usually broken up with considerable difficulty. Breakfast in bed;
concentrated liquid foods or easily digested solids, particularly
carbohydrates; aerated waters; cold fruit juices and cracked ice are
easy to retain and tend to allay nausea.

=Neurotic vomiting.= Severe vomiting which is due to some kind of mental
stress or suffering, and commonly called “neurotic vomiting,” is not
always so easily relieved. In the opinion of many psychiatrists the
vomiting frequently constitutes a protection, or possibly a protest,
which the patient has developed subconsciously, because of some reason
for fearing, or not wanting, to become a mother.

It is difficult to outline the nursing care of such patients with any
degree of precision, as no two can be cared for in quite the same way.
While in some cases the patient is a selfish, overindulged woman who
objects to motherhood because of its inconveniences, in others, she is
tortured by fear of inability to go through her pregnancy successfully,
though sincerely wanting to; or she may be bewildered and overwhelmed by
the prospect of the dangers of childbirth and responsibilities of
motherhood, a truly pathetic figure whose distress may often be greatly
relieved by the nurse who has enough insight to grasp the situation. As
I have discussed this subject more at length in the chapter on mental
hygiene, I shall say only a word here, as a reminder that the nurse will
need all of the tact, resourcefulness, sympathy and understanding which
she is capable of offering, if she is to give real help to some of her
patients who suffer from neurotic vomiting.

In addition to the mental nursing, which will be necessary, the patient
also needs physical care, for though her trouble may be of emotional
origin, she is, nevertheless, physically ill. As a rule, the best
results are obtained by putting the patient to bed and separating her
from her family as completely as possible. A daily routine should be
adopted and rigidly observed, and the patient repeatedly assured that
the course being followed will end in recovery.

It is usually considered advisable not to offer food by mouth, in the
beginning, but instead to give nourishment, as well as large amounts of
saline and sugar solutions by enemata, during the first few days. One
routine is to give 500 cubic centimetres _very slowly_, every six hours
at first, gradually decreasing the treatments to one a day as the
patient improves. The rectum is irrigated with a simple enema, once
daily, immediately preceding one of the injections, consisting of an
ounce of dextrose or glucose and one dram of salt to a pint of water.

Small amounts of liquid nourishment are finally given by mouth, and
given frequently, the quantity being increased gradually as the patient
improves. Very light and easily digestible solid foods, chiefly
carbohydrates, are added by degrees, and in the end, five or six small
meals, rather than three full ones, are given in the course of the day.

In some cases the patient is induced to drink, daily, two or three
quarts of sugar solution (an ounce of lactose to a pint of water), and
to nibble at will on olives, walnuts, crisp crackers, or some such
articles of food, which are kept within reach on her bedside table.
These are usually retained, excepting in very severe cases, to the
patient’s great encouragement.

The duration and severity of the attacks vary widely. Some patients are
very ill and for a long time, even requiring an abortion before showing
signs of improvement, while others recover in a few days if wisely
managed. If a patient once suffers from neurotic vomiting, she is very
likely to have it in subsequent pregnancies, particularly if the
circumstances of her life remain unaltered.

=Toxemic vomiting= is regarded by some doctors as a very grave and very
rare complication of pregnancy, which is usually fatal; by others as
simply a severe form of the very common “morning sickness,” which they
believe is always toxic, no matter how mild; while still others, as
already stated, doubt the occurrence of such a condition as toxemic
vomiting of pregnancy. I mention these differences of opinion in order
that the nurse may be aware of their existence and be prepared to adjust
herself whole-heartedly to the different methods of treatment for which
they are responsible. For no matter what else may vary, the earnestness
and sincerity of the nurse’s attitude must be a veritable Gibralter of
reliability.

The chief =symptoms= of toxemic vomiting, in addition to persistent
vomiting, as described by those who recognize its occurrence, are
coffee-ground vomitus; a diminished amount of urine, possibly containing
albumen, acetone bodies and casts; coma and sometimes convulsions. The
disease may run its course swiftly and the patient die in a week or ten
days, or it may persist less acutely for weeks, in which case there is
extreme emaciation and prostration. In those cases which come to autopsy
there is a definite and characteristic, central necrosis of the liver
lobule.

The =treatment= and nursing care vary widely because so little is
definitely known about the cause, and because of the varieties of
theories concerning it which are held by different obstetricians. Some
believe that prompt emptying of the uterus is about the only course
which is effective, while others feel that because of the probable
toxicity of the patient it is advisable also to stimulate all of the
excretory organs. Accordingly, they give free purges, colonic
irrigations, hot packs and copious amounts of sugar and saline solution
by mouth, rectum, intravenously and by infusion.

Corpus luteum, too, is sometimes given hypodermically two or three times
weekly. Although this treatment is not in universal use or favor, some
patients seem to be given absolute relief by its administration.

A fairly typical method of treating toxemic vomiting, and of which the
nursing care forms a large part is somewhat as follows: When the
vomiting is only moderately severe, the patient is put to bed and
isolated from relatives and friends, because of her nervousness
resulting from the toxemia. She is given an abundance of very cold, 5
per cent. lactose solution by mouth in water or lemonade; from four to
six ounces being given every half hour if she is able to retain it. If
she is unable to take, by mouth, a total of about three litres of this
solution, in the course of twenty-four hours, she is sometimes given one
or two litres (of a 10 per cent. solution) by rectum by means of the
drip method. At least three hours are devoted to giving this amount of
fluid, the rectum being first washed out with a simple enema.

It is usually considered important to persist in giving small amounts of
practically any article of food that the patient fancies, in order to
encourage her in the belief that she can take nourishment and also to
accustom her stomach to receive and retain food. Olives and nuts are
particularly valuable for this purpose and are often kept on the
patient’s bedside table where she can reach them and nibble on them at
will. Ice cold fruits and fruit juices are useful, while strained apple
sauce, ice cold, is very valuable as a starting point from which a more
generous diet may be gradually developed. All foods should be very cold
except broths, which should be very hot. The dietary is gradually
increased to six small meals daily from which fats and proteids are
omitted.

In more severe cases, or if the patient does not improve, an injection
of 300 cubic centimetres of fresh 5 per cent. solution of glucose is
given under each breast daily, and sometimes a mild sweat-bath, given
with blankets and lasting twenty minutes. (See page 197 for sweat-bath.)

In very severe cases when the patient is unable to retain anything taken
by mouth; loses weight and strength; when possibly the urine decreases
in amount and contains acetone bodies and ammonia, the situation is
serious and the treatment is more drastic. All effort to give fluid by
mouth is abandoned and in addition to the sub-mammary injection of
glucose solution, a colonic irrigation of one and a half to two gallons
of sodium bicarbonate solution (from 2% to 5%) at 110° F., is given once
daily by the drip method. The daily hot pack is continued; a mustard
leaf is applied to the abdomen if necessary to relieve the pain and
nausea; glucose solution may be given intravenously and also a nutritive
enema, three times daily, consisting of a raw egg, four ounces of
peptonized milk and one-half ounce of whiskey.

The method employed at the Toronto General Hospital in treating patients
suffering from toxemic vomiting is outlined as follows by Dr. J. G.
Gallie: “The patient is given as much as she is able to drink. A
nutrient enema is given three or four times daily, consisting of six
ounces of a 10 per cent. solution of glucose in saline. Bromide and
chloral may have to be added to the last nutrient in the evening. A
simple enema is given each morning. Nutrients are discontinued when the
urine becomes free of acetone bodies. In more severe cases, where fluid
cannot be taken by mouth, it may be supplied interstitially or
intravenously, a 5 per cent. solution of glucose being used. When
vomiting ceases, and solid food can be taken, the feeding is begun very
carefully with small quantities of carbohydrates. Lactose is added where
possible to any fluid taken. Frequent small meals are then
instituted—six between 7 a.m. and 10.30 p.m., thus reducing to the
smallest space of time the period of starvation during the twenty-four
hours. Protein may be added to the diet when nausea is under control,
but fat should be left out for some time.”

Such a course of treatment, quite evidently, is designed to relieve a
toxic condition, in which increased elimination is important, and to
quiet an irritable nervous system.

As the patient with toxemic vomiting is often very uncomfortable because
of a bad taste and dryness of her mouth, some kind of a mouth wash which
she finds refreshing should be used frequently. And since a degree of
toxicity which is capable of producing such a condition as is described
above will almost inevitably produce nervous symptoms, as well, the
nurse’s attitude toward her patient must always be one of sympathy,
encouragement and optimism.

When the patient’s condition is so desperate that pregnancy is
terminated, with the hope of saving her life, ether or nitrous oxide
gas, or both, is used as an anesthetic rather than chloroform, which of
itself tends to produce a liver necrosis.

PRE-ECLAMPTIC TOXEMIA is the most common of all the toxemias of
pregnancy, occurring several times in every hundred pregnancies. It
develops more frequently among women who are pregnant for the first time
than among those who have borne children, and one attack usually confers
an immunity against a recurrence.

As pre-eclamptic toxemia usually responds to treatment, but if
neglected, frequently ends in the much more serious disease of
eclampsia, the imperative need of supervision and care during pregnancy
are once more borne in upon us.

=Symptoms.= Pre-eclamptic toxemia seldom appears before the second half
of pregnancy, usually not until after the sixth or seventh month, and
the symptoms vary widely in severity. They may range from headache and
nausea, so slight as to cause the patient little or no inconvenience, to
coma and death.

The patient may be entirely normal for six or seven months and then
notice that her rings and shoes are a little tight, because of the
slight swelling of her hands and feet. Puffiness of the eyelids may
appear, and other parts of the body may also be slightly swollen.
Headache, dizziness, lassitude, drowsiness, depression, apprehension,
nausea and vomiting are all symptoms, as also are high blood pressure
and a diminished amount of urine, containing albumen. The patient
frequently complains of visual disturbance, which may be only a slight
blurring, but in severe cases may amount to total blindness.

Other symptoms, when the condition is grave, are epigastric pain; rapid
pulse; extreme nervousness and excitement, which may amount almost to
insanity; or drowsiness, which grows deeper and deeper until the patient
sinks into a coma. Under such conditions, she may die without recovering
consciousness, but more frequently, eclampsia ensues. The child may
perish as a result of the toxemia and a dead, premature baby be born.

=Prevention= is of course, the most important aspect of the treatment
and is accomplished by means of the pre-natal care and supervision which
were described in the last chapter. In this connection must be mentioned
again the danger, during pregnancy, of overeating. It is more and more
frequently observed that toxemic seizures follow in the wake of a
single, large, heavy meal, such as one is so likely to take at
Thanksgiving or Christmas time. This is particularly true of patients
who have had nausea or who have even slightly disabled kidneys, which,
though able to meet the ordinary demands made by pregnancy, are
inadequate to cope with the sudden strain imposed by a large meal. In
such a case, toxic materials which should be excreted are retained
within the body, and the familiar symptoms of toxemia are the result.

Much the same condition is produced by the patient’s getting wet or
chilled. The excretory function of the skin is interfered with, under
such circumstances, and the kidneys are unable to do enough extra work
to make up for the skin’s failure, and again toxic material is retained,
instead of being excreted.

=Treatment and Nursing Care.= As might be expected, the details of
treatment and nursing care of a pre-eclamptic patient vary with
different doctors and with the severity of the attack. But the
essentials of treatment, the country over, may be summed up as rest and
elimination, coupled with close watching for unfavorable symptoms.

The surest way to have the patient really rest is to put her to bed,
even in mild cases, and recovery is so hastened, thereby, that she is
well paid for the temporary inconvenience.

Since it is widely believed that the metabolic disturbance, in toxemia,
is related to the nitrogenous part of the diet, the course usually
followed in this particular is a reduction of the nitrogen intake. This
is accomplished by putting the patient on a very low protein diet or a
milk diet, consisting of two quarts of milk daily. This amount of milk
provides adequate nourishment, for the time being, and also supplies a
large part of the fluid which is needed to promote elimination. In
addition to this, however, the patient is given one, or better still,
two quarts of water every day, and free saline purges.

Very frequently this treatment is all that is necessary. The blood
pressure falls in a few days, the albumen in the urine gradually
disappears, the patient completely recovers and in due time has a normal
labor.

But in more severe and less amenable cases it is necessary to increase
the eliminative treatment and give copious colonic irrigations; sweat
baths, in the form of hot packs or hot air baths, and even venesection
and saline infusions, in order to relieve the symptoms. Sometimes, even
these are not enough and the high blood pressure and albumen, which are
probably the most significant symptoms, will continue. If so, and the
patient grows worse, or if she simply fails to respond to the treatment,
the usual practice is to induce labor. A daily output of five grams of
albumen to a litre of urine, and a blood pressure of 200 millimetres are
usually regarded as insistent indications that pregnancy should be
terminated. Otherwise, eclampsia, always so dreaded, is practically sure
to follow and endanger the life of both mother and child.

It may be mentioned here that the normal blood pressure, during the
latter part of pregnancy, is about 120 millimetres. A gradual increase
to 130, or even 140 millimetres, may not be serious, but a sudden rise
or a pressure of 150 millimetres should be regarded with alarm, even
though all other symptoms be absent. The reason for this is that
eclampsia may, and sometimes does, occur with little or no warning
except the high, or suddenly increasing blood pressure.

ECLAMPSIA. Pre-eclamptic toxemia, as the name suggests, is a condition
that frequently precedes eclampsia, and the importance of the
prevention, early recognition and prompt treatment of this forerunner is
due to the seriousness of eclampsia which threatens to ensue. This
disease, which may be defined as a toxemia occurring before, during or
after labor, is one of the gravest complications which arise in
obstetrics. It is usually associated with both tonic and clonic
convulsions, unconsciousness and coma.

Patients who have a tendency to kidney trouble and to digestive
disturbances, such as so-called “biliousness,” are evidently likely to
have eclampsia; and in eclampsia there is a peripheral necrosis of the
liver which occurs in no other condition. These facts suggest that
possibly when metabolism is proceeding normally, the liver converts
certain material, whose retention within the body is inimical to health,
into a form which the kidneys can excrete without great effort; that if
the liver fails in this function, the kidneys are unable to stand the
increased strain put upon them, as is evidenced by casts and albumen
which appear in the urine, and the retained material gives rise to
toxemia. It is possible that disturbed functions of other glandular
organs, such as the thyroid, may play a part in causing eclampsia, but
this, too, is only conjecture.

The frequency with which the disease occurs has been variously estimated
at from one in 500 to one in 100 cases, apparently being more common in
first pregnancies than subsequent ones, but more serious when occurring
among women who have had children before. One attack is believed to
confer an immunity, or, as Dr. Chipman puts it, “the woman with
eclampsia vaccinates herself.” The average death rate from eclampsia is
from 20 to 35 per cent. of the mothers and about 50 per cent. of the
babies, except where the desired care can be given, either at home or in
a hospital, when the mortality is greatly reduced. These figures vary,
somewhat, according to the time of the onset, as the disease is usually
more fatal if the convulsions occur before or during labor, than
afterward.

Some authorities feel, however, that eclampsia is quite as fatal after,
as before, labor.

=Symptoms.= The symptoms, as a rule, are those of pre-eclamptic toxemia
which have persisted and grown more severe, accompanied by convulsions
and coma. The blood pressure may be from 150 to 250 millimetres and the
urine, in addition to showing many and varied casts, contains albumen,
which varies in amount from a few grams per litre to more than a hundred
in severe cases. In those cases which prove fatal and come to autopsy,
there is always found a characteristic, peripheral necrosis of the
liver, and since it is found in no other disease it definitely
establishes the diagnosis. It is true that this is of no help to the
poor woman who died, but it is of help to those investigators who are so
earnestly studying the disease with the hope of finding its cause and
cure.

Although there are frequently pre-eclamptic symptoms which have grown
worse, with or without treatment, it sometimes happens that the patient
has no warning discomfort and the first sign of the disease is a
convulsion; or a patient who has been treated for pre-eclamptic toxemia
may apparently recover, even to the extent of having the albumen
disappear from her urine, and suddenly have a convulsion.

Convulsions, which are both tonic and clonic in character, occur in
about 99.5 per cent. of all eclamptic cases and are very distressing to
watch. They are sometimes preceded by an aura, but often are so
unheralded that they may even occur while the patient is asleep. They
ordinarily begin with a twitching of the eyelids; the eyes are wide open
and staring and the pupils are first contracted and then dilated. The
twitching extends to the muscles about the nose and mouth, then to the
neck and arms, and so on until the entire body is convulsive. The
patient’s face is usually cyanotic and badly distorted, the mouth being
drawn to one side; she clenches her fists, rolls her head from side to
side and tosses violently about the bed. She is totally unconscious and
insensible to light, and during the seizure may not breathe beyond
giving one or two struggling gasps. Her head is frequently bent
backward, her neck forming a continuous curve with her stiffened, arched
back. Another distressing feature is the protruding tongue and the
frothy saliva, which is blood stained if the patient is not prevented
from biting her tongue by the introduction of some sort of a mouth gag
between her teeth.

Such is the typical eclamptic convulsion.

The attacks vary greatly in their intensity and duration. There may be
only a few twitches, lasting ten or fifteen seconds or violent
convulsions lasting as long as two minutes, their number and severity
increasing with the seriousness of the patient’s condition. In mild
cases there may be but one or two convulsions, particularly if the onset
is either late in labor or postpartum. But as a rule, there are several
convulsions; ten, twenty or thirty, and sometimes, though rarely, as
many as a hundred.

The patient always goes into a coma after a convulsion and this also
varies in length and profundity, her condition during the intervals
being very suggestive of the probable outcome of the disease. If the
attacks recur frequently, as they usually do in extreme cases, the
patient is likely to remain unconscious during the entire interval; but
she will usually awaken between attacks that are far apart, and this is
regarded as a hopeful sign. The respirations are labored and noisy as a
rule, and the pulse full and bounding, in which case the outlook is
good. The temperature is often normal, but may go as high as 104° F. or
105° F., dropping rapidly as the attacks subside. But a weak, rapid
pulse together with a high temperature, and above all, a persistently
high blood pressure, no matter what the other symptoms may be, are
always unfavorable.

Concerning the varied results of eclampsia, the opinion seems to be
growing that if it develops during late pregnancy, labor is likely to
set in and a premature child be born spontaneously; in some cases,
however, for reasons already given, labor is induced, while in others
the mother dies undelivered. The fetus may die, after which the
convulsions practically always cease and the infant is often born later
in a macerated state; or the patient may recover, go to term and give
birth to a normal, healthy baby.

When eclampsia occurs during labor the pains usually increase in force
and frequency, thus hastening delivery, after which the convulsions
usually cease. It will be noted that death or expulsion of the fetus is
in almost all cases followed by immediate cessation of the symptoms and
by ultimate recovery.

=Treatment and Nursing Care.= There is so little definite information
about the cause of eclampsia that there is quite naturally some
difference of opinion as to the best methods of curative treatment.
Unquestionably, prevention is of first importance and this is
accomplished through the watchfulness and care during the antenatal
period as described.

Dr. Edgar characterizes eclampsia as a preventable disease, and though
an occasional case will develop in spite of preventive treatment the
general results achieved tend to bear out his definition. For example,
in a series of 1200 maternity cases at Bellevue Hospital during 1920,
prenatal care was given to 900 women and not one case of eclampsia
occurred among them, while among the remaining 300 women who had not
been seen during pregnancy, there were ten eclamptics. It is but fair to
bear in mind that as some of these patients were taken into the hospital
because of their having eclampsia, the proportion is abnormally high.
The Henry Street Settlement reports through its maternity service that
there was but one case of eclampsia among 7600 women who were given
prenatal care by its nurses in 1920. These figures, contrasted with the
average of one case in about every 500 pregnancies, furnish astounding
evidence of what can be done through prenatal care in the prevention of
this one disease alone.

As to curative treatment, the variations of opinion are after all of
little consequence to the nurse, for there is almost entire unanimity
concerning the general principles, and it is these that shape the
nursing care. Broadly speaking, they comprise effort to dilute the toxic
material in the system, promote its elimination through the various
excretory channels and quiet the patient’s nervous excitability.

Since eclampsia occurs only in connection with pregnancy, and the
convulsions usually cease if the fetus dies or is born, one line of
reasoning is that the most effective way to treat the disease is to
terminate pregnancy. Formerly this was almost always done, and is still
practised by some obstetricians. Those who do not agree with this theory
contend that the eclamptic woman is a very ill woman whose nervous
system is so irritated that the slightest stimulation or irritation
works harm. In view of this they feel that manual or instrumental
dilation of the cervix, preparatory to delivering the child through that
channel, or delivery through an incision in either the abdominal wall or
cervix, constitutes a shock that outweighs the advantages of emptying
the uterus; therefore, that as a rule, less harm is done by
noninterference, quieting the patient and increasing her eliminative
functions, than by terminating pregnancy. This line of reasoning also
takes into consideration the fact that from 15 per cent. to 20 per cent.
of the cases of eclampsia are postpartum, indicating that convulsions
may occur even after the uterus has been emptied.

The growing tendency is to adopt a middle course and treat each
individual case according to the conditions and indications which it
presents. Thus the same doctor will hastily induce labor in a case where
the blood pressure and albumen remain alarmingly high, or increase, in
spite of all efforts to reduce them, and in another case will go to the
extreme of conservatism, doing nothing but quiet the patient with
morphia or chloral, or both, and stimulate all of her excretory organs
with abundant fluids.

But the nurse’s duties, and I may say her opportunities, for she is
privileged to do much, are virtually the same no matter which course is
followed, except, of course, the preparation for delivery, if this is
performed.

The nurse is concerned with helping to reduce the intake of nitrogenous
food, or proteids; diluting the toxines retained in the body; promoting
the activity of the kidneys, bowels, liver, lungs and skin; guarding the
patient against all avoidable stimulation from without, such as noise,
light, ungentle handling and undue resistance to the patient’s
convulsive movements; and protecting her from injuring herself by biting
her tongue, falling out of bed or striking the wall or head of the bed
during convulsions.

By striving to accomplish these general results for her eclamptic
patient the nurse will aid immeasurably in saving her life.

A milk diet is the means of reducing the nitrogen intake; or in some
cases even that small amount of proteid is deemed too much, and only
water is given until 24 to 48 hours after the convulsive seizures have
ceased. From three to five litres of these fluids should be given in the
course of twenty-four hours, in order to increase elimination by way of
both kidneys and skin, and it usually taxes the nurse’s patience and
ingenuity to give this amount, for the patient will seldom take large
quantities of fluids willingly, even when quite conscious. A surprising
amount of water may be given to the sleeping or unconscious patient by
dropping it into her mouth from the point of a teaspoon, taking care to
give it only at those moments when she is lying quite still. If the
nurse attempts to hold the restless patient’s head, or so much as places
her hand upon the chin to steady it in order to give water, the
irritation, though slight, may be enough to cause a return of the
tossing and struggling.

Lithia water and cream-of-tartar lemonade (a teaspoonful of cream of
tartar to a pint of water), are frequently given because of their
diuretic and diaphoretic action; but whatever the fluid, it must be
given persistently, with greatest gentleness and with care that the
patient does not choke nor aspirate it into her lungs and thus possibly
cause pneumonia. Food even in liquid form is not given while the patient
is unconscious, because of this danger of aspiration and subsequent
pneumonia.

The bowels are stimulated to greater activity by powerful purges, such
as croton oil, in olive oil, dropped on the back of the tongue, or salts
or castor oil given by stomach tube.

Copious _colonic irrigations_, alternating with hot packs so that one or
the other is given every six, eight or twelve hours, according to the
seriousness of the case, are frequently given and with excellent
results. A colonic irrigation may be given by means of the Murphy drip
method or through a rectal tube so contrived that a two-way flow of
fluid is possible. Water, normal saline (2 drams of salt to a quart of
water), or a weak solution of sodium bicarbonate (an ounce of soda to a
quart of water), are all used for colonic irrigations, which are given
at a temperature of 110° F., very slowly, with the receptacle for the
solution placed so low that the flow is under very slight pressure. The
patient should lie on her left side, in a comfortable position and be
warmly covered. The tube should be introduced from 12 to 18 inches, and
the stop cock arranged so that it will take from twenty to thirty
minutes for each gallon of fluid to run in and out. About two gallons
are usually used for the first irrigation, the amount being increased
until five gallons are used each time. The beneficial effects of the
colonic irrigations are two-fold, for in addition to removing the toxic
material that may be in the colon and rectum, a good deal of fluid is
absorbed through the intestinal wall.

The function of the lungs may be promoted by using oxygen and by keeping
the air in the patient’s room fresh and constantly moving, but moving so
gently that there is no perceptible draft. The nurse must remember that
the skin also is an excretory organ whose function is being stimulated,
and this necessitates its being kept warm.

Some obstetricians feel that it is as important to increase the
excretions of the skin as of the kidneys, and that inability to induce
perspiration is an unfavorable sign. Others, who disagree on this point,
believe that the skin is of minor importance but that the bowels are of
equal consequence with the kidneys. However, the nurse will do no harm,
and will err on the safe side if she takes care to keep her patient warm
and constantly protects her from being chilled, that is from exposure or
changes in the temperature of her surroundings. A flannel nightgown or
dressing gown will help to this end, or if neither is available, at
least the patient’s chest and arms may be protected by warm bed jacket,
or sweater, put on backwards and fastened at the back of the neck. This
protection, together with a number of blankets, with or without hot
water bags between them, will often induce a slight but constant
perspiration, particularly if fluids by mouth are being forced at the
same time. This may be all of the stimulation that the skin needs, and
has the advantage of not greatly disturbing the patient, a point that
cannot be too constantly borne in mind.

[Illustration:

  FIG. 48.—Patient in hot pack given with dry blankets and hot-water
    bags. The blankets are turned back in this picture to show their
    arrangement. (From photograph taken at Johns Hopkins Hospital.)
]

If something more is needed, the _hot dry pack_ is a widely used and
usually efficacious method of producing a sweat and can be given easily
in the patient’s home with no more equipment than the average family
possesses or can obtain. The articles needed are two rubber sheets or
two heavy quilts; four blankets; three, four or five hot water bags; an
ice cap or a basin with ice and two cloths for the patient’s head; a
pitcher of the fluid that she is taking, and a feeding cup, drinking
tube, small pitcher or a spoon with which to give it. One rubber sheet
(or one of the quilts), and two blankets should be slipped under the
patient, after the regular bedclothes have been loosened at the foot. If
the patient is having convulsions it is better to leave on her a warm
garment with sleeves to insure against her arms and chest being
uncovered, otherwise the nightgown may be removed.

The patient is covered with one blanket which is tucked between her legs
and around her body with her arms out, so that no two surfaces of the
skin come in contact. The blanket on which she lies is brought up about
her; another blanket should be laid over this and tucked in well about
the neck, shoulders and entire body, while the fourth blanket is next
wrapped around her from below. One long or two short hot water bottles
should be placed on each side of the patient and one at her feet, _all
being placed outside the four blankets_. The second rubber sheet, or
quilt, is thrown over the whole and the ice cap, or cold compresses
(changed every four or five minutes) placed on her forehead. (Fig. 48.)

A patient may usually be left in such a pack as this from half an hour
to an hour, but since any sweat bath is more or less depressing, she
must be watched constantly for evidence of exhaustion, such as a weak,
rapid, irregular pulse and increased weakness, or the sudden relaxation
of an active eclamptic patient.

In some instances the hot-water bags may be inadvisable, because of
supplying more heat than the condition of the patient warrants; but if
they are used, the nurse must remember how easily an unconscious or ill
person is burned. She must watch the bags, move them frequently and take
care that one of them does not slip under the patient. And while the
pack is in progress, an even greater effort than ever should be made to
force the fluids.

If the blankets are wrapped snugly about the patient, alternately from
below and above as described, they will frequently provide all of the
restraint that is necessary should she have a convulsion while in the
pack. The importance of protecting her against exposure and chilling
while in the pack cannot be too insistently stressed.

If I have seemed to dwell at surprising length upon rudimentary nursing
details, in this connection, it is because the patient’s life literally
depends upon the nurse’s conscientious and painstaking attention to
these same details. The doctor may study the case ever so earnestly and
order the treatment ever so wisely, but if every detail of that
treatment is not thoughtfully and skilfully carried out, it may do the
patient more harm than good. And on the other hand, I can think of no
circumstance that gives the nurse deeper gratification than the almost
miraculous improvement in an eclamptic patient, sometimes only
overnight, after she has taxed to the utmost all of her ingenuity to
make her ministrations effective.

Appliances for giving hot packs and hot-air baths are usually found in
all hospitals, and the nurse will use them as directed, which obviates
any necessity for describing them here. But in addition to correctly
adjusting and using the appliance itself, she must watch her patient for
evidence of exhaustion or shock; protect her from burns; keep cold
applications on her head and give her as much fluid as possible. And
when the hot pack is over, the patient must be taken from it gradually;
one blanket at a time, or the heat slowly reduced, and then the greatest
care taken that she is not chilled while being put into dry clothing,
for she must be kept warm and perspire slightly even after the sweat is
finished.

Restraint during convulsions should be as mild as possible, for
resistance only increases the patient’s excitement, and sustained effort
should be made to reduce it instead. To this end there are innumerable
details to be considered. Every act must be performed as quietly as
possible. The nurse must walk lightly and if her tread will be made
softer by wearing bedroom slippers, she should wear them. She should
consciously guard against kicking or striking the bed. All talking
should be in low tones; doors opened and closed quietly; papers should
not be rustled nor furniture scraped on the floor. The room should be as
dark as is feasible and the source of light screened from the patient’s
eyes.

She should be saved from biting her tongue by having placed between her
teeth something that will serve as a mouth gag and still not cut nor
bruise the mucous membranes. In a private home, one will find that a
cork answers admirably; or the handle of a wooden spoon well wrapped
with gauze or a clean handkerchief; or a small roll of bandage or clean
cloth tightly rolled. Another method is to take a fresh handkerchief, or
napkin, in the fingers by opposite corners, twist it slightly into a
roll and force it between the teeth and tie the two corners firmly
together at the back of the neck.

_Venesection._ The large intake of fluids tends to dilute and eliminate
the toxins which are giving so much trouble, but another very prompt and
efficacious measure is to withdraw from 500 cubic centimetres to 1000
cubic centimetres of blood by venesection, according to the condition of
the pulse. In preparing for a venesection the nurse will slip a small
rubber, covered with a towel, under the arm that is to be opened, and
scrub the inner surface of the elbow with soap and solutions according
to the wishes of the doctor in charge, and cover the cleaned area with a
dry sterile towel or one wet with a disinfecting solution. A sterile
towel should be slipped under the patient’s arm, one laid over the arm
above and one below the cleaned area so that the entire surrounding
field is protected by sterile towels.

For the puncture there will be needed a sterile canula, or infusion
needle, with a piece of rubber tubing attached; a sterile receptacle for
the blood, usually a 1000 cubic centimetre, graduated measuring-glass;
both dry and alcohol sponges or cotton pledgets; adhesive plaster, or a
bandage to hold in place the small dressing which is applied after the
needle is withdrawn; and a tourniquet for tight application to the upper
arm to impede the return of the venous blood and thus distend the large
vein to be seen near the surface of the inner curve of the arm. This
vein usually may be easily pierced, without incising the skin, the
canula pointed toward the hand to meet the blood stream, after which the
tourniquet is removed. Sometimes it is necessary to incise the skin in
order that the vein may be exposed and the needle inserted into it
directly. In this case the doctor will need, in addition to the articles
already mentioned, a scalpel, a pair of tissue forceps, three or four
artery clamps, a needle holder, skin needles and sutures.

A venesection is practically always followed by a drop in the blood
pressure and a marked improvement in the general condition.

_Infusions_, or subcutaneous injections of saline solutions, are also
frequently given to eclamptic patients with beneficial results. About
1000 cubic centimetres at 105° F. is introduced slowly into the tissues,
and the solution may be normal saline, consisting of two drams of common
salt to a litre of distilled water, filtered and sterilized; or possibly
one containing five grains each of sodium bicarbonate and sodium
chloride to the litre.

The articles necessary, in addition to the soap and solutions for
cleaning up the skin, are a small rubber to protect the bed; three or
four sterile towels; a flask of the solution at 105° F.; sterile
infusion bottle, or can, with rubber tubing fitted with a piece of glass
tubing at some point in its length, through which the flow of the
solution may be watched, a stopcock, and an infusion needle (I cannot
refrain from cautioning the nurse to be sure that the tubing does not
leak; is not collapsed and stuck together at any point along its length,
and that the needle is sharp, free from rust and contains a wire as
evidence of not being clogged); two hot water bottles about half full,
with air expelled; a pole or stand upon which to hang the bottle; a
package of gauze sponges, or squares, and narrow strips of adhesive.

The fluid is usually introduced between the breast tissues and
underlying muscles; the area to scrub up in preparation being just below
the breast, where the curve begins, and toward the axilla. The bottle
which contains the solution should be stoppered with sterile cotton, or,
if a can, covered with a sterile towel, and hung between the hot water
bottles, to keep the fluid warm, and held in place with a towel pinned
around them, top and bottom. (Fig. 49.)

If the nurse is to give the infusion, she should grasp the end of the
needle, to which the tubing is attached, with her right hand, pierce a
piece of sterile gauze; open the stop cock and allow the air and cold
fluid to escape, leaving a drop on the point of the needle; lift the
patient’s breast with her left hand and quickly plunge the needle in
just under it. The direction of the needle should be parallel to the
chest wall to insure its running below the breast tissue, and above, not
between the ribs. The needle, and the gauze through which it runs, may
be held in place by means of narrow strips of adhesive plaster. The stop
cock should be so adjusted that the warm fluid will flow into the
tissues very slowly, about an hour being required to introduce 1000
cubic centimetres. During this time the patient must be kept well
covered and the solution kept at about 105° F. as some of the heat is
lost in its course through the tubing. A hot water bag placed upon the
bed, over a coil of the tubing, is another means of maintaining the
desired temperature, but it must be watched and moved from time to time,
to guard against burning the patient. In hospitals where the infusion
apparatus is equipped with a heater, hot water bags are, of course not
needed, but they are of practical service in a patient’s home.

[Illustration:

  FIG. 49.—Infusion being given under breast; needle held in place by
    strips of adhesive and the solution kept warm by hot-water bottles
    suspended on each side of the infusion bottle.
]

_Termination of pregnancy_ is resorted to much less frequently than
formerly, because it is believed that an eclamptic patient is
particularly susceptible to infection and also that the shock of an
induced labor is serious to so ill a woman.

The method of terminating pregnancy, when this is finally deemed
necessary, depends upon the condition of the cervix; the size of the
child; and upon the patient’s general condition. The method may be
simple induction of labor, by the introduction of a bougie, if haste is
not imperative; introduction of a bag; manual dilation of the cervix, if
it is soft and partly obliterated; vaginal hysterectomy, or even
cesarean section.

Chloroform is not used as an anesthetic, in eclampsia, nor to relieve
the labor pains nor control the convulsions because of its tendency to
increase the liver necrosis which is incidental to the disease.

Recovery is comparatively rapid, when it occurs. The blood pressure
drops to normal; the albumen and casts disappear from the urine and all
symptoms subside in from two to four weeks. (Chart 1.) And, happily,
since one attack confers an immunity, the patient who recovers from
eclampsia need not fear a recurrence of the disease.

NEPHRITIC TOXEMIA is a serious toxemia, sometimes complicating
pregnancy, and though it may occur at any time during the period of
gestation, it usually develops during the latter months. As a rule, it
is simply an exacerbation and accentuation of a previously existing,
chronic nephritis, of which the patient may, or may not, have been
aware; though in some instances the disability of the kidneys may arise
during pregnancy. In many cases, so far as the kidneys are concerned,
the patient is entirely normal in the non-pregnant state, and even
during pregnancy, up to a certain point; then her kidneys prove to be
unequal to the added metabolic strain of pregnancy, and signs of renal
insufficiency appear.

Such a patient will suffer from toxemia, with each recurring pregnancy,
the symptoms almost always appearing earlier, and with increased
severity, with each pregnancy, as the permanent damage to the kidneys is
increased by each successive attack.

[Illustration:

  CHART 1.—Chart showing relatively rapid disappearance of albumen from
    the urine and return of blood pressure to normal, after delivery in
    eclampsia.
]

=Symptoms.= The symptoms in nephritic toxemia are practically the same
as those in chronic nephritis: lassitude, headache, visual disturbances,
edema, high blood pressure and casts and large amounts of albumen in the
urine. In some instances, the patient suffers such slight discomfort
that the increased blood pressure and urinary symptoms are the only
precursors of coma, and possibly convulsions which cannot be
distinguished from an eclamptic seizure.

As the patient may die in the coma, no matter how suddenly it develops,
the value of regular urinalyses and observations upon the blood
pressure, which are included in prenatal care, must once more be
mentioned.

In severe, chronic cases _infarcts_ (hemorrhagic or necrotic areas)
appear in the placenta. These may be extensive enough to interfere with
the nourishment of the fetus, which, being already weakened by the toxic
effects of the disease, is unable to survive. As a result, nephritic
toxemia is second only to syphilis in causing premature deaths. When the
child dies, the symptoms usually begin to subside in a week, or possibly
two, and the dead fetus is expelled.

=Treatment and Nursing Care.= The treatment and nursing care are
virtually the same as for pre-eclamptic toxemia; rest in bed, milk diet,
forced fluids, purges, and in addition, observations upon the intake and
output of fluids. The output of urine will not equal the amount of fluid
which the patient takes in, at first, but in those patients who improve,
the amount of urine gradually increases until it equals the amount of
fluid ingested. The edema and other symptoms improve, except the high
blood pressure and the albumen in the urine, which sometimes persist for
months. (Chart 2.)

If the patient has coma or convulsions, the treatment is the same as in
eclampsia.

A patient with inadequate kidneys who has never been able to carry a
child to term may sometimes achieve this coveted end by going to bed a
few weeks before the period in her pregnancy when the toxic symptoms
have usually appeared, taking only milk for food, drinking large amounts
of water, and keeping her bowels moving freely.

It is impossible to distinguish between eclampsia and nephritic toxemia
during an attack, but this is of no importance at the time, as the
treatment of the two diseases is the same.

[Illustration:

  CHART 2.—Chart showing persistence of high blood pressure and of
    albumen in the urine, after delivery, in _nephritic toxemia with
    convulsions_.
]

But during the puerperium, the differential diagnosis may be made, for
in eclampsia the blood pressure falls rapidly to normal and the casts
and albumen disappear from the urine in from two to four weeks. In
nephritic toxemia, on the other hand, although the blood pressure falls
somewhat, and the albumen decreases in amount as the patient’s general
condition improves, by the end of the puerperium the blood pressure is
still elevated and casts and albumen are still present in the urine.

In eclamptic cases that come to autopsy, there is a typical, peripheral
necrosis of the liver, but in nephritic toxemia there is no liver
lesion.

ACUTE YELLOW ATROPHY OF THE LIVER is one of the grave but very rare
toxemias of pregnancy and though it may occur at any stage it usually
appears during the latter part of pregnancy or during the puerperium.
This complicating condition is not peculiar to pregnancy alone, although
from forty to sixty per cent. of the cases which occur are in pregnant
women.

The symptoms, which sometimes come on suddenly in a woman who previously
has been entirely well, may suggest phosphorus poisoning. They are
abdominal pain, headache, vomiting, and diarrhea followed in some cases
by coma and convulsions, and in others by violent delirium. With these
symptoms are jaundice and a diminished amount of urine, which contains
albumen, casts, and usually a good deal of blood. The picture is
practically that of pernicious vomiting plus jaundice and pain.

Little is known of the ultimate cause of the disease, but it produces
rapid atrophic and degenerative changes in the liver, and though mild
cases sometimes recover, the outcome is usually fatal. It was formerly
thought that the termination of pregnancy virtually cured the condition,
but the present belief is that delivery produces little or no effect.
The tendency now, therefore, is simply to employ the same kind of
eliminative treatment that is used in eclampsia.

Among the more serious complications of pregnancy, which are not due to
that condition, but which it is important to recognize and treat early,
may be included syphilis, heart lesions, pulmonary tuberculosis,
thyroidism, gonorrhea and pyelitis.

“SYPHILIS is one of the most important complications of pregnancy,” in
the opinion of Dr. Williams, “as it is the most important single cause
of fetal death.”

In support of this contention, Dr. Williams reports upon a series of
10,000 consecutive deliveries which took place under his observation,
and in which syphilis caused 26.4 per cent. of the deaths among 705
babies who died after the seventh month of pregnancy or during the first
two weeks after birth. Furthermore, nearly as many more babies who were
discharged alive, at the age of two weeks, died in a short time or gave
evidence of having syphilis later on in life.

Believing in the importance of diagnosing and treating this disease
during pregnancy, Dr. Williams subsequently made observations upon 4,000
cases in which Wassermann tests were given, and to which 421 women gave
positive reactions. In this series of 4,000 deliveries, 302 babies died
during the last two months of uterine life, or the first two weeks of
extra-uterine existence. The relative frequency of the various causes
which worked destruction in these 302 little lives is given by Dr.
Williams in the following table:—

       Syphilis                                 104 cases  34.44%
       Dystocia                                  46 cases  15.20%
       Toxemia                                   35 cases  11.55%
       Prematurity                               32 cases  10.59%
       Cause unknown                             26 cases   8.61%
       Placenta prævia and premature separation  16 cases   5.28%
       Deformity                                 11 cases   3.64%
       Eleven other causes                       32 cases  10.69%
                                                ———       ———————
                        Total                   302       100.00%

It will be seen from these figures that syphilis caused almost as many
deaths as the three causes, next in order, combined.

The effect upon the child’s chances for life, of treating the expectant
mother for syphilis, is suggested by comparing the results among the 421
syphilitic women who were not treated at all; those treated
insufficiently by receiving but two or three doses of salvarsan and no
after-treatment of mercury (because of the patient’s lack of cooperation
or because treatment was instituted too late in pregnancy); and those
treated satisfactorily, which meant the administration of from four to
six doses of salvarsan followed by mercurial treatment continued
sufficiently long to result in a Wassermann reaction that was negative,
and remained so.

Among those mothers who were not treated, 52 per cent. of the babies
were born dead or had syphilis; among those treated incompletely, 37 per
cent. and among those treated until cured, syphilis caused the death of
or was demonstrable in but 6.7 per cent. of the babies.[5]

The deductions to be made from these dramatic figures is, that although
syphilis seems to have about the same effect upon the pregnant, as the
non-pregnant woman, it constitutes a serious menace to infant life and
health.

Accordingly, it is very important that every pregnant woman be given the
Wassermann test as early as the third or fourth month, and any woman who
gives a positive reaction should be urged to submit to intensive
treatment until cured. Her compliance will apparently multiply by seven
or eight her expected baby’s chances for life.

HEART LESIONS sometimes present grave complications during pregnancy, or
at the time of labor, because the damaged or weakened heart is unable to
meet the greatly added strain put upon it at these times. Spontaneous,
premature labor sometimes results from serious heart trouble, while in
some cases labor is artificially induced to relieve the overworked organ
of the strain that is evidently exhausting it. Quite obviously it is an
important step toward the prevention of both these deplorable
occurrences to have the difficulty recognized early. Rest in bed and the
same kind of medical treatment that would ordinarily be given for a
poorly compensating heart will sometimes enable the disabled organ to
carry its load throughout pregnancy. But care is necessary.

PULMONARY TUBERCULOSIS is so common under all conditions that it is not
surprising to find it fairly often among pregnant women. Since the
treatment for this disease consists largely of effort to conserve the
patient’s forces and build up the bodily resistance, the drain which
pregnancy makes upon the system is likely to be inimical to the
tuberculous patient’s improvement. It is the general opinion, therefore,
that the tuberculous patient grows worse during pregnancy, and is still
further weakened by the ordeal of labor and the drain of nursing her
baby.

Some women with tuberculosis improve during the period of pregnancy, but
decline after delivery. The disease may advance rapidly in such cases
and the patient succumb very early.

There is great reluctance to terminate pregnancy in tuberculous
patients, except in extreme cases as a last resort, to save the mother’s
life, or when, after the child is viable, its chances for life would
seem to be better if it were brought into the world, because of the
mother’s possible death.

Certain it is that the care which is given to the non-pregnant
tuberculous person is needed to an even greater degree by the expectant
mother who is suffering from this disease. And under such care, it not
infrequently happens that the patient will go through pregnancy safely,
and if the care is continued after delivery, and her baby not allowed to
nurse, her ultimate recovery does not seem to be retarded by the
experience.

Tuberculosis is sometimes, though not frequently, transmitted from the
mother to the fetus; but babies born of these mothers are not likely to
be robust, particularly as they must be deprived of that bulwark of
early infancy—maternal nursing.

THYROIDISM in pregnancy has been, and still is, so widely discussed and
studied that the nurse will do well to at least take cognizance of that
fact, even though no definite conclusions seem to have been generally
accepted.

The toxemias of pregnancy are so shrouded in mystery, and knowledge of
the functions and inter-relations of the ductless glands is still so
meagre, though it is known that one, the ovary, is inevitably concerned
with pregnancy, that one is not surprised to find certain investigators
considering these two problems together. Nor is it surprising that
directly opposite views are held concerning the relation of thyroidism
to toxemia.

Since the nurse will sometimes care for toxemic patients who are treated
for thyroidism, either by means of gland therapy or operative procedure,
she should understand the rationale of such treatment when she meets it.

Dr. Williams says, for example, “A considerable amount of work has been
done in this direction, but the consensus of opinion is that
abnormalities of the thyroid secretion play no part in the causation of
eclampsia.”

On the other hand, it will be remembered that the thyroid gland is
usually somewhat enlarged during pregnancy, and in this connection Dr.
Edgar observes that “The normal enlargement of this organ in the gravida
has been wanting in certain cases of eclampsia.”

Dr. Edward P. Davis summarizes his opinions on the subject as follows:
“Hyper-thyroidism in pregnancy produces a toxic condition in the mother,
which exposes her to the danger of the toxemia of pregnancy and her
child to the dangers which accompany that condition. During pregnancy,
the patient has a rapid pulse, often with high tension, and attacks of
breathlessness and syncope, and intense nervousness. When uterine
contractions begin, the action of the heart becomes exceedingly rapid;
there is difficulty in breathing and the patient is brought into great
distress. It is often necessary to give prompt assistance in labor, and
this may require the performance of cesarean section. The child is
exposed to the risks of rapid delivery, although, if section be
performed, the risk to the child is reduced to the lowest point. When
the placenta is examined, it is found that certain changes have taken
place in its structure which interfere with the circulation of the blood
through the placenta, and may indirectly bring about the death of the
fetus. The child is also subject to the same toxic conditions which the
mother has had and may die from failure of the liver and kidneys or in
convalescence.

“A minute discussion of the subject would be occupied largely by the
question of exactly what are the poisons which cause this condition, and
this question has not yet been definitely answered.

“So far as neutralizing the results of excessive action of the thyroid,
it is best accomplished by rest, a diet from which meat and other heavy
proteins are excluded, regulation in the action of the bowels and the
avoidance of nervous excitement or undue exertion. If the action of the
heart is excessively disturbed, those drugs which control cardiac action
must be used. In extreme cases, morphine and atropine are given.”

PYELITIS is a fairly common, and sometimes a very painful and serious
complication arising during the latter half of pregnancy. It is an
inflammation of the pelvis of the kidney, most frequently the right,
caused by a damming back of urine, because of pressure of the enlarged
uterus on the ureter where it crosses the pelvic brim; and by infection,
which may travel up from the bladder or be conveyed by the lymph and
blood streams, frequently from the intestines. The colon bacillus is the
commonest offender, though the streptococcus, gonococcus or even the
tubercle bacillus may be the cause.

Frequently the patient will be entirely well, aside from a slight
irritability of the bladder causing frequent micturition, and suddenly
have paroxysms of acute pain in the region of the kidney, which may be
swollen and very painful on palpation. She will have fever and sometimes
chills and a catheterized specimen of urine will contain pus and
bacteria. The kidney may suddenly empty itself of pus after which the
pain and swelling will subside, only to recur when the pus accumulates
again.

The treatment is rest in bed, a bland diet and an abundance of milk and
water to drink. As the infection is often of intestinal origin, drugs
are usually given to prevent intestinal fermentation and keep the bowels
moving freely. Sometimes, though rarely, when the patient does not
improve under treatment, pregnancy is terminated to relieve the pressure
on the ureter and thus drain the diseased kidney by permitting an
unobstructed flow of urine.

The tendency of the disease is to subside spontaneously, but sometimes
it is necessary to incise and drain the kidney, or even to remove it;
while in others the infection is so virulent that the patient dies of
septicemia.

GONORRHEA during pregnancy may cause great discomfort in the shape of
irritation and itching of the vulva, or even excoriation of the mucous
membrane, and sometimes abscesses of the vulvovaginal glands.
Occasionally the infection reaches the decidua and causes an abortion.
But the chief danger in gonorrhea is that, after delivery, if the
disease has remained uncured, the organisms may travel up from the
vagina to the uterine cavity and tubes, and there set up an
inflammation, or possibly cause a general postpartum infection. The
greatest danger to the child is that its eyes may become infected during
the passage of the head through the birth canal. This is the reason for
the very great care that is taken of the eyes of the newborn, which will
be described in a later chapter.

It is very important, therefore, for the sake of both mother and child,
that gonorrhea be discovered early, for treatment started at this stage
is often attended by very gratifying results, as the disease may be
entirely cured before it is able to invade the uterus and tubes. This is
because the closure of the internal os, by the membranes, converts the
vagina and cervix into more or less of a cul-de-sac, to which the
infection is restricted. Being thus localized, it may often be
eradicated with relatively little trouble.

The yellow vaginal discharge, characteristic of gonorrhea, may become
profuse and purulent. It is removed by means of low, very gently given
douches. Tampons and vaginal suppositories are sometimes used, while
abscesses and abrasions are given appropriate surgical treatment.

The nurse must observe the strictest technique while caring for these
patients because of the danger of infecting herself and others with the
discharges. She should wear a gown and rubber gloves when giving douches
or dressing diseased vulva, and because of the possibility of
contamination by splashing fluids, she should hold her head well to one
side in addition to protecting her eyes with goggles. All utensils for
each patient should be isolated and they should also be washed and
boiled after each time that they are used.


  “Lying-in is neither a disease nor an accident, and any fatality
  attending it is not to be counted as so much per cent. of inevitable
  loss. On the contrary, a death in child-bed is almost a subject for
  an inquest. It is nothing short of a calamity which it is right that
  we should know all about, to avoid it in future.”

                                                 FLORENCE NIGHTINGALE.



                                PART IV
                         THE BIRTH OF THE BABY

  CHAPTER X. PRESENTATION AND POSITION OF THE FETUS. Breech, Head, Face,
    and Vertex Presentations. Longitudinal and Transverse Presentations.
    Position of Fetus. Time of Engagement. Methods of Ascertaining
    Position and Presentation of Fetus. Abdominal Palpation. Vaginal
    Examination. Rectal Examination. Auscultation of the Fetal Heart.

  CHAPTER XI. SYMPTOMS, COURSE, AND MECHANISM OF NORMAL LABOR. Onset of
    Labor. Three Stages of Labor.

  CHAPTER XII. NURSE’S DUTIES DURING LABOR. General Principles of
    Treatment and Nursing Care. Psychology of the Patient. Preparation
    for Vaginal Examination or Delivery. Nurse’s Duties during First
    Stage. Second Stage. Maintaining of Surgical Cleanliness. Immediate
    Care of the Child. Resuscitation of New-born Child. Third Stage.
    Immediate Aftercare of the Patient. Nurse’s Duties if the Doctor Is
    Delayed. Prolapsed Cord. Post-partum Hemorrhage. Obstetrical
    Anesthesia: Chloroform. Ether. Nitrous Oxide Gas Analgesia. Twilight
    Sleep. Complete Anesthesia.

  CHAPTER XIII. OBSTETRICAL OPERATIONS AND COMPLICATED LABORS.
    Conditions Giving Rise to Operations. Preparation for Operation in
    the Home. Perineal Lacerations. Episiotomy. Breech Extraction.
    Version. The Use of Forceps. Symphysiotomy. Vaginal Hysterotomy.
    Cesarean Section. Ruptured Uterus. Destructive Operations. Induced
    Abortions and Premature Labors. Accouchement Forcé.



                               CHAPTER X
                 PRESENTATION AND POSITION OF THE FETUS


[Illustration:

  FIG. 50.—Most frequent attitude of fetus in uterine cavity, at term.
]

Returning for a moment to the pregnant uterus at term, we find it to be
a thin-walled, muscular sac containing the mature fetus, attached by
means of the umbilical cord to the placenta and floating in the amniotic
fluid, which is contained within a sac formed by the amniotic and
chorionic membranes.

The average fetus at term is about 50 centimetres long, weighs about
3250 grams and is curved and folded upon itself into an ovoid mass,
occupying the smallest possible space. (Fig. 50.) Its most frequent
attitude is with the back arched; the head bent forward, with chin
resting upon chest; arms crossed upon chest below chin; thighs flexed
upon abdomen and knees bent.

[Illustration:

  FIG. 51.—Illustrations from the first textbook on obstetrics,
    Roesslin’s “Rosengarten,” 1513, which gives an amusing impression of
    early ideas of the position of the fetus in utero.
]

With a few exceptions the long axis of the fetus is parallel to the long
axis of the mother, and most frequently the head is downward. It was
formerly believed that the child stood upright in the uterus until
toward the end of pregnancy and then somersaulted to the position it
occupied immediately before birth. (Fig. 51.) But it is now known that
though the fetus may move about and change its position during the early
part of pregnancy, it is not likely greatly to alter its relation to the
mother’s body during the tenth lunar month.

[Illustration:

  FIG. 52.—Attitude of fetus in breech presentation.
]

It seems advisable to define here certain terms which are in common use
in discussing patients in labor, and which will be employed in the
following pages.

A _nullipara_ (0–para) is a woman who has not had children.

A _primigravida_ is a woman who is pregnant for the first time.

A _primipara_ (1–para) applies to a woman during her first labor and
until the beginning of her second labor.

_2–para_, _3–para_ and _4–para_ apply to women in succeeding labors
which correspond to the numerals used.

A _multipara_ is a woman who has had more than one child.

There is also a terminology, with abbreviations, which is fairly
generally used in this country and England to designate the position
which the child, about to be born, occupies in relation to its mother’s
body. A diagnosis of this position is, of course, absolutely necessary
to a skilful management of labor, and the nurse should understand the
meanings of the terms used, and also their distinctions and
subdivisions.

[Illustration:

  FIG. 53.—Attitude of fetus in vertex presentation.
]

The _presentation of the fetus_ is the term which is employed to
indicate the part of the baby’s body which is at the brim of the
mother’s pelvis. Thus the part of the fetus which is lowermost is
designated as the _presenting part_ and gives the presentation its name.
If the breech is downward, therefore, it is a _breech_ presentation
(Fig. 52), and if the head is the lower pole it is termed a _head_, or
_cephalic_ presentation. (Fig. 53.) The head presentations are divided
into two main groups, which are designated, respectively, as _face_ and
_vertex_ presentations. For example, if the baby’s neck is so arched
that the chin rests upon the chest, the crown of its head, or the
vertex, is the part that is lowest in the birth canal and is the part
that will be seen first at the vaginal outlet. Therefore, this is called
a vertex, or occipital presentation. But if the neck is bent sharply
backward, the face becomes the presenting part and we have a face
presentation.

The breech, face and vertex presentations are sometimes referred to as
_longitudinal presentations_ since in these instances the long axes of
the bodies of mother and child are parallel. In _transverse
presentations_, however, the child lies across the uterus, with one side
or the other at the pelvic brim.

The transverse presentations are infrequent, occurring once in about 250
cases, and are regarded as abnormal because spontaneous delivery under
such circumstances is extremely rare. They are more likely to be seen,
when they do occur, among multiparæ and women who have contracted
pelves.

The longitudinal presentations, however, constitute something over 99
per cent. of all cases and are regarded as normal, since the child
occupying this relationship may be born spontaneously. In about 3 per
cent. of the longitudinal presentation the breech is the presenting part
and in about 97 per cent. it is the head. Of these, the vertex
presentation is the one most commonly seen and is the one in which the
child is most easily delivered. Face presentations are very rare,
occurring in only a fraction of 1 per cent. of all cases.

In addition to the child’s presentation, there is also its _position_,
which is an entirely different matter, for in each longitudinal
presentation the presenting part may occupy any one of six positions.

By _position_ is meant the relation of some arbitrarily chosen point on
the presenting part of the fetus, to the right or left side of the
mother, and to the front (anterior), side (transverse) or back
(posterior) segment of that side.

Taking these up in turn, we find, that in transverse presentations the
shoulder, _acromion_ process, is the point on the baby’s body which is
chosen, to give the four possible positions their names.

In breech presentations the sacrum is the arbitrarily chosen point.

In face presentations it is the chin, or _mentum_, while in vertex
presentations the occiput is the point chosen.

Presentation, then, describes the relation of the long axis of the
entire fetal body to the mother’s body, while position describes the
relation between the baby’s shoulder, sacrum, face or occiput to the
mother’s pelvis.

If the child is so placed in the uterus that the head is the presenting
part; the neck arched with chin on chest, and the occiput directed
toward the mother’s left side, and more to the front than to the side,
the presentation would be longitudinal, of the vertex variety, and the
position would be a left-occipito-anterior. The arbitrarily chosen point
on the child’s body (the occiput) would be directed toward the left,
anterior segment of the mother’s pelvis. This is the situation most
commonly seen and the description of this presentation and position are
abbreviated, by taking the first letter of each word, into L. O. A.

[Illustration:

  FIG. 54.—Diagram showing the six possible positions in a vertex
    presentation.
]

If the occiput were turned directly toward the mother’s left
side, neither to the front nor the back, we should have a
left-occipito-transverse, L. O. T., and if it were directed toward the
left posterior segment of the pelvis the position would be
left-occipito-posterior, or L. O. P. As there are three corresponding
positions on the right side, anterior, transverse and posterior, there
are six possible positions for the child to occupy in the vertex, or
occipital presentations, as follows:

 Left-occipito-anterior, abbreviated to L.O.A.
 Left-occipito-transverse, abbreviated to L.O.T.
 Right-occipito-posterior, abbreviated to L.O.P.
 Right-occipito-anterior, abbreviated to R.O.A.
 Right-occipito-transverse, abbreviated to R.O.T.
 Right-occipito-posterior, abbreviated to R.O.P. (Fig. 54.)

Similarly there are six face (Fig. 55) and six breech (Fig. 56)
presentations. Thus, if the chin (mentum) is resting in the left
anterior segment of the mother’s pelvis, the position would be
left-mento-anterior, or L. M. A. If the breech presents and the sacrum
is in that relation the position is left-sacro-anterior, or L. S. A.

[Illustration:

  FIG. 55.—Diagram showing the six possible positions in a face
    presentation.
]

In describing the transverse presentations, four words, instead of three
are used; thus, left-acromio-dorso-anterior, or L. A. D. A.

There are but four varieties of transverse presentations,
since the shoulder is either anterior or posterior: thus
left-acromio-dorso-anterior, left-acromio-dorso-posterior and the two
corresponding positions on the right side.

[Illustration:

  FIG. 56.—Diagram showing the six possible positions in a breech
    presentation.
]

During the last two to four weeks of pregnancy, particularly among the
primiparæ, the top of the fundus settles to the level which it reached
at about the eighth month, and the lower part of the abdomen becomes
more pendulous than formerly. The patient usually breathes much more
comfortably after this change in contour takes place, but, at the same
time, she may have cramps in her legs as a result of the increased
pressure; more difficulty in walking; frequent micturition and desire to
empty her bowels, while the vaginal discharge may be considerably
increased. It is at this time that the presenting part enters the
superior strait and is spoken of as being “engaged.”

The time at which engagement takes place depends upon three factors:
Whether the patient is a multipara or a primipara; the size and
normality of the pelvis; the size and position of the fetus. It is often
helpful to the obstetrician in planning for the delivery to know whether
or not the presenting part is engaged, particularly in primiparæ.

Although in primiparæ engagement usually occurs about four weeks before
labor begins, it does not normally take place in multiparæ until
immediately before labor. This difference is accounted for in the
increased tonicity of the uterine and abdominal muscles of primiparous
women. In certain abnormalities, or marked disproportion between the
diameters of the child’s head and mother’s pelvis, engagement may not
take place until labor is well advanced, or possibly not at all.

The presentation and position of the fetus are ascertained by means of
abdominal palpation, vaginal examination, rectal examination and
auscultation of the fetal heart.

Palpation of the child’s body through the mother’s abdominal wall is
possible under ordinary conditions, because the uterine and abdominal
muscles are so stretched and thinned that the various parts may be made
out through them. But it is sometimes difficult in hydramnios and is
practically impossible in very fat patients or in the case of a ruptured
uterus when the fetal outline is obscured by hemorrhage. This procedure
has been practiced only during comparatively recent years, and is
regarded by many obstetricians as one of the most important factors in
reducing the frequency of puerperal infections and thus in decreasing
maternal deaths. The explanation is that in general the dangers of
puerperal infection are believed to increase in direct proportion to the
number of times a patient is examined vaginally; and since it has been
known how to diagnose the child’s position by means of abdominal
palpation, the necessity for vaginal examinations is not so great and
they are accordingly made less frequently.

[Illustration:

  FIG. 57.—First maneuver in abdominal palpation to discover position of
    fetus.
]

Rectal examinations may also be regarded as a factor in preventing
infection, for, since much the same information may be obtained by means
of them as by vaginal examinations, after the onset of labor, they often
replace direct exploration of the easily infected birth canal.

Abdominal palpation, as usually practiced, consists of four maneuvers,
with the patient lying flat and squarely on her back with the abdomen
exposed. The nurse should bear in mind that successful palpation
requires even pressure. Cold hands applied to the abdomen or quick,
jabbing motions with the fingers will usually stimulate the muscles
lying beneath them to contract, thus somewhat obscuring the outline of
the child. Such palpation is also very uncomfortable for the patient;
but firm, even pressure, started gently, with warm hands, does not hurt.

[Illustration:

  FIG. 58.—Second maneuver in abdominal palpation.
]

_First Maneuver._ The purpose of the first maneuver is to ascertain what
is in the fundus; this is usually either the head or the breech. The
nurse should stand facing the patient and gently apply the entire
tactile surface of the fingers of both hands to the upper part of the
abdomen, on opposite sides and somewhat curved about the fundus. (Fig.
57.) In this way the outline of the pole of the fetus which occupies the
fundus may be made out. If the head is uppermost, it will be felt as a
hard, round object which is movable or _ballottable_ between the two
hands, and if the breech, it will be felt as a softer, less movable,
less regularly shaped body.

[Illustration:

  FIG. 59.—Third maneuver in abdominal palpation.
]

_Second Maneuver._ Having determined whether the head or the breech is
in the fundus, the next step is to locate the child’s back and the small
parts in their relation to the right and left sides of the mother. This
is accomplished by slipping the hands down to a slightly lower position
on the sides of the abdomen than they occupy in the first maneuver, and
making firm, even pressure with the entire palmar surface of both hands.
The back is felt as a smooth, hard surface under the palm and fingers of
one hand, and the small parts, or hands, feet and knees, as irregular
knobs or lumps, under the hand on the opposite side. (Fig. 58.)

[Illustration:

  FIG. 60.—Fourth maneuver in abdominal palpation. (This series of
    pictures is from photographs taken at Johns Hopkins Hospital.)
]

_Third Maneuver._ Unless the presenting part is engaged, the third
maneuver virtually amounts to a confirmation of the impression gained by
the first maneuver, by showing which pole is directed toward the pelvis.
The thumb and fingers of one hand are spread as widely apart as
possible, applied to the abdomen just above the symphysis and then
brought together to grasp the part of the fetus which lies between them.
If not engaged, the head will be felt as hard, round and movable, while
the breech will be less clearly defined. (Fig. 59.)

[Illustration:

  FIG. 61.—Diagrams showing relation of nurse’s hands to fetus in the
    four maneuvers of abdominal palpation.
]

_Fourth Maneuver._ The fourth maneuver is of particular value after the
presenting part has become engaged. The nurse faces the patient’s feet
in this position, and directs the first three fingers of each hand down
into the pelvis, on either side of the fetus, to ascertain whether it is
a face or vertex presentation, by discovering whether chin or occiput is
the higher cephalic prominence in the mother’s pelvis. (Fig. 60.) If it
is a vertex presentation, the neck will be flexed, with the chin on the
chest and consequently higher in the pelvis than the occiput. The
nurse’s fingers of one hand will accordingly come in contact with the
chin on the side opposite to the child’s back, before the fingers of the
other hand reach the occiput. If, however, it is a face presentation,
the neck will be bent sharply backward and the nurse’s fingers will feel
the occiput first, and on the same side as the baby’s back. This
maneuver tells, also, how far into the pelvis the presenting part has
descended.

[Illustration:

  FIG. 62.—Diagram showing method of ascertaining position of fetus by
    means of rectal examination. Examining finger palpates head through
    recto-vaginal septum.
]

=Vaginal Examination.= The information obtained by vaginal examination,
before the cervix is dilated, is rather uncertain since the child’s
presenting part must be palpated through the fornix. But after complete,
or even partial dilatation, the exploring finger is able to feel the
sagittal suture and one fontanelle, in a vertex presentation, and
diagnose the position by discovering the direction of the suture and
whether it is the anterior or posterior fontanelle that is felt. The
anterior fontanelle, it will be remembered, is relatively large and
four-sided, while the posterior is small and more nearly triangular in
shape. In a face presentation, the features may be felt; in a breech the
examining finger can palpate the buttocks and genital crease.

Because of the possible danger of introducing infective material into
the birth canal, the tendency is to make fewer and fewer vaginal
examinations, and then only after the most painstaking preparation which
will be described presently. Needless to state, vaginal examinations are
not within the province of the nurse.

=Rectal Examinations.= More and more frequently rectal examinations are
being employed to obtain information about the child’s position, as the
examining finger is able to feel the surface of the presenting part
through the recto-vaginal septum, after the cervix is dilated, and there
is no danger of infecting the birth canal while so doing. For this
reason nurses are frequently taught to make rectal examinations, thereby
increasing the value of their assistance to the doctor in watching the
progress of labor. (Fig. 62.)

=Auscultation of the fetal heart= is valuable in confirming the
diagnosis of presentation and position which has been made by palpation.
In vertex and breech presentations the heartbeat is best heard through
the baby’s back and in face presentations it is transmitted through the
chest, which presents a convex surface in this case and fits into the
curve of the uterine wall. In anterior vertex presentations the heart is
heard a little to the side and below the umbilicus; in transverse,
further to the side, and in posterior, well toward the back.



                               CHAPTER XI
             SYMPTOMS, COURSE AND MECHANISM OF NORMAL LABOR


Labor may be defined as the process by means of which the product of
conception is separated and expelled from the mother’s body. It
ordinarily occurs about 280 days from the beginning of the last
menstrual period. (See p. 93.)

The cause of labor is not known. Many theories have been advanced to
explain why the uterine contractions, which have occurred painlessly
throughout pregnancy, and without expulsive force, finally become
painful at the end of the tenth month and so changed in character as to
extrude the uterine contents; but as yet, none is wholly satisfactory
nor generally accepted. Nor is it known why some labors are premature
and some delayed.

The onset of labor is usually marked by the patient’s becoming conscious
of the uterine contractions through dragging pains which may be felt
first in the back and then in the lower part of the abdomen and the
thighs. At first the pains are feeble and infrequent, but they gradually
grow more severe and more frequent. Intestinal colic is sometimes
mistaken for labor pains, but when the paroxysms are rhythmical and the
uterus is felt, through the abdominal wall, to grow hard as the pain
increases and soft as it subsides, there can be no doubt but that the
patient is in labor. The first signs of labor may be a gush of amniotic
fluid, caused by the rupture of the membranes, or of blood, but these
are not typical.

For purposes of convenience, labor is usually described as consisting of
three periods or stages. The first stage begins with the onset of labor
and lasts until the cervix is completely dilated; the second stage
begins with the complete dilatation of the cervix and lasts until the
child is born; the third stage begins with the birth of the child and
lasts until the placenta is expelled.

The entire duration of labor may vary from a few moments, comprising a
few pains, to several days of severe and exhausting pain, but the
average length of the first labor is 18 hours and of subsequent labors
about 12 hours, divided respectively into the three periods as follows:

                 _1st stage._ _2nd stage._ _3rd stage._ _Total._
       Primipara 16 hours     1¾ hours     15 minutes   18 hours.
       Multipara 11 hours     45 minutes   15 minutes   12 hours.

The longer labor in primiparous women is due to the greater tone, and
thus the greater resistance offered by the muscles of the cervix and
perineum. Elderly primiparæ are likely to have longer labors than young
primiparæ.

=First Stage.= This is frequently called the stage of dilatation. During
this period the contractions of the uterine muscles make pressure upon
the amniotic sac of fluid, forcing it gradually down and into the cervix
as a water wedge, widening the internal os first, then the external os,
until the entire canal is fully dilated (thinned out); shortened to
about one-half inch in length and finally obliterated so that it is
uninterruptedly continuous with the lower uterine segment. (Figs. 63,
64, 65, 66.)

The first stage pains begin by being mild and occurring at intervals of
from 15 to 30 minutes, but they gradually increase in frequency and
intensity until at the end of 14 to 16 hours they are very severe and
recur every three or four minutes, each pain lasting about one minute.
The pains begin in the back, pass slowly forward to the abdomen and down
into the thighs.

The patient is entirely comfortable, as a rule, between pains and until
they become very frequent will usually feel able, in fact prefer, to be
up and about, but if she is on her feet when a contraction begins she
will usually seek relief by assuming a characteristic leaning position
(Fig. 67) or by sitting down, until the pain subsides. As dilatation
advances, the patient has an increasing, sometimes persistent, desire to
empty the bowels and bladder because of encroachment upon these two
organs by the descending head. She may vomit, also, when the cervix
becomes nearly or quite dilated.

[Illustration:

  FIG. 63.
]

[Illustration:

  FIG. 64.
]

[Illustration:

  FIG. 65.
]

[Illustration:

  FIG. 66.
]

 FIGS. 63, 64, 65, AND 66 are diagrams showing stages of dilatation and
                  obliteration of cervix during labor.

In the course of this stretching process, the cervix sustains many tiny
lesions, from which blood oozes and tinges the vaginal discharge. This
blood-stained secretion is often called the “show” and usually appears
toward the end of the first stage.

[Illustration:

  FIG. 67.—Characteristic position which patient often assumes during
    pains in first stage.
]

As a rule, when the cervix is fully dilated the membranes rupture and
there is a sudden gush of that part of the fluid which was below the
fetus in the amniotic sac, but the rupture of the membranes does not
necessarily mark the end of the first stage. In some instances they
rupture before the cervix is fully dilated; in others, though not often,
before the patient goes into labor, thus producing what is known as a
“dry” labor.

The abdominal muscles do not contract very forcibly during the first
stage, the expulsive force in this period coming almost entirely from
the uterine contractions. The patient’s cries at this time are sharp and
complaining in contrast to the groans and grunts which accompany the
second stage.

Complete dilatation of the cervix marks the termination of the first
stage.

[Illustration:

  FIG. 68.—Diagram indicating the rotation and pivoting of baby’s head
    during birth.
]

=Second Stage.= The second stage is sometimes called the stage of
descent, or expulsion, of the fetus. The patient should and is usually
quite willing to be in bed throughout the second stage, during which she
should not be left alone. The pains are now regular, occurring at
intervals of about two minutes from the beginning of one to the
beginning of the pain following, and as the contractions last about one
minute and are excruciatingly painful, the patient has very little
respite from her suffering. Her face is flushed and she may perspire
freely.

The abdominal and respiratory muscles are brought into active use during
the second stage, contracting simultaneously with the uterine muscles
and increasing their expulsive force. These are apparently controlled by
the patient’s will at first, and she is able somewhat to increase their
power by taking a deep breath, closing her lips, bracing her feet,
pulling against something with her hands, straining with all her might
and “bearing down.” Finally, however, the whole bearing down process
becomes involuntary, is accompanied by intense pain and the deep
grunting sound, which is characteristic of the well-advanced second
stage. Under normal conditions, the child descends a little farther into
the pelvis with each contraction, and finally the presenting part begins
to distend the perineum and to separate the labia advancing at the
height of each pain and slipping back a little as it subsides.

[Illustration:

  FIG. 69.—Anterior shoulder being slipped from under symphysis to
    facilitate birth of posterior shoulder.
]

The baby descends into and through the mother’s pelvis by means of a
series of twisting and curving motions, accommodating the long axes of
its head to the long diameters of the pelvis. The head being somewhat
compressible and mouldable, because of imperfect ossification, is
capable of a good deal of accommodation to the mother’s pelvis.

The mechanism of labor, therefore, is virtually a series of adaptations
of the size, shape and mouldability of the baby’s head to the size and
shape of the mother’s pelvis. If the head passes through the inlet
satisfactorily, the rest of the labor will usually be accomplished with
comparative safety. But a marked disproportion between the diameters of
the head and pelvis may interfere with the engagement or descent of the
head and produce a serious complication.

[Illustration:

  FIG. 70.—Delivery of posterior shoulder.
]

The long diameter of the head must first conform to one of the long
diameters of the inlet, usually oblique, and then turn so that the
length of the head is lying antero-posterior in conformity to the long
diameter of the outlet through which it next passes. As the head
descends and rotates it also describes an arc because the posterior wall
of the pelvis, consisting of the sacrum and coccyx, is about three times
as deep as the anterior wall formed by the symphysis. That part of the
baby’s head which passes down the posterior wall of the pelvis must
therefore travel three times as far in a given time as the part which
simply slips under the short symphysis pubis.

[Illustration:

  FIG. 71.—Diagrams showing Duncan and Schultze mechanisms of placental
    separation.
]

In a vertex presentation, left-occipito-anterior position, while the
occiput passes under the symphysis and appears at the distending vaginal
outlet, the face passes down the posterior wall and along the floor of
the pelvis. As pressure is exerted by the rapidly succeeding
contractions, the head pivots about the pubis, thus extending the neck
and pushing the face farther downward and forward. After emergence of
the back and top of the head below the symphysis, the forehead appears
over the posterior margin of the vagina, then the brow, eyes, nose,
mouth and chin in turn, and the entire head is born. (Fig. 68.) The
baby’s head then drops forward, in relation to its own body, with its
face toward the mother’s rectum and the occiput in front of the pubis,
but soon the occiput rotates toward the mother’s left side, resuming the
relation that it bore to the inner aspect of her pelvis before
expulsion. The undelivered shoulders are now antero-posterior, one under
the pubis and the other resting on the perineum. (Fig. 69.) The lower,
or posterior shoulder is born first (Fig. 70), followed quickly by the
anterior shoulder and the rest of the body, and the amniotic fluid which
was behind the child’s body. Thus is the second stage completed.

[Illustration:

  FIG. 72.—Longitudinal section through uterus showing thinness of
    uterine wall before expulsion of fetus, contrasting sharply with
    thickened wall in Fig. 73. (From photograph of specimen, to which
    twin placentæ are still adherent in upper segment, in the
    obstetrical laboratory, Johns Hopkins Hospital.)
]

=Third Stage.= The third stage, sometimes termed the placental stage, is
that period following the birth of the child, during which the placenta
is delivered. For a few moments after the baby is born the tired mother
lies quietly and free from pain, as there is a temporary cessation of
the uterine contractions, and she often sleeps as a result of the
anesthetic given during the second stage.

[Illustration:

  FIG. 73.—Longitudinal section through uterus, immediately after labor,
    showing marked thickening of wall as a result of muscular
    contraction. (From photograph of specimen in the obstetrical
    laboratory, Johns Hopkins Hospital.)
]

The uterus has greatly decreased in size, the fundus now lying below the
umbilicus where it may be felt as a firm, solid mass. The uterine
contractions are resumed in the course of a few moments and as they
persist, the uterus grows smaller, thereby greatly decreasing the area
of placental attachment. As the placenta is non-contractile it cannot
accommodate itself to this decreased area of attachment, and so is
literally squeezed from its moorings. It is then gradually forced down
into the lower uterine segment where it may be located by the distension
of the abdominal wall which it produces just above the symphysis. After
the separation of the placenta is complete the uterus rises in the
abdominal cavity until the fundus is felt above the umbilicus. The
placenta, finally, may be completely expelled spontaneously, or
expressed by slight pressure made upon the fundus by the accoucheur.

The placental detachment may begin at the centre, the area of separation
spreading to the margin, or the detachment may start at the margin of
the placenta and extend toward the centre. Either is normal. These two
modes of placental separation are named the Schultze and the Duncan,
respectively, from the men who first described them. (Fig. 71.)

In the Schultze mechanism, which occurs most frequently, the separating
process begins at the centre of the placenta and the glistening fetal
surface appears at the vaginal outlet. In this case there is practically
no bleeding during the third stage as the inverted placenta blocks the
vagina and holds back the blood.

In Duncan’s mechanism the detachment begins at the margin, the placenta
rolls upon itself and presents at the outlet by its roughened maternal
surface and there is usually slight but continuous bleeding from the
time the separation begins. When the placenta is delivered, the
collapsed membranes trail after it like a tapering cord. A good deal of
blood is lost at the time of the placental expulsion and immediately
afterwards, but this profuse bleeding usually subsides in a few moments.
Although the loss of blood may be as much as 500 cubic centimetres
without its being regarded as serious, the average amount is about 350
cubic centimetres.

The patient has been through a severe ordeal and at the end of the third
stage of labor she is usually tired out and cold.



                              CHAPTER XII
                    THE NURSE’S DUTIES DURING LABOR


The extent of the nurse’s helpfulness during labor, both to the patient
and to the doctor, will depend very largely upon the intelligence with
which she grasps what is taking place and upon her own attitude, as an
individual, toward the patient and the miraculous event which
approaches. Important as is the preparation of the room and dressings,
this other factor is almost equally influential.

It will be wiser, therefore, for the nurse to try to picture the process
of labor in each instance, and to be guided by a few broad principles
that apply to all cases under all conditions, rather than to try to
memorize the details of her duties and of the desirable equipment and
preparation.

The process of labor we have just described.

As to the general principles: If there is any time in a nurse’s career
when she should give scrupulous attention to establishing and
maintaining asepsis, it is during labor, for the patient’s life may, and
often does depend upon it. If there is any time when she should be
watchful for developments and for symptoms of complications, it is
during labor, for again the patient’s life may depend upon this.

Her powers of adaptability to doctor, patient and surroundings may be
severely tried, for though they all may be infinitely varied, the nurse
must invariably be clear-headed and efficient and the adequacy of her
service must never fail.

The sympathetic insight, which should constantly underlie the work of
the obstetrical nurse, will be needed at this crucial time of labor in
the fullest and finest and completest sense. This is almost her test as
a nurse and as a womanly woman, for she needs to be both, supremely.

Perhaps she had better imagine for a moment what this occurrence, that
we baldly term labor, may mean to the patient and look at it as nearly
as possible from the standpoint of the patient herself. It is one of the
most stirring and momentous experiences of her life, particularly if the
expected baby is her first child. She is about to realize the sweetest
and tenderest of dreams—that of motherhood—cherished throughout nine
long months. She is also approaching a period of excruciating pain, and
knows it, with her eyes wide open to the possibility of not surviving
it; and an event so amazing in its mystery and wonder that to only the
most stolid can it fail to be a deeply emotional experience.

And so, the young woman, to whom we refer so impersonally as “the
patient,” is an intensely personal being at this time, experiencing a
number of the most poignant of the human emotions: awe, expectancy,
doubt, uncertainty, dread and in some cases fear amounting almost to
terror. And through it all her body is being racked and exhausted with
pain that grows harder and harder to bear.

It is known that the ravaging effects of pain, coupled with great
emotional stress, such as fear, worry, doubt, anger or apprehension,
upon the physical well-being of surgical patients, is such that death
itself may be caused by excessive fear and suffering. Accordingly, many
careful surgeons take elaborate precautions to tranquillize a patient
who is about to be operated upon, if for no other reason than to
increase his chance for recovery.

There can be no doubt that nervous and emotional disturbances are
detrimental to the physical well-being of the patient in labor, also,
and this fact alone is enough to warrant an effort to avert them. If the
nurse appreciates the significance of the emotional influence and shapes
her attitude and conduct accordingly, she will thereby help to increase
the ease and safety of the actual delivery. Just what that attitude
shall be, no one can say, for it must be developed, in each case, in
such a way as to win the confidence and meet the needs of that
particular patient.

But in all cases the nurse should impress her patient with her sincere
sympathy and appreciation of the fact that she, the patient, is going
through a difficult time. Through it all the nurse must be cheerful,
encouraging and optimistic; very gentle; very calm and reassuring in all
that she does in preparing for the delivery. She must steadily increase
the patient’s realization of the part which she herself must play in the
effort which is being made to carry the event through to a happy issue.

The occasion need not, should not, be a mournful one but it is often a
very sacred one to the patient, and the nurse should be dignified,
almost reverential in her bearing.

If the patient feels secure in the belief that her ordeal is not being
taken lightly; that it is being regarded seriously, as it merits, and
that every known precaution is being taken, and taken confidently, to
safeguard her and her baby’s welfare, her actual physical condition will
be favorably affected by the condition of mind thus produced. And her
patience and courage will often be strengthened if the nurse will
explain, from time to time, the cause of certain conditions that
normally arise, and which otherwise might give her alarm. It is the
mysterious events, the unexpected and unexplained that so often terrify.

This giving of comfort and strength to the variety of temperaments and
mentalities which the nurse meets among her patients will involve a very
sensitive adjustment of manner on her part, but it is one aspect of her
duty, none the less, and one which will give her great satisfaction.


                              FIRST STAGE

Happily, the onset of labor is usually gradual, as has been described,
and there is accordingly ample time during the first stage for
deliberate and unhurried preparation for the birth of the baby. The
character of the preparation and of the nurse’s assistance will vary
greatly according to the wishes of the attending doctor; the duration of
labor; the circumstances and condition of the patient, and whether she
is at home or in a hospital.

It is a fairly general routine, at present, both in hospitals and in the
home, to give the patient a soap-suds enema and a shower or sponge bath,
at the onset of labor; to braid her hair in two braids and dress her in
freshly laundered stockings and nightgown and a dressing gown. The enema
is given to empty the rectum of material which might be expelled during
labor and contaminate the field. For this reason, enemata are often
given until the fluid returns clear, virtually irrigating the rectum,
and are repeated every six or eight hours during the first stage. The
enema should be given to the patient in bed and expelled into a bed-pan,
as it is not wise for her to use the toilet after labor has begun.
Sometimes the vulva and perineal region are shaved and scrubbed at the
onset of labor, either before or immediately after the bath and enema.
But the time and sequence of the different steps in the preparation for
labor are governed entirely by the wishes of the individual doctor, to
which the nurse may very easily adjust herself.

The patient should be given a bed-pan and encouraged to void every four
hours. If she is unable to do so, and the bladder becomes distended, the
doctor will usually wish to have her catheterized, and with a rubber
catheter. This distension is not uncommon, and in extreme cases the
bladder may reach to the umbilicus. The nurse should therefore observe
the amount of urine which the patient voids and also watch the lower
abdomen for bladder distension, which may be observed easily, excepting
in very fat patients.

The seriousness of a distended bladder lies in the fact that it may
markedly retard labor, partly by interfering with the descent of the
baby’s head and partly through reflex inhibition of the uterine
contractions. The prevention of a distended bladder during labor,
therefore, is of considerable importance.

As the pains are infrequent and not severe at first, the patient will
usually prefer to be up and about, most of the time during the first
stage, when it occurs in the daytime, and many doctors think it
important that she should be. They feel that patients tend to stay in
bed too much during the first stage, since being on their feet would
really promote their comfort and also have a tendency to make the pains
more regular and efficient. But, on the other hand, the patient must be
cautioned against tiring herself, and should, therefore, lie down often
enough and long enough to avert fatigue. When labor begins at night, it
is well to advise the patient to stay in bed and to sleep as much as
possible until morning. Even though her sleep be disturbed and broken by
the labor pains, she will be much less tired in the morning than if she
had gotten up and had no sleep at all.

The patient should also be advised against trying to hasten labor by
bearing down during first stage pains, since the only result at this
time will be to waste her strength which will be needed later. This is
one of the points that the nurse will do well to explain; that no
voluntary effort on the patient’s part, during the first stage, will
advance labor and if she tires herself by making such efforts before the
second stage pains begin she will not be able to use them as effectively
as she would were she in a rested condition.

Bearing in mind the importance of conserving all of her forces, it is
usually advisable for a patient in labor to have no visitors,
particularly the type of person who would be likely to offer advice and
gratuitous information.

She should drink water freely and take some kind of light nourishment
about every four hours. As pain of any kind tends to retard digestion,
the diet during labor is usually restricted to fluids, such as broths,
weak tea or coffee and sometimes milk or cocoa; while occasionally
crackers and crisp toast are allowed. Whatever nourishment is given must
be very light because of the probability of the patient’s vomiting and
the possibility of her having to be given complete anesthesia before the
termination of labor.

The maternal temperature, pulse and respirations should be taken every
two or four hours and the fetal heart rate from every hour to every two
hours, according to the wishes of the doctor.

The time at which the nurse should call the doctor is the subject of
considerable discussion. Doctors never want to be called too late,
neither do they wish to be called unnecessarily early, though they
prefer to have the nurse err on that side, if at all. On general
principles the doctor should be notified as soon as the patient goes
into labor, in order that he may make his various plans with the pending
delivery in mind. But if the nurse remembers that in primiparæ the first
stage of labor usually lasts about sixteen hours and in multiparæ about
eleven hours, she will realize that if the pains begin between the hours
of eleven p.m. and seven a.m., and are of average character, mild and
infrequent, she is not warranted in disturbing the doctor’s much needed
sleep, unless he has explicitly requested her to do so. But under
average conditions he should be notified by seven o’clock in the morning
that the patient is in labor; at what hour the pains began; their
character and frequency at the time of the report; the patient’s
temperature, pulse and respirations and general condition and the fetal
heart rate.

During the early hours of the first stage the nurse should begin to
arrange the room and bed for delivery. She will need two, or preferably,
three tables, though the top of a bureau may be used in place of one
table. A washstand or the bathroom should be equipped for the doctor
with soap; two sterile brushes; nail scissors or clippers and file or
orange stick; hot water; alcohol and a solution of bichlorid 1–1000,
biniodid 1–5000, lysol 2 per cent. or any solution that he may wish;
sterile gloves and sterile vaseline or albolene to lubricate his hands.
In short, an equipment which will enable him to prepare his hands
exactly as he would for performing a major operation.

A large receptacle of water may be boiled, covered and set aside to
cool; a boiler or large kettle placed in readiness for boiling
instruments or other appliances that the doctor may bring; the room may
be given a final cleaning: floor wiped up, furniture and all small
articles wiped with a damp cloth; the unopened packages of dressings,
sterile douche pan, irrigation-bag and basins may be placed on the
tables, ready to be opened when needed, together with the other articles
which have been prepared.

In preparing the bed in a patient’s home, it is practically always
advisable to make it firm by slipping a board, or the leaves from a
dining-table, between the mattress and springs. The bed should be made
up with three freshly laundered sheets, the entire mattress being
protected by means of a rubber placed under the lower sheet; next a
rubber draw sheet, covered by one of muslin, while the top sheet, light
blanket and counterpane should be left free at the foot. A flat hair
pillow is better than one of feathers.

If the doctor wishes to make a vaginal examination, it devolves upon the
nurse to prepare the patient with the most scrupulous care, as it is by
means of vaginal examinations, made without careful preparation, that so
many parturient women are infected. In fact, even the most conscientious
preparation sometimes seems to be an inadequate safeguard, for infection
has been known to follow in its wake. For this reason, some
obstetricians prefer to make no vaginal examination during labor, when
previous inspection has indicated that the case is normal, depending
rather upon rectal examinations for guiding information.

The patient should be placed in bed, on a douche pan, with knees flexed
and well separated; gown tucked up under her arms; draped with a sheet
or the bedding folded down to her knees according to the extent of the
area to be prepared; and the articles needed for the preparation
arranged on a table at the bedside. The nurse should trim her nails,
scrub her hands with soap and hot water; shave the vulva, supra-pubic
region and inner surface of the thighs and rinse with sterile water. In
shaving the vulva, the strokes should be from above downward, greatest
care being taken not to allow hair, soap or water to enter the vaginal
opening. She should then scrub her hands vigorously for three minutes,
scrubbing about the nails with especial thoroughness. Some obstetricians
have the entire area from the umbilicus to the knees prepared as for an
operation, while others prepare only the supra-pubic region, inner
surface of the thighs and the vulva. The number and kind of solutions
which are used in this preparation also vary greatly, but in general the
shaving is followed by a thorough scrubbing, by clean hands, with green
soap and sterile water, then iodin, lysol or alcohol and bichlorid or
biniodid solution, according to the custom of the doctor. (Fig. 74.)

But the kind and number of the solutions are probably not so important
as the nurse’s technique. Throughout the entire course of the
preparation she must apply the principles of what she was taught about
the technique of preparing the skin for an operation and regard the
perineal region in the same light as she would the field which was being
prepared for a major operation; scrubbing from the centre toward the
periphery, always, in order not to carry infective material from an
unclean to a clean area, which in this case is the vaginal outlet.

[Illustration:

  FIG. 74.—Bathing the vulva preparatory to vaginal examination or
    delivery. (From photograph taken at Johns Hopkins Hospital.)
]

The supra-pubic region and abdomen are scrubbed across, back and forth,
working up from the symphysis; the strokes on the thighs are up and
down; in the groin, down toward the rectum, and away from the vagina,
_never toward it_, and fluids poured upon the vulval region must never
run into the vagina from over surrounding skin. A sponge or scrub ball
must be discarded after approaching the rectum, or stroking away from
the vagina in any direction. Some obstetricians instruct the nurse to
place a firm, sterile cotton pad or scrub ball between the labia,
against the vaginal opening while scrubbing and flushing the adjacent
areas, to preclude the possibility of introducing fluids. But with a
painstaking nurse this is scarcely necessary.

[Illustration:

  FIG. 75.—Patient draped for vaginal examination; vulva covered with
    sterile towel. (From photograph taken at Johns Hopkins Hospital.)
]

After the surrounding areas have been prepared, the labia are separated
and the inner surfaces scrubbed, first across, then from above downward,
and flushed by pouring the solution directly between the folds. After
the patient has been given this preparation, a dry sterile towel or pad
is placed over the vulva; the douche pan is removed, the back and hips
are dried, after which the patient is so draped with a clean sheet that
only the perineal region is exposed, and a sterile towel is slipped
under the buttocks. (Fig. 75.)

To summarize the preparation for vaginal examination or delivery:

  1. Trim nails and scrub hands with soap and hot water.

  2. Shave vulva.

  3. Scrub and soak hands.

  4. Scrub vulva, inner surface of thighs and lower abdomen with green
       soap and sterile water, alcohol, 70%, and lastly bichloride
       1–1000 or lysol 1% or 2%, using sterile sponges and _taking care
       not to contaminate vulva from surrounding fields_.

  5. Cover vulva with sterile towel or pad.

This may be taken as a description of a fairly typical method of
preparing a patient for vaginal examination or for delivery, which is
widely employed and with satisfactory results. But it is by no means the
only satisfactory procedure, for many other and different methods of
preparation also are followed by excellent results, as measured by the
patient’s temperature during the puerperium.

The details of preparation vary so greatly, even among different doctors
in the same hospital, that the nurse will simply have to bear in mind
the general principles of asepsis and antisepsis, and adjust herself to
the practices of the individual doctor. And she must remember that in
spite of the best planning, there will be emergencies and precipitate
labors, when the preparation will necessarily be modified, and sometimes
so curtailed that even the bath and enema are omitted.

But in all cases the nurse can, and must, bear in mind that on one point
there is virtually no difference of opinion among obstetricians of
to-day; and that is the imperative necessity of having everything
sterile that is brought to the perineal region or used in any way in
connection with the delivery, or as nearly sterile as is possible under
the circumstances.

By many doctors this is considered the most important factor, as to
surgical cleanliness, in the entire preparation. In their opinion the
local preparation of the patient may, with safety, be restricted to
clipping the pubic hairs (instead of shaving), and scrubbing the vulva
with only soap and water. But these doctors believe at the same time
that the patient is dangerously susceptible to infection which may be
conveyed to her from without, and accordingly they do not permit vaginal
examinations to be made during labor, and make the most exacting demands
concerning the maintenance of perfect surgical technique, by all who
assist with the delivery.

[Illustration:

  FIG. 76.—Wrong and right methods of boiling gloves. Note that gloves
    in basin at the left are partly above the surface of the water and
    therefore will not be sterilized. Those in basin at the right are
    kept below the surface by the weight of the towel and will be
    sterilized by the boiling water.
]

In this connection, much depends upon the actual sterilization of the
rubber gloves, either by boiling or by steam under pressure; and the
method of putting on the gloves, in order that once having been
sterilized, they may be kept so. It is useless to attempt to sterilize
gloves by boiling, if they are thrown loosely into a kettle of water.
There will practically always be enough air in the fingers to keep at
least a part of the gloves out of the water, and consequently unaffected
by its heat. They should be put into a covered wire basket that will be
entirely submerged, or they may be wrapped in a towel, the weight of
which will carry them below the surface of the water (Fig. 76), and
insure their being completely covered while boiling, which should
continue for ten to fifteen minutes. The doctor will usually want boiled
gloves placed in a large basin of bichlorid solution, 1–1,000, or lysol
2 per cent., from which he may remove them after scrubbing his hands. If
dry gloves are used, there should be in readiness a sterile towel and
powder with which to dry and powder the hands before putting on the
gloves. (Fig. 77.)

[Illustration:

  FIG. 77.—Powdering hands before putting on dry gloves. (From
    photograph taken at the Brooklyn Hospital.)
]

Whether boiled or steamed, the cuffs of the gloves should first be
turned up toward the hand, to make it possible to put them on without
touching the glove fingers with ungloved hands. (Fig. 78.) For no matter
how long and carefully the hands are scrubbed and soaked, they cannot be
made absolutely sterile, and therefore, in relation to the gloves which
are sterile, the bare hands must always be regarded as unclean. Too much
thought and attention cannot be given to the sterilization and handling
of the gloves, for the patient’s very life may depend upon their aseptic
condition.

After the doctor has seen the patient, the nurse will make observations
and communicate with him in accordance with instructions which she must
make sure to obtain from him at that time. Many doctors wish to be with
a primipara continuously from the time the cervix is completely dilated,
and with multiparæ after it is half dilated. But that, of course, is a
matter which each doctor decides for himself. The nurse’s responsibility
is to learn his wishes.

[Illustration:

  FIG. 78.—Successive steps in proper method of putting on sterile
    gloves to avoid contaminating outside of gloves with bare fingers.
    (From photographs taken at the Long Island College Hospital.)
]

_Watchfulness_, then, is of extreme importance; watching for symptoms of
complications or change in the patient’s condition, and watching the
progress of labor in order to keep the doctor fully informed about his
patient’s condition. Nurses are very frequently taught to make rectal
examinations for the sake of increasing the value of their assistance in
this respect.

Although unexpected symptoms do not, as a rule, develop suddenly during
the first stage, the nurse must be none the less vigilant for them. The
doctor should be notified if the pains suddenly grow either more or less
frequent, or more or less severe; if there is any bulging of the
perineum; if the membranes rupture; if there is any bleeding or a
prolapsed cord; if there is extreme restlessness or any evidence of
unusual distress; a rising temperature or pulse; a temperature of 100°
F. or a pulse of more than 100 or less than 60; a fetal heart rate of
more than 150 or less than 116, or any marked change of any kind in the
patient’s condition.

During the latter part of the first stage, and during the second stage,
the patient has an almost continuous desire to empty her bowels, because
of pressure made upon the rectum by the descending head. This is another
point which the nurse explain to her patient, in assuring her that
frequent attempts to use the bed-pan will give no relief.

The end of the first stage is reached when the cervix is fully dilated,
at which time the pains occur about every two minutes, are stronger and
more severe, and the patient begins to feel like bearing down. The
membranes frequently rupture at this point and the vaginal discharge is
blood tinged. The patient should remain in bed and not be left alone
from this time on.

To sum up the nurse’s duties during the first stage of labor, when the
patient is almost entirely in the nurse’s care:

  1. She must be a sympathetic, encouraging friend to the patient.

  2. She must help the patient to preserve her strength by giving her
       light nourishment about every four hours; by advising her not to
       bear down; not to exhaust herself by walking about too much but
       to lie down when tired.

  3. She must watch the progress of labor and watch for symptoms of
       complications.

  4. She must employ strictest aseptic and antiseptic methods.

  5. She must prepare for the birth of the baby.


                              SECOND STAGE

The second stage is shorter, harder and more perilous than the first.
The uterine contractions are stronger; more frequent and more expulsive,
and the baby steadily curves and rotates its way down through the birth
canal.

With the onset of the second stage the nurse should complete the
preparations for the baby’s birth, bearing in mind that with a primipara
the baby probably will not come for an hour and a half or two hours, but
may come in half an hour or less if the patient is a multipara.
Everything which is to be used should be conveniently placed, but the
packages are not necessarily opened at this time.

In addition to the sterile dressings, basins, gloves, instruments and
various other articles which have been enumerated, the nurse must
remember that there should be for the baby a box or basket lined with a
blanket and containing one, or preferably two, hot-water bottles at 125°
F.; in hospitals, an adhesive strip for the baby’s name or a name
necklace; a binder of flannel or sterile gauze, according to the custom
of the doctor; sterile olive oil or albolene for the first oiling and
one or two tubs, in case the baby needs to be resuscitated.

There will be needed, also, a covered basin for the placenta; chloroform
and an inhaler; Wassermann tubes, for those doctors who make this test
as a routine; hypodermic syringe and needles, with pituitrin, ergotole
and drugs for stimulation which the doctor may specify. (Figs. 79, 80.)

In the meantime, the force and frequency of the pains should be noted,
and some doctors require a record of both the fetal and maternal pulse
rate every half hour, and notification if the baby’s is over 150 or
below 116, or the mother’s over 100 or below 60. Extreme restlessness,
distress, vaginal bleeding, prolapsed cord, a temperature of 100° F., or
any marked change must be communicated to the doctor immediately, if it
occurs before he has started for his patient.

The patient may complain of intense pain in her back and cramps in her
legs during the second stage. Pressure made by the nurse’s hand, or a
small pillow slipped under the small of the back will frequently relieve
the backache, while cramps in the legs may be relieved by straightening,
and slightly elevating the leg, and rubbing it while in that position.
As these pains are usually due to pressure they have no serious
significance and subside as soon as the child is born.

[Illustration:

  FIG. 79.—Bed and simple equipment in readiness for normal delivery.
    (From photograph taken at Johns Hopkins Hospital.)
]

             _On table by bed_:
                 Sterile: cover.
                          towels, 6.
                          bag of sponges.
                          delivery pad.
                          pair of leggings.
                          delivery sheet.
                          doctor’s gown.
                          perineal pads.
                          cord ligatures.
             _Lower shelf_: douche pan.

             _Window sill_:
                 Baby box with hot-water bag
                     at 125° F., and blanket.
                 Chloroform dropper and inhaler.
                 Sterile albolene for baby.
                 Alcohol.
                 Baby band.
                 Wassermann tubes.

             _Second table_:
                 Basin of instruments.
                 Basin of bichloride, 1–1,000 with pair
                     of gloves.
                 Sponge sticks in alcohol.
                 Hypo, tray: pituitary liquid.
                             ergotole.
                             syringe and needles.
                             alcohol.
                             pledgets.
             _Lower shelf_: 2 tubs for resuscitating baby.
                            Covered placenta basin.
                            Dressing basin.

             _Head of bed_:
                 Nightgown.
                 Sheet.
                 Stockings.
                 Towel.

The nurse may find herself in any one of three situations during the
second stage. The doctor may arrive in ample time to conduct the
delivery; he may be slightly delayed and the nurse endeavor to retard
labor, according to instructions; or the baby may be born, with or
without the expulsion of the placenta, before his arrival.

When the doctor arrives at the onset of, or during the second stage of
labor, the nurse acts solely under his direction, the nature of her
offices depending somewhat upon the condition and surroundings of the
patient, and whether or not the nurse is the only person at hand to give
assistance. In any case, the gloves, and instruments for repairing a
tear should be boiled and in readiness; the dressings and other articles
to be used are to be conveniently arranged upon the tables and opened at
the proper time.

[Illustration:

  FIG. 80.—Instruments for normal delivery shown in boiling basin on
    table in Fig. 79: Needle holder. Blunt hook. Blunt scissors. 2 small
    Kelly clamps. Mouse tooth forceps. 4 towel clips. 2 large perineal
    needles and 2 cervical needles in gauze sponge.
]

After having everything ready and at hand for the delivery, the nurse
may be called upon to clean up and act as an assistant, or to give the
anesthetic. If she cleans up, she should wear a sterile gown and gloves,
and if it is the doctor’s custom, a cap and mask as well, having
prepared her hands somewhat as follows:[6]

  1. Scrub hands and arms with hot water and green soap for five
       minutes, paying especial attention to the fingers and nails.

  2. Clean and trim nails and scrub again for five minutes.

[Illustration:

  FIG. 81.—Old prints illustrating early ideas of suitable methods of
    making examinations and conducting deliveries, furnishing
    interesting contrast with present-day methods. Concern seems to be
    divided between the patient and the signs of the Zodiac in the
    picture at the right.
]

  3. Soak and scrub hands and forearms in alcohol, 70%, for two minutes.

  4. Soak in bichloride solution, 1–1000, for five minutes.

  5. Put on gloves out of second bichloride solution, avoiding contact
       with fingers of ungloved hand. (See Fig. 78.)

[Illustration:

  FIG. 82.—Patient draped with sterile towels, leggings, sheet and
    delivery pad for delivery. (From photograph taken at Johns Hopkins
    Hospital.)
]

The patient is given a final scrubbing with green soap and sterile water
and an antiseptic solution, by some one with clean hands, and is further
protected by means of sterile leggings, a sterile towel across the
abdomen and one covering the inner surface of each thigh, held in place
by sterile clips or safety pins. The lower half of the bed is covered
with a sterile sheet while a sterile delivery pad is slipped under the
patient’s hips. (Fig. 82.)

If the delivery is made with the patient lying on her side, the sterile
dressings are so arranged as to cover all but the perineal region after
she is placed in the desired position.

This brings up the question of the nurse’s obligation to protect her
patient from the embarrassment of unnecessary exposure at any time
during labor. The field which is prepared must be uncovered temporarily,
and while the patient is being draped for examination or delivery a
certain amount of exposure is unavoidable; but there are many little
ways in which the nurse may show her consideration for the patient in
this connection and the patient always appreciates the protection.

During the second stage, the preservation of asepsis, watching the
progress of labor and watching for unfavorable symptoms, are of even
greater importance than during the first stage. After the patient has
been prepared and draped with sterile dressings, neither they nor the
perineal region should be touched with anything unsterile.

If for any reason it has not been possible to sterilize sheets and
towels, or more are needed after the prepared supply has been exhausted,
the inner surfaces of towels and sheets that have been ironed either by
hand or machinery, and folded with the ironed surfaces inside without
being touched, may be regarded as practically sterile.

As the second stage advances, the patient may greatly aid the progress
of labor by voluntarily bearing down during pains, and the nurse in turn
may be called upon to help by encouraging her and explaining just what
she should do. At the beginning of a pain the patient should take a deep
breath, close her lips, brace her feet and strain with all her strength.
If she opens her mouth and cries out, she fails to use her pains to the
best advantage. The effect of this bearing down may be increased by
providing the patient with straps, attached to the foot of the bed, upon
which she may pull during the contractions, as she bears down. (Fig.
83.) Or, what is often a great comfort to her, she may pull upon the
nurse’s hands as the latter braces herself so as to offer strong
resistance. If the nurse can be spared from other duties to give this
kind of assistance, it is indeed a comfort to the patient, who appears
to derive from it both a moral and physical sense of being helped in her
struggle. It is also important to assure the patient, between pains,
that she is doing well, and that her efforts are advancing the baby, if
this is true; and if not, she may under ordinary conditions be urged to
make greater effort.

[Illustration:

  FIG. 83.—Patient pulling on straps while bearing down during second
    stage pains. (From photograph taken at Johns Hopkins Hospital.)
]

Before the head can be seen at the outlet or its advance noted by
perineal bulging, the stage of its descent is often ascertained by
palpating through the perineum, the fingers of a gloved hand pressing
upward, on one side of the vulva. (Fig. 84. See Figs. 85, 86, 87, and 88
for appearance, advance and birth of head during normal delivery.)

Immediately after the birth of the head, and before the birth of the
body, the nurse is frequently asked to wipe the baby’s mouth and eyes
and sometimes to drop nitrate of silver into the eyes. In such a case
she should wipe out the mouth very gently with a bit of sterile gauze,
wet with boric, wrapped about her little finger, reaching well back into
the throat; the eyes should be wiped from the nose outward, a separate
wipe being used for each eye. The purpose of these maneuvers, when they
are employed, is to favor respiration from the beginning by removing
mucus that might impede it and to remove possible infective material
from the lashes before it is spread to the conjunctivæ by the baby’s
winking. The silver solution is to destroy germs that may have gotten
into the eye.

[Illustration:

  FIG. 84.—Palpating through the perineum to ascertain the stage of
    descent of the baby’s head. (From photograph taken at Johns Hopkins
    Hospital.)
]

As soon as the baby is completely born a sterile douche pan should be
slipped under the patient or a small sterile basin placed close to the
perineum, to receive the blood which escapes during the third stage.
This is partly to protect the bed, but chiefly that the blood may be
measured, as in no other way can it be ascertained how much the patient
loses. A loss of 600 cubic centimetres or more is regarded as a
hemorrhage.

[Illustration:

  FIG. 85.—Baby’s head appearing at the vulva at the height of a pain.
    (This and succeeding pictures of a normal delivery are from
    photographs taken at Johns Hopkins Hospital.)
]

[Illustration:

  FIG. 86.—Advance of the head indicated by stretching of the vulva and
    perineum.
]

[Illustration:

  FIG. 87.—Holding back the head at the height of a pain to prevent a
    perineal tear.
]

[Illustration:

  FIG. 88.—Birth of the head immediately followed by external rotation.
]

[Illustration:

  FIG. 89.—Wiping mucus from baby’s mouth with gauze wrapped about
    little finger.
]

=Immediate Care of the Child.= After the baby has been brought safely
into the world, it is of greatest possible importance to make sure that
it begins its separate existence by crying lustily, in order fully to
expand its lungs. This provides for oxygenation of its blood, which has
taken place, until now, through the placental circulation. In many cases
the baby cries satisfactorily without aid, but not infrequently must be
stimulated to do so. In all instances the first step is to clear the air
passages of the mucus lodged in the mouth and throat, by some one of the
many approved methods. One is by means of a piece of wet sterile gauze
wrapped about the little finger, and wiped gently about in the back part
of the baby’s mouth (Fig. 89), though many doctors object to this
procedure for fear of abrading the very delicate mucous membrane, no
matter how lightly it is done. They prefer to hold the baby by its feet,
with the head hanging down and the neck sharply curved backward, when by
gravity the mucus will drop out of the mouth; or, holding the baby by
the feet, to run the thumb and forefinger along the neck on either side
of the trachea, toward the mouth, and force out the mucus in that way.
If the baby does not cry well after the mucus is removed, it may usually
be stimulated to do so if held by the feet, head downward, and the back
gently rubbed (Fig. 90) or the face stroked or the buttocks spanked two
or three times. When holding the baby in this position the nurse should
slip one finger between the ankles and grasp them firmly.

[Illustration:

  FIG. 90.—Stroking baby’s back to stimulate respirations.
]

After the baby has cried well it may be laid on the foot of its mother’s
bed. At this juncture it seems pertinent to stress two points which must
be remembered throughout the entire routine of the baby’s care, namely:
the importance of protecting it from infection and from being chilled.
As the baby lies on the mother’s bed, before the cord is cut, it finds
itself in a room which is many degrees cooler than the very warm habitat
from which it has just emerged; it is struggling to establish its
functions, which are suddenly deprived of the mother’s help, chief of
which at the moment are respiration and the circulation. Body warmth is
one of the most valuable aids in promoting an even circulation, and
accordingly the baby should be kept warm from the beginning. For this
purpose there should be a small sterile blanket, or piece of flannel, in
readiness to protect the little body as it lies on the bed, awaiting
further developments. The hands and feet of the newborn baby that lies
uncovered for even a quarter of an hour, or more, are nearly always
cold, and as this must be guarded against in an older, more securely
established baby, it cannot be desirable for the newly born.

[Illustration:

  FIG. 91.—Showing two clamps on cord after pulsation has ceased.
]

[Illustration:

  FIG. 92.—Wrong and right method of tying knot in cord ligature. A will
    slip. B will not.
]

As soon as the cord ceases to pulsate, it is usually clamped with two
clamps about two inches apart (Fig. 91) and cut between the clamps. The
scissors should have blunt points, in order not to scratch or cut the
baby, who may be wriggling vigorously by this time. The cord is tied
tightly with a sterile cord ligature, in a square knot that will not
slip (Fig. 92), about an inch from the abdominal wall. It is considered
a safe precaution, after removing the clamp, to bend the cord back upon
itself and tie it a second time with the same ligature, as the danger of
hemorrhage from a loosely tied cord is serious when the baby is kept
sufficiently warm. The placental end of the cord is also tied, or it
remains clamped until the placenta is expelled, because of the
possibility of there being another child in the uterus and the danger of
its bleeding to death through the open cord.

Some doctors do not tie the cord, but crush the vessels with a clamp
which is left on the cord for about half an hour and then permanently
removed, but this should not be done by a nurse upon her own
responsibility.

Very often the person who performs the delivery removes the blood, mucus
and vernix from the baby’s body, as soon as the cord is tied, by
sponging it thoroughly with albolene or olive oil; wraps the cord stump
with a sterile, dry or alcohol sponge and applies the abdominal binder
while an assistant holds the baby by the feet, head down. It is also
very common simply to oil the baby with unsterile lard, oil or vaseline,
cover the cord with sterile gauze and leave the bath, cord-dressing and
binder to be attended to later.

If the delivery takes place in a hospital the baby must be marked
_before it is taken from the delivery room_, with adhesive plaster, upon
which its mother’s name is plainly printed, or with the name necklace,
now so frequently used.

The baby is once more wrapped in a warm blanket and placed, with a
hot-water bottle, at 125° F., in the basket or box, which was prepared
for it. Although the baby should be well covered, care must be taken to
leave the face fully exposed as a young baby is easily suffocated. It
was formerly customary to lay the new baby on its right side, but with
the present fuller knowledge of the fetal circulation and the changes
which take place after birth, this practice has been largely done away
with.

=Resuscitation of the Newborn Baby.= If the baby breathes feebly, or
even if it does not cry vigorously, the effort to stimulate the
respirations may have to be continued for an hour or more after the cord
is tied. In addition to the simple methods, previously described, which
are very commonly employed at the time of labor, such as stroking the
baby’s back or holding him by the feet and spanking him (Fig. 93), the
following measures are sometimes resorted to if the baby’s condition
demands it:

[Illustration:

  FIG. 93.—Stimulating respirations by holding the baby head downward
    and sharply spanking him. Note the method of grasping the baby’s
    ankles with one finger between them to prevent his slipping from the
    nurse’s hand.
]

One method is to hold the baby with its chest resting on the palm of one
hand, with head, legs and arms hanging forward, thus compressing the
chest wall and favoring expiration (Fig. 94), and then turning it over
on its back, in the other hand, in which position the head, legs and
arms hang backward, thus expanding the chest and favoring an inspiratory
movement. (See Fig. 95.) Alternate repetitions of these positions, about
twelve times a minute, will often stimulate the child to breathe
satisfactorily.

[Illustration:

  FIG. 94. (See also Fig. 95.)


  FIGS. 94 AND 95 show method of stimulating respirations by resting the
    baby alternately on his chest and back on the nurse’s hands. (From
    photographs taken at Bellevue Hospital.)
]

Another method is alternately to plunge the baby into tubs of hot and
cold water. But as there is doubt about the wisdom of chilling the
entire surface of the baby’s body, the cold plunge is forbidden by many
doctors, who, instead, dash a little cold water upon the face and chest,
while the body is immersed in water at about 110° F.

[Illustration:

  FIG. 95.—Resuscitating the baby. (See also Fig. 94.)
]

A widely used and efficacious method is to hold the baby continuously in
a tub of water at about 110° F., and alternately extend and fold its
body, thus keeping it warm while stimulating inspiration and expiration.
(Figs. 96, 97.)

Direct insufflation may be employed while the baby is in the warm water,
by protecting its face with clean dry gauze and blowing directly into
its mouth at intervals corresponding to those of normal inspiration.
(Fig. 98.)

[Illustration:

  FIG. 96. (See also Fig. 97.)


  FIGS. 96 AND 97 show method of resuscitating the baby by alternately
  extending and folding his body under warm water. (From photographs
  taken at Johns Hopkins Hospital.)
]

Another procedure is to hold the baby by the shoulders, with its body
hanging down, thus expanding the chest, and then to toss it quickly
upwards, folding the legs upon the chest to compress it. This method is
objected to by many obstetricians on the ground that it both exhausts
and chills the baby.

[Illustration:

  FIG. 97.—Resuscitating the baby. (See also Fig. 96.)
]

The outstanding requirements in resuscitating a baby are to stimulate
its respiratory movements, by alternately expanding and contracting the
chest; to promote its circulation by keeping it warm, and to avoid
exhausting the very frail little body. Gentle handling, therefore, is
important.


                              THIRD STAGE

After the birth of the baby, some doctors request the nurse to rest one
hand on the mother’s abdomen in order to feel the fundus as it rises
while expelling the placenta, and to keep him informed concerning its
consistency. Others regard this as a dangerous practice and forbid it.

As a rule, there is little bleeding until the placenta has separated. If
bleeding does occur, it is the practice of some doctors to have the
uterus gently massaged through the abdominal wall, to stimulate
contractions, while others consider this inadvisable.

[Illustration:

  FIG. 98.—Stimulating respiration by means of direct insufflation, the
    baby’s face being covered with clean gauze. (From photograph taken
    at Johns Hopkins Hospital.)
]

After the placenta separates and descends into the lower uterine
segment, it produces a bulging just above the symphysis, while the
fundus may be felt as a firm, hard mass above the umbilicus. Since the
placenta is entirely separated from the uterus at this time, its
complete expulsion is usually aided, when it does not occur
spontaneously, by gentle pressure upon the fundus. The accoucheur holds
his hand just below the vaginal outlet, to receive the placenta (Fig.
99), which he turns over and over in his hands, thus twisting the
membranes, and gradually draws it away from the mother, the membranes
trailing after in the form of a tapering cord. (Fig. 100.) It is
important that the placenta and membranes be carefully examined to make
sure that they are intact, for if fragments of either are retained
within the uterus they will prevent its firm contraction and thus may be
a cause of post-partum hemorrhage. For this reason, only very gentle
pressure and traction are used in expressing the placenta and
withdrawing the membranes, for the use of force might leave small
particles adhering to the uterine lining, which would otherwise separate
with the rest, in due time, as a result of the uterine contractions.

[Illustration:

  FIG. 99.—Delivery of the placenta.
]

Having been inspected, the placenta should be placed in a covered
receptacle to be disposed of as the doctor directs, as many physicians
make a routine laboratory examination of the placenta and wish to have
it kept for this purpose.

With the birth of the placenta comes a gush of blood, as the uterine
vessels, some of which are as large as a lead pencil at this time, are
left wide and gaping. The bleeding usually subsides very shortly,
however, as the blood vessels are closed by involuntary contraction of
the network of uterine muscle fibres in which they are enmeshed, and
which are sometimes referred to as “living ligatures.” If the bleeding
continues, these contractions should be stimulated by massage. This is
done by grasping the uterus through the abdominal wall firmly with one
hand and kneading vigorously. Rubbing the top of the fundus with the
fingers usually is not enough. The fundus should be grasped by the
entire hand; the thumb curved across the anterior surface and the
fingers, directed deep into the abdomen, behind it. (Fig. 101.)

Pituitrin or ergot, or both, are frequently given to further stimulate
contractions of the uterine muscles. Since the action of pituitrin is
quick, but evanescent, and the effect of ergot is slower and more
lasting, both a quick and lasting effect is obtained by giving them
together.

[Illustration:

  FIG. 100.—Twisting the membranes while withdrawing them from uterus.
]

The expulsion of the placenta ends the third stage and completes the
process of labor.

[Illustration:

  FIG. 101.—Grasping fundus through abdominal wall in giving massage to
    stimulate uterine contractions.
]

=Immediate After-care of the Patient.= The patient should be bathed and
dried about the thighs and buttocks, the vulva being bathed with alcohol
or an antiseptic solution, and a sterile perineal pad applied. The
douche-pan, wet towels, delivery pad and draw sheet are replaced by a
dry draw-sheet and a towel or pad slipped under the patient’s hips,
while a fresh nightgown is put on if the one worn during labor is wet or
soiled. The perineal pad is very commonly held in place by a T. binder,
with which all nurses are familiar, but some doctors prefer an abdominal
binder to which a perineal strap is attached. This abdominal support may
be a straight swathe or a Scultetus bandage, varying with the wishes of
the doctor, and it may or may not be used in conjunction with a pad, so
applied as to make pressure over the fundus. Other doctors forbid the
application of any kind of a perineal dressing from the time of
delivery, but instead, have a large, sterile pad slipped under the
patient to receive the discharge.

The patient is usually tired and cold at the conclusion of labor, and
may even have a nervous chill. Although this chill is not serious, the
patient is none the less uncomfortable, and she should be warmly
covered, be given something hot to drink, and a hot-water bag placed at
her feet.

All possible effort must now be made to secure for her rest, quiet, and
an opportunity to sleep. Every one but the doctor and the nurse had
better be excluded from the room, which should be absolutely quiet,
somewhat darkened and well ventilated. In addition to this, the majority
of doctors now require that either they or the nurse shall stay with the
patient and keep one hand resting on the fundus for at least an hour
after delivery as a safeguard against post-partum hemorrhage. As long as
the fundus is felt through the abdominal wall as a firm, hard mass, its
irregularly arranged muscle fibres are contracted upon the blood
vessels, and will prevent an escape of blood. But if the fundus feels
soft and boggy, its muscles are relaxed, the constrictions are somewhat
released from the open vessels, and serious bleeding may occur unless
they are stimulated to contract again.

=If the Doctor Is Delayed.= It sometimes happens that labor progresses
with unexpected rapidity, or that the doctor is delayed in his arrival
and the nurse is accordingly confronted with the emergency of being
alone with the patient during part or all of the delivery.

When the baby is making such rapid descent that the nurse fears it may
be born before the doctor’s arrival, she may somewhat retard labor by
covering her hand with a folded, sterile towel, if she has not had time
enough to put on gloves, and hold back the head by pressing against the
perineum during pains, at the same time instructing the patient to open
her mouth, breathe deeply and try not to bear down. It is sometimes
easier for the patient not to bear down if she lies on her side.

If by mischance, or in spite of her efforts, the baby so far descends
that the brow appears before the doctor’s arrival, the nurse cannot
safely hold it back longer because of the danger of the baby becoming
asphyxiated. She should, up to this point, hold the head back during
pains in order that the perineum may be stretched slowly, with the hope
of preventing a tear. (See Fig. 87.) It is the sudden distension of the
perineum and expulsion of the baby’s head at the height of a pain that
frequently causes lacerations. If fecal matter is expressed during
pains, the field should be wiped, downward, with sterile sponges and
bathed with the antiseptic solution at hand.

After the brow is born, the nurse may gradually release the pressure and
allow the head to emerge, and remembering the position of the child and
the mechanism of its birth, assist Nature in its complete delivery.
After the head is born, it drops down toward the mother’s rectum, after
which external rotation, or restitution, takes place. (See Fig. 88.) A
finger should be slipped around the neck in search of coils of cord,
which, if felt, should be slipped over the baby’s head. Otherwise,
pressure upon the cord in that unnatural position might so interfere
with the circulation as to asphyxiate the baby.

The shoulders may be born spontaneously or the nurse may grasp the head
with both hands, curving the fingers of one hand under the baby’s chin,
and of the other, under the occiput, and make gentle, downward traction
(See Fig. 69.) in order to slip the anterior shoulder from under the
symphysis; and then pull gently upward, to deliver the lower or
posterior shoulder (see Fig. 70.), after which the rest of the body
follows easily.

This description of how a nurse may conduct a normal delivery by fairly
typical and generally approved methods is only intended to guide her in
an emergency, when there has been no understanding between her and the
doctor about what she should do in event of his absence; or when he has
authorized her to use her best judgment in safeguarding the lives of
mother and baby.

It is obviously of extreme importance for the nurse to ascertain
definitely the doctor’s wishes in this connection, as he sometimes will
be unwilling to have the nurse give any attention to either mother or
baby, even to tie the cord, before his arrival.

=Prolapsed Cord.= If the umbilical cord should prolapse at any time
during labor, in the absence of the doctor, or lacking instructions, the
nurse should elevate the patient’s hips, in order that gravity may
lessen the pressure on the cord as it lies between the presenting part
and the pelvic brim. Otherwise, the interference with the placental
circulation may result in asphyxiation of the baby. (Fig. 102.)

[Illustration:

  FIG. 102.—Drawing showing how prolapsed cord may be pressed between
    baby’s head and pelvic brim, thus cutting off placental circulation.
]

The elevated Sims position is often effective. Or, a straight chair may
be upturned and pushed under the mattress, from the foot toward the
head, in such a way that the patient will be lying on an incline which
slopes upward from the head of the bed toward the foot. Or the chair may
be placed in the same position on top of the mattress, with the top of
the chair-back under the patient’s shoulders. The chair should be padded
with pillows in order to minimize the patient’s discomfort as she lies
in this trying position.

=Post-partum Hemorrhage.= Should a post-partum hemorrhage occur, in the
absence of the doctor, the nurse should massage the fundus, unless she
has been instructed not to, and have some one elevate the foot of the
bed on blocks or the seat of a firm, straight chair. The use of ice bags
or cold compresses on the abdomen is sometimes helpful and some
physicians advise placing the baby at the mother’s breast immediately,
since the suckling stimulates the uterine muscles to contract.

In anticipation of a post-partum hemorrhage, the nurse must have a clear
understanding of the doctor’s wishes, particularly in regard to the
administration of pituitrin and ergot which are so widely and
efficaciously used to check post-partum bleeding.


                              ANESTHETICS

Those of us who are accustomed to seeing anesthetics used to relieve
patients of the worst of their pain, during labor, find it hard to
realize that until comparatively recent years women went through this
suffering without mitigation.

The use of anesthesia was introduced into obstetrical practice, in 1847,
by Sir James Y. Simpson of Scotland, who first used ether but later
adopted chloroform when he learned that it also had anesthetic
properties. Its use in America was subsequently introduced by Dr.
Channing of Boston.

In the early days, the idea of using anesthesia during labor was greeted
with a storm of protest, both from the clergy and the laity, because of
their belief that the relief of women in childbirth was contrary to the
teachings of the Bible, as set forth in God’s curse on Eve, when He
said, “In sorrow thou shalt bring forth children.”

There is to-day practical unanimity of opinion concerning the advantages
which are derived from the use of anesthesia when any operative
procedures are employed; but there is still some objection to its use in
spontaneous deliveries. This is partly on medical grounds because of the
possible ill effects of anesthetics and is partly a persistence of the
early religious protest. However, in the vast majority of cases, some
kind of an anesthetic, or analgesic, is administered to the woman in
labor because the advantages of its use are generally conceded.

[Illustration:

  FIG. 103.—Method of giving chloroform for obstetrical anæsthesia.
]

The agents used are chloroform, ether and nitrous oxid gas, while what
is popularly called “twilight sleep” is produced, completely or in a
modified degree, by the hypodermic administration of scopolamin and
morphine.

=Chloroform.= Of these various drugs chloroform is apparently the
anesthetic most widely used in normal obstetrics. Its advantages are
that it is easy to give; quick in its action and is followed by little
or no nausea or other ill effects. For some reason, as yet not
explained, the woman in labor enjoys a certain amount of immunity
against chloroform poisoning, but this tolerance exists only during
labor as the puerperal woman is subject to the same dangers as any other
individual.

Chloroform is not usually administered until the patient is well along
in the second stage, or until the head may be felt through the perineum,
or is in sight. The patient’s face should be oiled and protected with a
towel or gauze folded across her brow, mouth and chin to prevent burns
that might follow the inadvertent dropping of chloroform on her face.
With the beginning of a pain, a few drops are poured on the inhaler
which is held about an inch from the face to give a free admixture of
air, and the patient is told to breathe in deeply. (Fig. 103.) The
inhaler is removed as soon as the pain subsides, but reapplied as soon
as another pain begins. The patient retains consciousness and is able to
talk under this degree of anesthesia, but her suffering is greatly
relieved. It has the advantage, also, of lessening the danger of
perineal tears, as the accoucheur has better control of the delivery
when the patient lies quietly than when she tosses violently about the
bed, and a tear resulting from the sudden delivery of the head at the
height of a pain may in this way be averted.

This light, intermittent anesthesia, now so widely used, is called
obstetrical anesthesia or anesthesia _à la reine_, after Queen Victoria,
upon whom it was first employed at the birth of her seventh child, in
1853.

When the perineum is distended to its maximum, obstetrical anesthesia is
not always sufficient, and complete anesthesia may be employed; but even
this requires very little chloroform. Under ordinary conditions, the
anesthesia is discontinued as soon as the child is born, for unless
there is an extensive tear, the patient is sufficiently anesthetized to
permit of a perineal repair and the delivery of the placenta.

Chloroform is not often given early in labor because of the general
belief that its free or prolonged use lessens the force and frequency of
uterine contractions, thus prolonging labor, and also may unfavorably
affect the child. But small doses seem to stimulate rather than retard
contractions, and by having her pain relieved, the patient is prompted
to make greater effort to use her abdominal muscles, an end greatly to
be desired.

If complete anesthesia is needed for more than a few moments, after the
child is born, ether usually replaces the chloroform, being considered
more satisfactory for prolonged anesthesia, but many obstetricians
prefer not to give it until after delivery because of its possible
effect upon the child.

[Illustration:

  FIG. 104.—Giving ether for obstetrical anæsthesia. Ether is poured
    into cone which is covered with nurse’s hand to prevent evaporation.
    When the beginning of a contraction is felt by hand on abdomen, the
    cone is placed about an inch from the patient’s face. (From
    photograph taken at the Maternity Hospital, Cleveland.)
]

As chloroform poisoning is likely to produce degenerative changes in the
liver, and eclampsia also causes a liver necrosis, chloroform is not
used for an eclamptic patient.

[Illustration:

  FIG. 105.—As pain increases and patient becomes accustomed to ether,
    the cone is lowered and held close to her face until pain subsides.
    Sufficient ether to control the next pain is then poured into cone.
    (From photograph taken at the Maternity Hospital, Cleveland.)
]

=Ether=, also, is used widely in normal obstetrics and is almost always
preferred for continuous anesthesia, because of its being safer than
chloroform. Unlike chloroform, ether is sometimes given in the first
stage after the pains have become severe and frequent. About a dram of
ether is poured into the cone which is held just off the patient’s face
(Fig. 104.) until the beginning of a contraction, at which time it is
lowered and held close to her face (Fig. 105.) As the action of ether is
slower than chloroform, it should be poured into the cone in advance of
a pain, which the nurse anticipates by feeling the uterus begin to grow
hard under the hand which she keeps upon the patient’s abdomen. If the
ether is not poured into the cone until a pain begins, its anesthetic
effect may be lost because of the delay in its administration.

At the Cleveland Maternity Hospital, where ether is used during normal
labor, the nurses are taught to give it as has just been described, with
further instructions from Miss MacDonald, as follows: “A patient will
vaporize about one dram of ether per pain during the early first stage,
gradually vaporizing a greater amount until she will vaporize two or
three drams per pain near the end of the second stage. Should the
patient reach the excitement stage of ether before she is in the second
stage of labor, discontinue the ether for from five to fifteen minutes,
then give a lessened amount.

“Should it be necessary to control the descent of the presenting part,
light anesthesia may be given. This may be managed by putting about two
drams of ether in the cone at intervals frequent enough to sufficiently
retard the descent of the presenting part. This procedure almost
obliterates contractions. Lift the cone from the face for a few moments
at frequent intervals to admit air. Keep the ether vapor of such
concentration as avoids choking, coughing or vomiting. This may be done
by administering a small amount frequently, rather than a large amount
at longer intervals. When the desired stage is reached, try to keep the
patient at this degree of anesthesia by giving a few drams of anesthetic
at regular intervals.”

=Nitrous Oxid Gas Analgesia.= The effect of this drug is termed
analgesia rather than anesthesia, because the patient does not lose
consciousness but is unconscious of pain. From a medical standpoint it
is considered practically ideal for use in obstetrics. If given
skillfully it seems to have no bad effects upon the child; it tends to
stimulate, rather than diminish uterine contractions; it may be started,
with safety; as soon as the patient begins to suffer severely, and
continued for several hours if necessary.

Its disadvantages are that it is very expensive; it can be given safely
only by a skillful, trained person; the apparatus necessary for its
administration is expensive, heavy and difficult to transport. But when
these difficulties can be overcome, its use is attended with very
satisfactory results.

“=Twilight Sleep=,” so called, or _Dämmerschlaf_, as it is termed in
Germany, has been and still is discussed so widely, that the nurse
should know something of it, whether or not she aids in its
administration. It may be described as a state of amnesia, or
forgetfulness, produced by the hypodermic injection of morphin and
scopolamin. The patient, therefore, is conscious of pain at the time but
speedily forgets it.

This treatment was first used widely in Freiburg. Following an
enthusiastic report from there upon a large number of cases in which it
had been used, there was such a clamor for it by American women, that
its temporary use was practically forced upon obstetricians in this
country. It was given what appears to have been a fair trial, but its
continued use in this country has not been widespread. Those
obstetricians who object to its use describe its disadvantages as
follows: It cannot be used outside of a well-conducted hospital; it
requires the constant attendance of a well-trained obstetrician or
obstetrical nurse throughout the entire course of labor; it is suitable
for use in certain selected normal cases only; it prolongs the second
stage and increases the percentage of cases in which operative
interference is necessary; it has an asphyxiating effect upon the child
and increases the percentage of fetal deaths.

On the other hand, the use of scopolamin and morphin is a routine in
certain excellent maternity hospitals, and by many obstetricians of the
first rank, who maintain that with a nurse in attendance and the
observance of ordinary precautionary measures, the advantages far
outweigh the disadvantages of a modified “twilight sleep.” An anesthetic
is usually administered during the second stage, after the use of the
scopolamin-morphin treatment.

COMPLETE ANESTHESIA. If an emergency should arise and the nurse be
required to change from the light anesthesia _à la reine_, and to give
complete anesthesia, her responsibilities increase, for she must watch
carefully the patient’s pulse, respirations, color and pupils. The flat
pillow which is ordinarily left under the patient’s head during normal
labor, should be removed and the inhaler should be held closely over her
face with the nurse’s fingers so placed as to hold it in position and
also to hold the patient’s jaw forward and up. (Fig. 106.)

The ether should be dropped in clean drops, not poured, upon the
inhaler. The dripping should be steady, but slow at first, gradually
increased as the patient becomes accustomed to the fumes.

[Illustration:

  FIG. 106.—Method of holding inhaler and supporting patient’s jaw in
    giving ether for complete anesthesia. (From photograph taken at
    Johns Hopkins Hospital.)
]

With the average, normal patient who is taking ether well the
_respirations_ become somewhat stertorous and more rapid, increasing to
possibly 36 or 40 per minute; the _pulse_ starts at a little above the
normal rate and increases to 116 or 120 and then drops to normal, which
is slightly below the rate at which it started; the _color_ is normal at
first and then may become crimson, or it may change very little; the
_pupils_ first dilate, and then contract almost to a pin point.

Unfavorable signs are: _respirations_ that are rapid and shallow, then
possibly slow, but still shallow; increasing _pulse_ rate, this being so
serious that the ether is usually stopped if the pulse approaches 140,
and stimulation is promptly given; _cyanosis_ which is slight at first
and then extreme, and dilated _pupils_.

It is obviously not wise nor possible to attempt, by means of a few
paragraphs and illustrations to teach a nurse so technical and important
a procedure as the administration of an anesthetic, but it is hoped that
these general suggestions may be helpful, particularly to the nurse who
is unexpectedly confronted by an emergency.

Under all conditions the nurse must remember that no matter what
anesthetic is given, nor by whom it is administered, she must guard
against the very prevalent tendency to talk freely while the patient is
going under, in the belief that she is unaware of what is going on about
her. Many patients suffer great mental distress because of hearing, or
partly hearing conversation not intended for their ears, which takes
place in their hearing while they are incompletely anesthetized.



                              CHAPTER XIII
             OBSTETRICAL OPERATIONS AND COMPLICATED LABORS


Unhappily, not all labors run the smooth and uncomplicated course which
was described in the last chapter. Certain abnormalities sometimes arise
to complicate delivery, occasionally necessitating operative
interference or relief.

There is little that a nurse can do alone, in the presence of
complicated labor, but her preparations and assistance will be more
effective if she understands the purpose of the operations, and she will
better appreciate the gravity of certain symptoms, which she is required
to watch for and report, if she realizes the extreme seriousness of
their import.

The principal conditions which give rise to, or follow complications,
prevent spontaneous delivery or necessitate operations at the time of
labor are perineal lacerations; contracted or malformed pelves; marked
disproportion between the diameters of the child’s head and mother’s
pelvis; ruptured uterus; exhaustion of the mother; poor muscle tone or
certain chronic and acute diseases of the mother; death of the fetus;
prolapsed cord; certain presentations of the fetus in which spontaneous
delivery is doubtful or impossible.

The preparations for operations in hospitals are all so carefully
planned and systematized that in the presence of such emergencies the
nurse will merely have to carry out the customary routine, but in a
patient’s home she may have to exercise a good deal of originality in
attempting to meet the needs of the occasion and imitate hospital
provisions.

A satisfactory operating table may be fashioned in any one of a number
of ways. If the bed is high enough, it may sometimes be made fairly
satisfactory by slipping a board, such as a table leaf, under the
mattress to make it firm. The use of a kitchen table is time-honored,
but it is an unsafe practice unless the available table is very secure
and firm, which is usually not the case with present-day kitchen tables.
A flat-topped chest of drawers, with the casters removed, makes an
excellent operating table, for it is firm, a good height and about the
right size. Or an ordinary bureau may be pressed into service after
taking out the casters and removing the mirror by unscrewing its
supports. The front and sides of a bureau, or chest of drawers so used
should be protected from the damaging effects of fluids and solutions by
being covered with a bed-rubber or newspapers. A pad for the top of the
improvised operating table may be arranged by folding a blanket or quilt
to the proper size and folding over that the rubber draw-sheet and a
clean muslin sheet.

If the operation requires that the patient be held in the lithotomy
position (on her back with thighs and knees flexed and knees well
separated), and the doctor’s equipment does not include a strap to hold
the legs, one may be improvised from a sheet. It should be folded
diagonally, over and over, into a strip possibly a foot wide, passed
over one shoulder and the tapering ends used to tie around the legs,
above the knees, to hold them in the desired position. Bandages or tapes
are not always satisfactory, for the support is subject to a good deal
of strain, and narrow strips sometimes cut painfully into the legs and
shoulders. Certainly if tapes or bandages are used, cotton pads or
folded towels should be interposed between them and the patient’s skin.

In general, the nurse will prepare as for a normal delivery, in each
instance adding such details of equipment, or preparation as the
contemplated operation requires. Rigid asepsis must be observed
throughout the preparations and the operations. When large instruments
or appliances are to be used, a wash boiler is probably the safest thing
in which to boil them, for it is scarcely possible entirely to cover
them with water in a smaller receptacle; and they must be well covered
while boiling, or they will not be sterile.

=Perineal Lacerations.= A large proportion of women during the birth of
the first baby sustain some degree of perineal laceration, which may
amount to nothing more than a nick in the mucous membrane, or it may
extend entirely across the perineal body and tear through the rectal
sphincter. The causes of these tears are generally conceded to be
rigidity of the perineal muscles; disproportion between the size of the
child’s head and the vulval opening; a sudden expulsion of the child’s
head, before the perineum is fully distended, and certain abnormalities
in the mechanism of labor. Lacerations may, therefore, be prevented, or
limited, in many cases by holding back the baby’s head and allowing it
to dilate the perineum slowly. But in spite of the most skillful and
careful efforts, tears of some degree occur in most primiparæ, and
probably in half of all multiparæ. These injuries are usually described
as being of the first, second or third degree, according to their
extent.

=A first degree tear= is one that extends only through the mucous
membrane, usually at the margin of the perineum, without involving any
of the muscles.

=A second degree tear= is one that extends down into the perineal body
and may involve the levator ani, or even extend down to, but not through
the rectal sphincter. Such a tear usually extends upward on one or both
sides of the vagina making a triangular injury.

=A third degree tear= extends entirely across the perineal body and
through the rectal sphincter and sometimes up the anterior wall of the
rectum. This variety is often called a =complete tear=, in
contradistinction to those of first and second degree, which are
incomplete.

It is a fairly general custom to repair these lacerations at the time of
labor, no matter what their extent, the sutures being introduced but not
tied, during the third stage. The patient is usually sufficiently
anesthetized to permit of this, without further anesthesia, in all but
complete tears, and as there is usually but very slight bleeding before
the expulsion of the placenta, the field is comparatively clear and the
stitches are easily put into place. They are not tied, as a rule, until
after delivery of the placenta because of the strain which its expulsion
would put upon the fresh stitches. In all but very slight tears, the
doctor will usually want the patient turned across the bed, with her
hips brought to the edge, and her legs supported in the lithotomy
position. As the few instruments necessary for perineal repairs should
be boiled and placed in readiness before labor, there is usually no
further preparation for the nurse to make, and the perineal dressing,
after the stitches have been taken, is ordinarily the same as that
following a normal delivery. (See Fig. 80 for necessary instruments.)

Some physicians prefer not to repair perineal tears until some days
after labor, contending that the congestion of the soft parts
immediately after delivery is not favorable to a satisfactory union.
When the repair is made subsequently, therefore, the nurse prepares as
she would for any perineal operation, performed independently of labor.
Repairs are not often postponed for more than a few days, since long
delayed or neglected attention frequently gives rise to gynecological
disorders, such as descensus or prolapse of the uterus.

=Episiotomy.= Some obstetricians prefer to anticipate a perineal tear by
making an oblique incision, usually on one or both sides, extending
downward and outward from the margin of the vaginal outlet down into the
perineum. This operation is termed episiotomy, and the incision is
sutured after labor just as a tear would be. It is the belief of those
who perform this operation that the clean-cut incision heals more
satisfactorily than an irregular tear, and that by directing the
incision to the side, away from the median line, the integrity of the
rectal sphincter is preserved, even though the perineum tears beyond the
end of the incision, when distended during the birth of the head.

=Breech Extraction.= In some cases of breech presentation, particularly
among primiparæ, it is necessary to assist nature in the delivery of the
child in order to save its life. Complete anesthesia is usually
necessary at such times and the patient is preferably on a table or at
the edge of the bed in a lithotomy position.

In the majority of cases, no effort is made toward assistance until the
body is born as far as the umbilicus, partly because of the difficulty
of taking hold of the child securely before that time, and partly
because the perineum is not likely to be fully distended, in which case
a serious tear would probably result. But after the body has been
extruded as far as the umbilicus, it is usually considered imperative to
complete the delivery within eight minutes to save the child from
asphyxiation, due either to pressure on the cord between the head and
pelvic brim, or to premature separation of the placenta. The baby’s feet
or legs are grasped by a towel to prevent slipping, and downward
traction is made on the body until the tips of the scapulæ appear at the
outlet. During this procedure the nurse may be called upon to make
pressure on the uterus with the idea of keeping the baby’s head flexed
forward; preventing the arms from becoming extended upward above the
head and also to help in expelling the child.

After the scapulæ appear, the arm lying posteriorly is brought down over
the chest and delivered. The body is then rotated until the other arm
lies posteriorly and that is delivered. After delivery of the arms and
shoulders the head is usually delivered by what is known as Mauriceau’s
maneuver as follows: The accoucheur slips the index finger of one hand
into the vaginal outlet and into the child’s mouth, and supports the
body of the child upon his hand and forearm; two fingers of the other
hand are slipped around the back of the neck and curved forward like
hooks over the shoulders and strong downward traction is made by these
fingers; not by the one in the baby’s mouth. The occiput emerges from
beneath the symphysis, after which the body is lifted upward and the
chin, nose, forehead and entire head are born.

=Version.= By version is meant the turning of the child within the
uterus so that the part which was presenting at the superior strait is
replaced by another part, in order to hasten or facilitate delivery. It
is usually performed as the patient lies flat on her back, completely
anesthetized, and with great gentleness, for fear of rupturing the
uterus.

Common indications for a version are a transverse presentation; a
prolapsed cord, when the head has just begun to enter the superior
strait; and in some cases of placenta prævia. When the fetus is so
turned that the head becomes the presenting part, the procedure is
termed a _cephalic version_; if so turned that the breech presents, it
is termed a _podalic version_. The methods of accomplishing these ends
are described as _external version_, if the turning is done entirely
with the hands working through the abdominal wall; _internal version_ if
one entire hand is introduced into the uterine cavity, and _combined
version_ when one hand is outside on the abdomen and two fingers of the
other are introduced through the cervix into the uterus.

External cephalic version is often performed late in pregnancy, or early
in labor, in transverse and also in breech presentations, to secure a
vertex presentation because of the high fetal death rate in breech
extractions. Podalic version, or making the breech the presenting part,
is often performed in transverse presentations, in placenta prævia and
when the cord or extremities are prolapsed. Having converted the
presentation into a breech, the usual breech extraction is performed.

=Forceps= are instruments which are used to extract the child when
presenting by the head in certain conditions which endanger the life of
mother or child. The value of forceps in obstetrics can scarcely be
overestimated, as before their invention the only operative method of
delivering a live baby was by means of version and extraction, and in
these the fetal death rate was high. The obstetrical instruments in use
up to that time, therefore, were all for the destruction of the child in
utero.

Forceps were devised, and first used, in great secrecy, early in the
17th century, by a Dr. Chamberlen, in England, who jealously guarded all
information relating to his invention from every one but members of his
own family.

There were several doctors in the Chamberlen family who practiced
obstetrics and who used these forceps, but knowledge concerning the
nature of the instruments and methods of using them was not shared with
members of the medical profession outside of that family, until the
beginning of the 18th century. Since that time the use of forceps has
been widely extended and the original Chamberlen instruments have been
so modified and altered and improved by different obstetricians, that
there is now a bewildering number and variety in existence and in use.
Probably the most widely used are those which were devised by Dr.
Tarnier of France and Dr. Simpson of England, respectively. (Fig. 107.)
The Tarnier instrument is known as an axis traction forceps, and can be
used in all kinds of forceps operations, while Dr. Simpson’s are
suitable for use only in low forceps cases.

There are two groups of indications for the use of forceps; those
relating to the condition of the child and those relating to the mother.

[Illustration:

  FIG. 107.—Two widely used forceps. A, Tarnier axis-traction forceps.
    B, Simpson forceps.
]

Indications for their use in the interests of the child are symptoms of
asphyxia, and these are the passage of meconium, in head presentations,
and a change in the rate or rhythm of the fetal heartbeat. As pressure
on the abdomen of the fetus during labor, in breech presentations, is
very likely to express meconium, this is not of special significance in
these cases. But in head presentations, the escape of meconium suggests
paralysis of the rectal sphincter muscles, due to imperfect oxygenation,
which, in turn, is caused by interference with the placental circulation
by pressure on the cord or premature separation of the placenta.

Conditions which menace the life of the mother, and indicate the use of
forceps, are inadequate contractions of the uterine and abdominal
muscles; exhaustion, as indicated by an increase in the maternal pulse
rate or elevation of temperature, and in certain chronic and infectious
diseases, when the patient may be unable to stand the strain of the
second stage.

Forceps are usually employed when the head fails to make satisfactory
advancement after two hours of good, second-stage pains, or when it
remains in one place on the perineum for an hour, in spite of good,
second-stage pains.

[Illustration:

  FIG. 108.—Patient in position and draped for forceps operation. (From
    photograph taken at Johns Hopkins Hospital.)
]

Otherwise, there is danger of necrosis or sloughing of the soft parts as
a result of pressure, with a subsequent recto-vaginal or vesico-vaginal
fistula.

Among the acute conditions in which forceps are indicated are typhoid
fever; pneumonia; acute edema of the lungs, hemorrhage from premature
separation of the placenta; intra-partum infection and eclampsia, while
they are sometimes used in such chronic conditions as pulmonary
tuberculosis; various heart lesions, particularly when there is broken
compensation.

Before applying forceps the operator will usually wish to satisfy
himself that the following conditions exist: Complete dilatation of the
cervix, otherwise severe lacerations with hemorrhage may result; the
head must have entered the pelvis, otherwise an imperfect application of
the forceps may result in death of the fetus and serious injury to the
mother; the position of the child’s head must be known in order that the
forceps may be properly applied over the ears; the membranes must have
ruptured or the forceps may slip.

Forceps operations are usually designated as being high, mid or low,
depending upon the level to which the head has descended into the
pelvis. If the head is at the superior strait, a high forceps operation
is necessary; mid forceps if the head is half way down and on a level
with the ischial spines and low forceps when the head is on or just
above the perineum.

[Illustration:

  FIG. 109.—Forceps sheet used in Fig. 108.
]

The application of low forceps is a simple operation and attended by
little danger to mother or child; mid forceps is more serious and high
forceps is very serious for the child and sometimes for the mother.

When forceps are applied, the patient must be at the edge of the bed or
preferably on a table, in the lithotomy position (Fig. 108), and
completely anesthetized. She should be shaved and scrubbed as for a
normal delivery, after which a sterile towel soaked in bichlorid 1–1,000
or lysol 2 per cent., is placed over the vulva and allowed to remain
until the operation is performed. She should be draped with sterile
leggings and towels, one of which is folded over the centre of a wide
strip of adhesive about twenty inches long, and hung curtain-like over
the rectum by strapping the free ends to the buttocks on each side,
while over all is placed a sheet with three openings; two slits for the
legs to pass through and one rectangle which exposes the field of
operation. (Figs. 109, 110.)

[Illustration:

  FIG. 110.—Two types of easily made leggings suitable for use during
    delivery or obstetrical operations.
]

=Pubiotomy=, or hebotomy, consists in sawing through the pubic bone on
one side of the symphysis with a string or Gigli saw. This operation is
performed in some cases of moderately contracted and funnel pelves,
through which the normal expulsive forces of labor are unable to force
the child. The separation of the bone allows it to gape, because of the
hingelike movement of the sacro-iliac joint, and thus the superior
strait is appreciably widened and the child may be delivered by high
forceps or version. As the bone heals by fibrous union, there is
sometimes permanent enlargement of the pelvis and there are seldom any
unsatisfactory after-effects, such as impairment of locomotion.
Pubiotomy is sometimes the operation decided upon when a patient is seen
for the first time after labor is well advanced, and a conservative
Cæsarean section is thought inadvisable because of the risk of
infection. But the operation is becoming more and more rare, for the
general practice of measuring the pelvis and supervising patients during
pregnancy discloses serious disproportions early enough to make a
Cæsarean section the elective operation.

=Symphysiotomy.= This operation is a cutting through the cartilage of
the symphysis pubis, instead of through the pubic bone, as in pubiotomy.
It was formerly performed for much the same reasons that pubiotomy is
now used, but has been practically abandoned since the development of
the latter operation. The reasons for giving it up were that the close
proximity of the bladder to the symphysis resulted in frequent injuries
to that organ, and as the cartilage of the symphysis does not heal as
well as the pubic bone, the patients frequently experienced difficulty
in walking and showed a tendency to tire more easily after the operation
than before it was performed.

=Vaginal Hysterotomy=, or vaginal Cæsarean section, as it is sometimes
called, consists of incising the cervix anteriorly and posteriorly,
delivering the child and placenta and suturing the wounds. It is
sometimes performed in cases which for some reason require immediate
delivery, as in severe cases of eclampsia. It is only possible when the
relation between the pelvis and the child’s head is such as to permit
the child to pass through the inlet. It is rarely done in primiparæ,
because rigidity of the outlet prevents proper exposure; or in multiparæ
at term as the incisions have to be extended so high to deliver a term
baby, that there is danger of tearing the lower uterine segment.

=Cæsarean Section= is the operation by means of which the child is
delivered through an incision in the abdominal and uterine walls. It is
believed by some that the operation was named for Julius Cæsar, who was
presumably delivered by this method, but this seems scarcely probable.
The operation was frequently fatal in those days and, moreover, as the
uterine wall was not sutured after the child was extracted, a woman was
not likely to have other children afterward even if she did live, and
Cæsar’s mother had several children after he was born. Another
explanation for the name is that during Cæsar’s reign a law was passed
which required that the abdomen be opened and the child extracted in
every case in which a woman died late in pregnancy, as one means of
increasing the population.

Thus it will be seen that the operation itself is very ancient, but as
performed to-day it embodies the most modern and scientific knowledge
and methods. The usual indications for it are cases of contracted or
deformed pelves; cases of tumors which block the birth canal or when
very speedy delivery is imperative as in some cases of eclampsia.

The anatomical indications for Cæsarean section are dependent upon the
degree and character of the pelvic contractions and upon the size and
mouldability of the child’s head in relation to the pelvis. This
explains why in two women with pelves of the same size and shape, one
will have a spontaneous delivery and one will require a section. The
former has a relatively small child which can pass through her pelvis;
while the second woman’s baby is too large, or the head not sufficiently
mouldable, to pass through hers.

This is one exemplification of the great importance of pelvimetry and of
constant watching during pregnancy, for the best results from Cæsarean
section are obtained when it is recognized that spontaneous delivery is
unlikely or impossible; the operation accordingly is performed at a time
which is deliberately selected by the obstetrician. The elected time is
often about two weeks before the expected date of confinement in order
that the baby may have the longest possible intra-uterine life and that
the operation may be performed before the patient goes into labor. In
these cases in which it is known that a section is to be performed
vaginal examinations are omitted after the pelvic measurements are
taken, in order to minimize the possibilities of infection, this being
one of the great risks of the operation.

Until recent years the operation was usually delayed until after the
patient had been vaginally examined, had been in labor long enough to be
exhausted and the only other courses open were high forceps or a
destructive operation upon the child. The results of the operation
undertaken under such circumstances were not good, and the maternal
deaths from infection were so frequent that the operation on the whole
was very hazardous. But improved surgical technique and extended
knowledge of the pelvis have so revolutionized Cæsarean section that it
is now successful in the majority of cases.

There are three main types of Cæsarean section: conservative, radical
and extraperitoneal.

The =conservative= operation consists of opening the abdomen in the
mid-line; incising the uterus; extracting the child and placenta, and
suturing both uterine and abdominal walls. This is the usual operation
when there is a choice, but because of the danger of infection, it is
ordinarily performed only before the onset of labor or in the early part
of the first stage, and many obstetricians are loath to undertake it
then if the patient has been examined vaginally, particularly if the
technique of the examination was open to question.

In the =radical= operation the abdomen and uterus are incised; the child
and placenta extracted and the uterus is amputated just above the
cervix. This operation is usually performed when labor is well advanced
and there is fear of infection.

In the =extraperitoneal= operation the incision in the abdomen is made
low down on one side, the peritoneum is not incised but is peeled back
from the bladder and lower part of the uterus. The uterus may thus be
opened and the child and placenta extracted, without entering the
peritoneal cavity, thereby greatly reducing the risk of infection, and
also without necessitating the removal of the uterus as a safeguard
against infection. This operation, also, is performed late in labor when
infection is feared, but is considered very difficult and therefore is
not common.

The nurse’s duties in connection with a Cæsarean section are the same as
those in any abdominal operation plus preparations for receiving and
reviving the baby.

=A Ruptured Uterus= is a splitting of the uterine wall at some point,
usually in the lower uterine segment, that has become thinned or
weakened and unable to stand the strain of further stretching incident
to uterine contractions, and is accompanied by an extrusion of all or a
part of the uterine contents into the abdominal cavity. The rupture of a
uterus during labor is a very rare accident, occurring but once in from
500 to 1,000 cases and usually only in prolonged labors, obstructed
labors or certain faulty presentations. It is also a very grave
accident, since the baby nearly always dies and sometimes the mother as
well.

The cause of a ruptured uterus may be found in scar tissue, following a
Cæsarean section or an injury; inherent defects in the tissues
comprising the uterine wall; contracted pelves; neglected transverse
presentations and the accident may occur during a version. It is usually
preceded by extreme tenderness in the lower uterine segment, the part
that is being abnormally stretched. The common symptoms, after the
rupture has occurred, are sudden and acute abdominal pain during a
contraction, which the patient describes as being unlike anything she
has ever felt and as though “something had given way” inside of her.
There is immediate and complete cessation of labor pains because the
torn uterus no longer contracts. Sooner or later the patient has
symptoms of shock because of the hemorrhage, which is usually internal,
though there may be vaginal bleeding as well. Her face becomes pale and
drawn and covered with perspiration; her pulse is weak and rapid; she
appears exhausted and collapsed and may complain of chilly sensations
and air hunger.

Abdominal palpation shows that the lower uterine segment is even more
sensitive than formerly and that the presenting part has slipped away
from the superior strait while at the side of the fetus the contracted
uterus, partly or entirely empty, may be felt as a hard mass. The
symptoms of shock may be delayed for some time when they will be
accompanied, as a rule, by abdominal distension, due to hemorrhage, and
a slight elevation of temperature.

The prevention of this disaster lies in performing version and prompt
extraction in transverse presentations, as soon as the cervix is
dilated, and in interference if the presenting part does not engage
after an hour of strong, second-stage pains.

The treatment of a ruptured uterus is influenced by many factors.
Possibly the most frequent course followed is to open the abdominal
cavity and repair or remove the uterus, after extracting the fetus and
placenta, according to existing conditions and the judgment of the
operator. Sometimes the fetus is removed through the vagina and the
uterus repaired through that channel.

=Destructive Operations= have as their purpose the crushing or
dismembering of the child in utero so that it may pass through the
pelvis. In the early days such operations were resorted to fairly often
in the presence of conditions that threatened the mother’s life and
which apparently could not be met in any other way. They are performed
less and less frequently to-day because of the success attending the
performance of Cæsarean section, version, pubiotomy and forceps
operations. They are never sanctioned by the Catholic Church in cases
where the child is alive.

=Induced Abortions and Premature Labors.= As was explained in the
chapter on complications and accidents of pregnancy, it is sometimes
deemed advisable, or necessary to terminate pregnancy by artificial
means, in the interests of the mother or child or both.

The procedures are termed _induced abortion_, _induced premature labor_
and _accouchement forcé_. The effects of these operations, _per se_,
when skillfully performed, for therapeutic purposes, are not usually
considered more serious for the mother than a normal delivery, since
they can be performed with deliberate care and cleanliness and can be
followed by adequate aftercare. When the reverse conditions prevail, as
in criminal abortions, the patient’s subsequent suffering or ill health
are more likely to be due to the poor obstetrics and unclean work which
is characteristic of practitioners who are willing to do illegal
operations, than to the termination of pregnancy itself. It is important
that the nurse fully appreciate this and be as scrupulously careful in
her preparations for, and assistance with these operations as for a
major operation or a normal delivery.

=Induced abortion= applies to the termination of pregnancy before the
child is viable, or before the end of the twenty-eighth week, and is
performed solely in the interests of the mother, as the fetus is always
lost. It is resorted to in those cases where the mother is suffering
from some condition, which may or may not be inherent to pregnancy,
which threatens her life or health but which it is believed may be cured
or arrested if uncomplicated by pregnancy. Such conditions may be
toxemic vomiting; nephritis, particularly with evidences of increasing
renal insufficiency; bleeding, due to an incomplete abortion; a dead
fetus; infection following an attempt at criminal abortion. Contracted
pelves and pulmonary tuberculosis are sometimes taken as indications for
inducing abortions, but with the development and improvement of
obstetrical operations, more and more women are able to go nearly, or
quite, to term and be delivered of live babies; while increasing medical
knowledge concerning the care of patients with tuberculosis, and also
with some heart lesions, is applied so successfully during the prenatal
period that some pregnancies which formerly would have been terminated,
are now allowed to continue, and with happy results.

The methods of induction depend upon the stage to which pregnancy has
advanced and also upon the importance of haste. In the very early
stages, one method is for the operator to dilate the cervix with a
dilator; insert one finger into the cervix and up into the uterus and
separate the placenta from its uterine attachment, while making pressure
on the uterus from above with the other hand on the abdomen. Another
method is to introduce a gauze pack into the cervix, packing it and the
vagina firmly and leaving the packing for twenty-four hours. When it is
removed the ovum frequently follows. Sometimes the membranes are
ruptured, after which the amniotic fluid drains off and the ovum is
expelled; or vaginal hysterotomy is sometimes performed when the
patient’s condition is such that haste is imperative. The termination of
pregnancy before viability is never sanctioned by the Catholic Church,
because of the almost certain loss of the child.

=Induction of premature labor.= This procedure is the termination of
pregnancy after the twenty-eighth week, or after the child is viable,
and may be performed to save either the mother or the child or both,
from conditions which would evidently work destruction if allowed to
persist. The indications for inducing labor prematurely may be a
seriously overtaxed heart or kidneys; pulmonary tuberculosis;
preëclamptic toxemia or nephritic toxemia; chorea, neuritis; pyelitis;
placenta prævia; a fetus that has been dead for two weeks, with no signs
of labor; in some cases of nephritis when the fetus during previous
pregnancies has died, and it is believed that the child may be saved by
inducing labor before the stage in pregnancy at which the others
perished.

Labor is sometimes induced when the mother’s pelvis is normal, but the
child has grown as large as is safe in anticipation of a spontaneous
labor, and particularly if the expected date of confinement has passed.

[Illustration:

  FIG. 111.—Rubber bougie used in inducing labor.
]

A common method of inducing labor when haste is not important, is to
introduce one or more bougies (Fig. 111) through the cervix into the
uterine cavity between the membranes and the uterine wall. The presence
of the bougies will often stimulate the uterine contractions and bring
on labor, with expulsion of the fetus, in from six to twenty-four hours.

[Illustration:

  FIG. 112.—Champetier de Ribes’ bag.
]

More speedy results are obtained by the use of rubber bags, which may be
collapsed before introduction and expanded afterward by filling them
with sterile salt solution. There is a great variety of bags for this
purpose, two of which that are frequently used are the Champetier de
Ribes (Fig. 112) and the Voorhees bags. (Fig. 113.) They come in
graduated sizes, the largest holding about 500 cubic centimetres.

[Illustration:

  FIG. 113.—Voorhees’ bag, collapsed.
]

[Illustration:

  FIG. 114.—Rubber bag rolled and held in forceps for introduction into
    uterus.
]

[Illustration:

  FIG. 115.—Syringe for introducing sterile water into bag after its
    insertion into the uterus.
]

The operation is performed with the patient in the dorsal position. The
cervix is drawn down into sight, with forceps, and if intact, is
slightly dilated. The bag is rolled tightly, held in suitable forceps
(Fig. 114), and after being well lubricated is introduced through the
slightly dilated cervix into the lower uterine segment, and pumped full
of sterile salt solution. The solution is first measured in order to be
sure that the bag is filled to its desired capacity, and is then
introduced by means of a syringe, (Fig. 115), through the rubber tubing
which is attached to the lower end of the bag, and which is then closed
off by the stop cock, to prevent escape of the fluid. It is very
important that the solution be sterile in view of the possibility of any
rubber bag rupturing, particularly when pressed upon by the contracting
uterus. (See Fig. 47 for position of bag after introduction into
uterus.)

The presence of this bag stimulates uterine contractions, the cervix
dilates, the bag is expelled and in some instances the child is
delivered spontaneously and in others by means of forceps. The effect of
this bag in producing labor may be hastened by tying a weight to the end
of the tubing and allowing it to hang over the side of the bed. This
traction and pressure help to dilate the cervix and seem to increase the
irritation of the uterine muscles, thus increasing the force of their
contractions.

=Accouchement forcé= is a speedy, forced delivery requiring the forcible
widening of an intact, or partly dilated cervix, manually, or
instrumentally. It is sometimes performed when existing conditions
require extreme haste, as in certain heart lesions; eclampsia; concealed
or accidental hemorrhage or in any condition which suddenly arises to
threaten the life of the patient or her expected baby. But as the shock
of this operation is great and the condition which threatens the patient
can usually be better relieved by means of some one of the operations
already described, it is less and less frequently performed.


                             THE MIRACLE[7]

                                   by

                       Elizabeth Newport Hepburn

                The wind blows down the street,
                  A shutter bangs somewhere,
                While twilight falls as softly as
                  A woman’s flowing hair.

                Within a quiet room,
                  Adventurers at rest,
                A mother holds her newborn son,
                  Safe, now, upon her breast!

                For out of Night and Pain,
                  The womb of mystery,
                Is sprung this miracle of Life
                  That she can touch and see.

                No seer’s prophetic dream,
                  No star in all the skies
                Burns with a lustre half so bright
                  As happy mother eyes.

                No quester for the Grail,
                  No searcher for the Truth,
                Counts more than those who bear and rear
                  And love and nurture Youth!

                Within her curving arm,
                  All safe and warm he lies,
                The heir of all that Man has won
                  Down countless centuries!



                                 PART V
                            THE YOUNG MOTHER

  CHAPTER XIV. THE PUERPERIUM. Physiology. Involution. After-pains.
    Lochia. Loss of Weight. Menstruation. Lactation. Abdominal Wall.
    Digestive Tract. Temperature. Pulse. Skin. Urine.

  CHAPTER XV. ROUTINE NURSING CARE DURING THE PUERPERIUM. Complications
    to be Guarded against. General Treatment of the Patient. Nursing
    Care. Position in Bed. Sitting up. The Daily Bath. Diet. The Bowels.
    The Bladder. Catheterization. Temperature, Pulse, and Respiration.
    Care of the Perineum. Care of the Breasts. Lactation. Stripping.
    Abdominal Binders and Bed Exercises.

  CHAPTER XVI. THE NURSING MOTHER. Normal Routine. The Establishment of
    Breast Feeding. The Mother’s Frame of Mind and State of Nutrition.
    Method of Nursing. The Nursing Schedule. Personal Hygiene of the
    Nursing Mother. Diet. Bowels. Rest and Exercise. Recreation.
    Weaning. Drying up the Breasts.

  CHAPTER XVII. NUTRITION OF THE MOTHER AND HER BABY. Importance of
    Adequate Nutrition in First Weeks of Life. Necessary Elements of an
    Adequate Dietary. “Vitamines.” Danger of Deficiency Diseases. Danger
    of Conditions Approaching Recognizable Disease. The Deficiency
    Diseases. Scurvy. Infantile Scurvy. Corrective Diet. Beriberi.
    Xerophthalmia. Pellagra. Rickets. Corrective Diet. Application of
    Principles of Nutrition to the Diet of the Nursing Mother.

  CHAPTER XVIII. COMPLICATIONS OF THE PUERPERIUM. Postpartum Hemorrhage.
    Causes, Treatment and Nursing Care. Puerperal Infection. History of
    Disease. Prevention. Symptoms, Treatment and Nursing Care.
    Phlegmasia alba dolens, or “Milk leg.” Puerperal Mania.



                              CHAPTER XIV
                    THE PHYSIOLOGY OF THE PUERPERIUM


The puerperium[8] is ordinarily regarded as comprising the five or six
weeks immediately following delivery. During this period the mother’s
body undergoes various changes which restore it very nearly to its
pre-pregnant state, leaving the patient in a normal, healthy condition.
The most important of these changes are involution of the uterus, loss
of weight and improvement in tone of the abdominal and perineal muscles.
The alterations which produce this restoration are normal physiological
processes, but mismanagement or lack of care while they are taking place
may result in serious complications; these may be immediate or remote,
such as hemorrhage and infection or chronic invalidism.

Recognition of these dangers, and the possibility of preventing them, is
responsible for the present custom of obstetricians to watch over their
patients during the puerperium. This is in sharp contrast to the old
practice of the doctor’s visiting the puerperal woman only when there
was a complication so apparent that he was summoned.

The precautions and the care which the doctor takes of his patient after
delivery involve intelligent and watchful nursing. In order to give this
the nurse must understand something of the normal physiology of the
puerperium, just as she did in pregnancy and labor. Otherwise she may
not be able to distinguish evidences of normal changes from symptoms of
complications.

=Involution.= Considerable attention is centred in the remarkable
atrophic changes that take place in the uterus during the puerperium,
for it is upon their being normal that the patient’s recovery and future
well-being so largely depend. Immediately after delivery the uterus
weighs about two pounds; is from seven to eight inches high; about five
inches across and four inches thick. The top of the fundus may be felt
above the umbilicus, and the inner surface, where the placenta was
attached, is raw and bleeding. At the end of six or eight weeks the
uterus has descended into the pelvic cavity and resumed approximately
its original position and size, and its former weight of two ounces; a
new lining has developed from the few glands which have not been cast
off in the discharges.

This rapid diminution in the size of the uterus is termed involution and
is accomplished by means of a process of self-digestion or _autolysis_.
The protein material in the uterine walls is broken down into simpler
components which are absorbed and eventually cast off largely through
the urine. This change and absorption of uterine tissues is similar to
the resolution that takes place in a consolidated lung in pneumonia.

Since satisfactory involution is necessary to the patient’s future
health, its progress should be watched with deep concern and interest,
and all possible effort made to promote it; firm consistency of the
uterus and a steady descent into the pelvis and normal lochia being the
chief evidences of satisfactory involution. There is evidently a close
relation between the functions of the breasts and of the uterus during
the puerperium, and as a rule involution accordingly progresses more
normally in women who nurse their babies than in those who do not.

The so-called “after-pains” are also affected by nursing, being more
severe as a rule when the baby is at the breast than at other times.
These pains are caused by the alternate contractions and relaxations of
the uterine muscles and are more common in multiparæ, than in primiparæ,
because the muscles of the former have somewhat less tone than the
latter and therefore tend to relax, and then contract, whereas the
better muscle tone of the primipara tends to keep the uterus steadily
contracted.

These after pains usually subside after the first twenty-four hours,
though they may persist for three or four days. They may amount to
little more than discomfort, but not infrequently are so severe as to
require the administration of sedatives. Persistent after pains may be
due to retained clots.

The cervix, vagina and perineum which have become stretched and swollen
during labor, gradually regain their tone during the puerperium, and the
stretched uterine ligaments become shorter as they recover their tone,
finally regaining their former state. Until the ligaments and the pelvic
floor and abdominal wall are restored to normal tonicity the uterus is
not adequately supported and therefore may be easily displaced.

=The lochia= consists of the uterine and vaginal secretions and the
blood and uterine lining which are cast off during the puerperium.
During the first three or four days this discharge is bright red,
consisting almost entirely of blood, and is termed the _lochia rubra_.
As the color gradually fades and becomes brownish it is called the
_lochia serosa_. After about the tenth day, if involution is normal, the
discharge is whitish or yellowish and is designated as the _lochia
alba_. The total amount of the lochial discharge has been variously
estimated at from one to three pints, being more profuse in multiparæ
than primiparæ, and in women who do not nurse their babies. Under normal
conditions the discharge is profuse at first, gradually diminishing
until it entirely disappears by the end of the puerperium. There may be
small amounts of blood retained during the first day or two and expelled
later as clots, without any serious significance, and there may be a
pinkish discharge after the patient gets up for the first time, but if
the lochia is persistently blood-tinged it may be taken as an indication
that the uterus is not involuting as it should.

The normal characteristic odor is flat and stale. A foul odor, no odor
at all or a marked decrease in the amount of the discharge is suggestive
of infection.

=Loss of Weight.= One of the striking changes during the puerperium is
the loss in weight, due largely to three factors: the elimination of
fluids from the edematous tissues; the decrease in the size of the
uterus and the escape of vaginal and uterine secretions, termed the
lochia. The smaller amount of food taken during the first few days
post-partum also may be a factor.

This loss in weight is extremely variable, fat women naturally losing
more than thin women and those who nurse their babies losing more than
those who do not.

Dr. Edgar estimates that the loss through the lochia amounts to
something over three pounds, and the loss through fluids from the
tissues, from nine to ten pounds. According to Dr. Slemons, the loss in
fluids equals about 1/10th of the patient’s weight at the beginning of
the puerperium, while all agree that the uterus decreases about two
pounds in weight. All told, then, the patient may normally lose from
twelve to fifteen pounds during the puerperium. This loss may be
somewhat controlled, however, by a suitable diet, and under most
conditions the patient should return to not less than her pre-pregnant
weight by the end of the sixth or eighth week.

=Menstruation.= Although in the ideal course of events, the mother does
not menstruate while nursing her baby, that is, for eight to ten months,
Dr. Slemons estimates that about one-third of all nursing mothers begin
to menstruate about two months after delivery, while according to Dr.
Edgar one-half of those who do not nurse their babies begin to
menstruate in six weeks after delivery.

Menstruation is more likely to return early in primiparæ than in
multiparæ. Patients sometimes wonder whether this early discharge is
menstrual or lochial, and though they can not tell, a physician can
easily decide by examination, and it is important that he be given the
opportunity to do so. A nursing mother may menstruate once and then not
again for several months or a year; or she may menstruate regularly and
nurse her baby satisfactorily at the same time, though menstruation is
usually regarded as unfavorable to lactation.

=Lactation.= During the first two or three days after the baby is born,
the breasts secrete a small amount of yellowish fluid called colostrum,
which differs from milk chiefly in that it contains less fat and more
salts and serum-albumen than milk and in the fact that it coagulates
upon boiling. About the third day after delivery, the meagre amount of
colostrum is replaced by milk and as it increases rapidly in amount, the
breasts usually become tense and swollen at this juncture, and sometimes
very painful; but this turgidity usually subsides after a day or two.

The function of the breasts, that of secreting milk, is definitely
stimulated by the baby’s suckling and will not continue for more than a
few days without this stimulation, a fact to be remembered if it is
desirable for any reason to dry up the breasts.

The ideal condition is for the breasts to secrete a quantity and quality
of milk which will adequately nourish the baby for eight or ten months.
The reverse of this condition is sometimes found in very young or in
elderly women, or in very fat or frail, undernourished women.

Ovulation is usually suspended during lactation, but a mother may become
pregnant a few weeks after delivery even while nursing her baby, though
the quality of her milk is likely to be unfavorably affected by the
pregnancy. But, as has been explained, the return of menstruation does
not necessarily exert as unfavorable an influence upon lactation as was
formerly believed.

=Abdominal Wall.= The abdominal wall is usually overstretched during
pregnancy, and immediately after labor when the tension is removed, the
skin lies in folds and the entire wall is soft and flabby. The normal
and desirable course is for the muscles gradually to regain their tone;
for the excess of fat to be absorbed and the walls to approach their
original state in the course of a few weeks. The striæ usually remain,
and the muscles sometimes fail to regain their tone, as for example when
pregnancies follow each other in rapid succession or when there has been
excessive distension. In such cases there is likely to be the pendulous
abdomen so often seen in multiparæ, and a diastasis, or separation of
the rectus muscles.

=Digestive Tract.= During the first day or two after delivery the mother
may have very little appetite but she is usually very thirsty. She will
almost inevitably be constipated, because of the loss of intra-abdominal
pressure; the sluggishness of the intestines acquired during pregnancy;
her recumbent position, lack of exercise and the fact that she is taking
relatively less food than usual and that her bowels were freely
evacuated at the onset of labor.

=Temperature.= The temperature often rises to about 99° F. immediately
after labor but it should drop to normal in a few hours and practically
remain so. For various causes, some of which are unexplained, the
temperature will not infrequently be slightly above normal at times
during the first few days of the puerperium, without the patient’s
seeming to suffer any ill effects. But the fairly general agreement
among obstetricians seems to be that a temperature of 100.4° F. is the
upper limit of normality and that infection is to be suspected if it
reaches that point and remains there for twenty-four hours.

=Pulse.= The normal pulse rate is usually slower during the puerperium,
being about 60 or 70 beats to the minute, and is referred to as
puerperal _bradycardia_. It is thought that this is due to the absolute
rest in bed and the decreased strain upon the heart after the birth of
the baby.

=Skin.= There is usually profuse perspiration during the first few days,
while the elimination of fluids is most active, but it gradually
subsides and becomes normal by the end of a week. The perspiration
sometimes has a strong odor and there is not infrequently an appreciable
amount of desquamation.

=Urine.= Many patients find it difficult, even impossible, to void urine
during the first several hours after delivery because of the removal of
intra-abdominal pressure; the recumbent position and the swelling and
bruised state of the tissues about the urethra. The bladder is likely to
be less sensitive than usual and the patient will be able to retain an
abnormally large amount of urine for several hours without discomfort,
or desire to void.

The output of urine during the first few days is greater than normal,
and there is also a considerable increase in the amount of nitrogen
excreted, beginning two or three days after delivery. This is evidently
derived from the broken down proteins in the uterine wall, and the
excess gradually subsides as involution progresses, and disappears by
the time the uterus descends into the pelvis.

When one considers the severe ordeal that the young mother has just
passed through, her recovery and return to a normal state are
surprisingly rapid, when she is given good care.



                               CHAPTER XV
               NURSING CARE DURING THE NORMAL PUERPERIUM


In general, the nursing care during the puerperium is much the same as
that which is given to a surgical patient, with special attention to the
breasts and perineum and a sustained effort to prevent complications and
restore the mother to a normal state of health in due time.

As the nurse doubtless realizes by this time, the principal
complications to guard against during the puerperium are hemorrhage from
the still raw area, where the placenta was attached to the inner surface
of the uterus; infection of the birth canal; breast abscesses;
displacement of the uterus and subinvolution, or failure of the uterus
to return to its normal size and condition in the usual length of time.

In addition to guarding against these definite complications, the nurse
must help to save her patient from the less tangible, but perhaps
equally injurious effects of fatigue of mind and body. As many young
mothers are in a more or less unstable, excitable condition after the
baby’s birth, the beneficial effect of promoting a tranquil and
contented state of mind can scarcely be overestimated.

The doctor may be ever so tactful and cheering and sustaining, but his
contacts with the patient are short and infrequent as compared with the
nurse’s constant companionship. She can, therefore, by her attitude,
manner and conduct practically create or destroy the atmosphere that is
necessary to her patient’s welfare.

In order to give the best and most helpful service the nurse must try
from the very beginning to understand her patient as an individual and
adapt herself to the patient’s temperament. Some women are rested and
soothed by being talked with, read to, diverted and amused in one way or
another, during most of the time, and will grow nervous and depressed if
left to their own devices. Others, who have greater resources within
themselves are happier and better off when left to themselves a good
deal, and given an opportunity to think things over. Some women are much
subdued as the consciousness of their motherhood grows upon them, and
they feel a kind of awe and wonder about this baby that they begin to
realize is their own. It is a big experience, this one of motherhood,
full of promise and responsibilities, and the young mother herself very
often wants to think it out. She will enjoy talking when she wants to
talk, but may be irritated and exhausted by a nurse who tries to
entertain her all of the time.

For this reason, the most conscientious and painstaking nurse imaginable
may destroy her usefulness, by adopting the wrong attitude toward her
patient during this period of enforced intimacy. Some women want, and
even need to be indulged and petted; but, on the other hand, a certain
type of reserved and dignified woman is affronted by such attention or
by the easy air of familiarity that another courts; one patient is
exhausted by the unvarying punctuality and precision of a conscientious,
but unadaptable nurse, while that very punctuality and precision is
satisfying and restful to another.

It is not a simple matter to sound the depths of a patient’s
personality, for they are all complex and each one is peculiar to
herself. That fact must not be overlooked for each patient is an
entirely new and different problem and not like any other that the nurse
has had before. But the nurse who is sincere and sympathetic and who
earnestly tries to put herself in her patient’s place and see things
from her standpoint, will, by virtue of that very attitude, accomplish
much toward sensing the patient’s temperament and establishing
harmonious relations. Moreover, the patient, herself, will all
unconsciously make something of an adjustment to the nurse when she
feels the nurse’s sincerity and her eagerness to be of service.

One factor in shaping the young mother’s state of mind, which the nurse
must take into account is that the entire scheme and purpose of her
patient’s life have been changed. She has been plunged very suddenly
into a wholly new condition and her reaction to this change will depend
upon her temperament, disposition and habits of adjustment.

She has spent nine months looking forward to an event that has been
consummated; she has spent nine months in a state of more or less
apprehension and suspense that have been abruptly ended, and we know
that it is quite natural for any one to experience a letting down, or
something akin to collapse, when long-continued uncertainty is ended,
even though it ends happily.

And as recovery progresses the patient becomes aware, perhaps only
vaguely, of another change which is not always a welcome one. For nine
months she has been the centre of interest in her immediate circle; she
has been the object of unremitting concern and solicitude, and much as
she and her family may have tried to keep her life normal, she and her
needs have constantly been given the first consideration. The very
mystery of the child developing within her has created an attitude of
respect, almost of reverence, which was never her portion before. In
every way she has been shielded, protected and cared for, and all eyes,
including her own, have steadily looked forward to the event for which
this care has been preparing her—her ordeal of childbirth and the coming
of her baby.

And now her ordeal is over. Her baby is here. Every one may be said to
be breathing easily at last and they are no longer apprehensive and
absorbingly interested in her. As a result the young mother will soon
become simply one of the family and the community, and will cease to be
the centre of reverential interest and solicitude.

It is scarcely human to welcome such a change in one’s state, and though
in all probability very few mothers are conscious of resenting it, very
many actually do. And for this reason very many unwittingly cling to a
rôle of semi-invalidism. It is entirely unconscious on their part and it
is also very human and natural.

To aid in the process of bracing up such a young woman to resume her
former life and to meet the demands which it imposes; or to protect
another patient of the eager, buoyant type from exposing herself too
early to the onslaughts made by everyday life, is far from being a
simple task, and to meet it no one rule can be laid down. There are all
of the variations and degrees between the timid or self-indulgent woman,
who must be encouraged and spurred on, and the too active, ambitious
patient, who must be steadied and held back for a time.

But here, again, this is simply a part of the nurse’s duty; one aspect
which makes nursing the gratifying service that it is.

Fortunately the majority of young mothers are happy and normal in their
outlook and may be kept so by the exercise of an average amount of tact
and amiability on the part of the nurse. The actual physical care of the
patient during the puerperium is a fairly simple matter for the well
trained nurse. She will find, however, that in hospitals, private
practice and public-health work alike there will be wide differences in
the treatment given by different doctors, during this period, just as
there were during pregnancy and labor, and she will have to carry out
the prescribed directions enthusiastically and loyally no matter how
they vary from those of the doctors who helped in her training.

The details of the care will be indicated by the individual doctor, but
the general, underlying principles—cleanliness, watchfulness,
adaptability and sympathetic understanding will apply to the nursing of
all patients. The most notable differences of opinion relate to the care
of the breasts, the perineum and the use of abdominal binders, the
accepted routine for the general nursing of average, normal cases being
fairly uniform the country over.


                              NURSING CARE

As has been stated, the general nursing care of the puerperal patient is
much the same as that given to any surgical patient, with such
adaptations as are indicated by the condition and needs of the young
mother.

=Position in Bed.= The question of the patient’s position in bed is
probably the first one that presents itself to the nurse after that
first hour when the patient must be kept flat on her back and the fundus
closely watched. She should continue to lie quietly on her back for a
few hours, with only a small pillow under her head, as moving about may
cause hemorrhage. Some doctors permit the patient to turn from side to
side at will after a few hours of quiet, while others do not allow this
for two or three days particularly if the patient has perineal stitches,
unless her knees are tightly bound together. Their reason for this
precaution is fear that the stitches may be torn out if the thighs are
separated and also that air may gain access to the uterine vessels,
through the relaxed and gaping birth canal, and produce air embolism. It
is a routine in some hospitals to keep the head of the patient’s bed
elevated during the first week, to promote drainage, but as a rule it is
in the usual position.

[Illustration:

  FIG. 116.—Height of fundus on each of the first ten days after
    delivery.
]

Quite commonly the patient is encouraged to lie first on one side and
then on the other, after she begins to move about in bed unassisted, and
then face downward at intervals, in order to change the position of the
uterus and thus tend to prevent backward displacement.

In many hospitals, it is part of the daily routine to measure and record
the height of the fundus (Fig. 116) above the symphysis, in addition to
noting the character, amount and odor of the lochia, in order to judge
if involution is progressing normally. A uterus that does not remain
firm and does not steadily shrink in size and descend into the pelvis is
not involuting properly, and the usual remedy is more rest and a longer
stay in bed, with an icecap over the fundus.

=Sitting Up.= Except when there are perineal stitches or the temperature
has been elevated at some time following delivery, the patient is
ordinarily allowed to sit up in bed about the sixth or eighth day. If
the lochia is normal, the uterus firm and in the proper position in the
abdomen and her general condition satisfactory, she is allowed to sit up
in a chair for a little while about the ninth or tenth day. Some
patients are able to sit up for an hour the first time without being
tired, but it is often better for them to sit up for a few moments
morning and afternoon on the first day, than for a longer time at one
stretch. The patient is usually allowed to sit up an hour longer on each
successive day and to walk a few steps on the third or fourth day after
getting up.

A patient with stitches does not usually sit up in bed until the ninth
or tenth day, when the stitches are removed, sitting up in a chair for
an hour, two or three days later. If she has had fever, the time at
which she may sit up will of necessity depend upon her condition.

The return to normal life must be very gradual and this also must be
regulated by the patient’s general condition and her recuperative
powers. A pinkish or red discharge or backache should be taken as
warnings against standing or walking or working. The possible
consequences of ignoring these warnings and being up and about too soon,
may be displacement, even prolapse of the uterus; hemorrhage, from
dislodgment of clots in the uterine vessels; metritis or endometritis.

It is not a good plan, as a rule, for the patient to go up and down
stairs until the baby is about four weeks old, nor wholly to resume her
normal activities within six or eight weeks after delivery.

In addition to this sustained, general care, it is a customary
preventive measure for the doctor to make a thorough pelvic examination
from four to six weeks after delivery. A slight abnormality, if detected
at this time may usually be corrected with little difficulty, but if
allowed to persist may result in chronic invalidism or necessitate an
operation. If the uterus is not properly involuted, for example, or the
perineum is found to be flabby, more rest in bed is indicated; while a
uterine displacement, which seems to be present in about a third of all
cases, usually may be corrected by the adjustment of a pessary.

The time of sitting up, of getting up and of walking about varies so
with the individual, therefore, that it is not possible to describe a
definite routine, for some patients recover slowly and would be injured
by getting up and about at a period which would be entirely safe and
normal for the majority. It must be determined in each case by the
condition of the uterus, the appearance and amount of the lochia and the
patient’s general condition.

Quite evidently, then, much ill health and many gynecological operations
may be prevented by caution, prudence and good care during the first few
days and weeks after the baby’s birth, while the patient returns to a
normal mode of living.

=The Daily Bath.= During the first week or two the patient’s skin must
aid in excreting fluids from the edematous tissues throughout the body
and broken down products from the involuting uterus. Therefore she
should have a bath of warm water and soap every day, to remove material
already on the surface and stimulate the skin to further activity, and
an alcohol rub at night, if possible. It is important for the nurse to
remember, while bathing her patient, that she is perspiring freely and
therefore may be easily chilled if not well protected.

It is often a good plan to have the patient, without stitches, begin to
bathe herself in bed, after the third or fourth day, for the sake of the
exercise, and also the encouragement that it offers. When all is going
well, tub-bathing is usually resumed by the third or fourth week.

=Diet.= Opinions as to diet vary slightly with different doctors and in
different hospitals, but in general, a patient in good condition is
given liquid food during the first twelve to twenty-four hours after
delivery; then a soft diet for a day or two, a nourishing, light diet
being resumed by the third or fourth day, or after the bowels have moved
freely.

The patient will usually have little appetite, at first, and will have
to be tempted by small amounts of invitingly served food. The factors
which the nurse must bear in mind when arranging the patient’s dietary
are the general nutrition of the mother; the desirability of minimizing
her loss of weight during the puerperium; increasing her strength and,
particularly, of promoting the function of her breasts, in order to
produce milk of a quality and quantity adequate to nourish the baby.

The best producer of such milk is a diet consisting largely of milk,
eggs, leafy vegetables and fresh fruits, taken with an appetite that is
made keen by constant fresh air. The nurse will do well to convince her
patient of this, in addition to bearing it in mind herself, and to place
little reliance on so-called milk producing foods.

The young mother’s dietary may well be made up from the groups of foods
that are suitable for the expectant mother. (See Chapter VI). At this
time, as during pregnancy, she must avoid all food which may produce any
form of indigestion, but for the baby’s sake, now, as well as her own.
While it is not generally believed, to-day, that there are many, if any
articles of diet which in themselves affect the mother’s milk
unfavorably, it is generally conceded that a derangement of her
digestion may, and usually does, have a deleterious effect upon her
milk, and therefore upon the baby.

The old, and widespread, belief that certain substances from such highly
flavored vegetables as onions, cabbage, turnips and garlic are excreted
through the milk, to the baby’s detriment, is not given general credence
to-day. On the other hand, it is known, however, that certain protective
substances in certain foods are excreted through the milk, to the baby’s
distinct advantage, and it is therefore, important that the mother’s
diet should regularly contain those articles of food which contain them.
These foods are milk; egg yolk; glandular organs, such as sweet-breads,
kidneys and liver; the green salads, such as lettuce, romaine, endive
and cress and the citrus fruits, or oranges, grapefruit and lemons.

These are called “protective foods” because they protect the body
against the so-called deficiency diseases known as scurvy, beri-beri,
xerophthalmia, which with rickets and pellagra are discussed in the
chapter on Nutrition. It is possible for a baby who nurses at the breast
of a woman whose diet is poor in protective foods, to be so
insufficiently nourished, in some particular, as to be on the border
line of one of these diseases, or even to develop the disease itself.
This is one reason for the statement that the nursing mother must “eat
for two.”

Certain drugs are excreted through the milk and may affect the baby in
the same way as though they were administered directly, for example:
salicylic acid, potassium iodid, lead, mercury, iron, arsenic, atropine,
chloral, alcohol and opium.[9]

In addition to her food the nursing mother should have an abundance of
water to drink, and to facilitate this it is a good plan to keep a
pitcher or thermos bottle of water on the bedside table, and replenish
it regularly, every four hours.

In general, the young mother should have light, nourishing, easily
digestible food, with little, if any meat; an abundance of cereals,
creamed dishes, creamed soups, eggs, salads and the fresh fruits and
vegetables which ordinarily agree with her; at least a quart of milk,
daily, in addition to that which is used in preparing her meals, and an
abundance of water to drink.

=The Bowels.= The puerperal patient is almost always constipated, and
needs assistance in regaining regularity in the movements of her bowels.

The routine use of cathartics and enemata varies, but it is very common
to give an enema on the second morning after delivery or castor oil or
Rochelle salts, followed by an enema if necessary. After this, a mild
cathartic or a low enema is given often enough to produce a daily
movement when this is not accomplished by means of the diet.

Some doctors, however, prefer that the bowels shall not move for four or
five days after delivery, believing that this delay reduces the danger
of infection from the intestinal contents, which are swarming with
organisms, particularly the colon bacillus.

In cases of third degree tears, catharsis is practically always delayed
for four to six days in order that the torn edges of the rectal
sphincter may become well united before being strained by a bowel
movement. In these cases an enema of six or eight ounces of warm olive
oil is often given and the patient encouraged to retain it over night,
in order to soften the contents of the rectum and lessen the strain and
irritation of evacuation.

=The Bladder.= The question of helping the patient to void after
delivery is one of extreme importance, because she will almost certainly
have difficulty in emptying her bladder, and yet catheterization is not
to be resorted to unless absolutely necessary. As a rule the patient
should be encouraged to try to void from four to eight hours after
delivery. If she is unable to do so at first there are several aids
which the nurse should employ before admitting the patient’s inability
to empty her bladder. Inducing her to drink copious amounts of hot
fluids is the first step. Very often she will then void if placed upon a
bedpan containing water hot enough to give off steam, and more warm,
sterile water is poured directly upon the urethral outlet; or hot and
cold sterile water may be dashed, alternately, upon the meatus.

The sound of running water is often helpful as well as the application
of hot stupes over the supra-pubic region. When everything else fails,
success frequently follows the application of a partly filled hot-water
bottle over the bladder, held in place by a tight binder, particularly
if the patient rests upon a pan of steaming water at the same time.

The danger of infecting the bladder, by carrying lochia into it upon the
catheter, is so great that some doctors choose what they regard as the
lesser of two evils, and allow the patient to be assisted to the sitting
position, if she has not a serious tear. Not infrequently the patient’s
inability to void is due to the fact that she is unaccustomed to using a
bedpan, and would have difficulty in using one under any conditions, but
is able to void while sitting up. As the danger of infection is greater
two or three days after delivery than at first, because of the beginning
decomposition of the lochia, it is very evidently important to help the
patient to establish the habit of voiding from the beginning, for if she
is catheterized once there is great likelihood that she will need to
have it continued for some days.

If the first attempts are unsuccessful, therefore, but the patient
thinks that she may be able to void later, if the efforts are repeated,
catheterization is sometimes delayed for as long as sixteen to eighteen
hours after delivery in the hope that it may be avoided altogether.

When the most persistent and painstaking efforts fail, and
catheterization is necessary, the nurse must remember the extreme
gravity of her responsibility and preserve asepsis throughout the
procedure. Although there is extreme danger of infection, it can be
prevented as a rule, and its occurrence is therefore regarded as almost
inexcusable.

In preparing for catheterization, the nurse should drape the patient as
for a vaginal examination, making sure that she is warmly covered, and
place her on a sterile douche- or bedpan. If it is done at night she
should place the light in a position at once safe and advantageous. She
should have at hand on a tray: sterile forceps; cotton pledgets; two
glass catheters (in case one should be broken or become contaminated); a
disinfecting solution such as bichlorid, 1–4,000 or lysol 1 per cent.; a
sterile receptacle in which to receive the urine; sterile towels and a
dressing basin or paper bag for the used pledgets.

The preparation of the nurse’s hands, at this point, varies in different
hospitals, but always the greatest care is taken to bring nothing
unsterile in contact with the vulva and meatus.

According to one method, the nurse scrubs her hands for three minutes
and prepares the patient as for a vaginal examination, removes the
douche pan and places a sterile towel over the vulva. She then scrubs
and soaks her hands as described in Chapter XII, puts on sterile gloves,
places a sterile towel over the patient’s abdomen and slips one under
her hips. She should then separate the labia with the gloved fingers of
the left hand, drawing the fingers upward a little to make the meatus
more prominent. The inner surface of the labia is then bathed with
pledgets soaked with the disinfecting solution, with downward strokes,
each pledget being used but once. Five or six pledgets should be used,
one after the other, to sponge the meatus, each pledget being placed
squarely against the orifice, without touching the adjacent tissues, and
given a slight, downward twisting motion and discarded. The bowl may
then be placed in position to receive the urine, and the catheter picked
up with the fingers, by its open end. The rounded end must be carefully
inspected to insure against using one that is cracked or broken, after
which it is slowly and gently introduced into the urethra for two or
three inches. If the urine does not flow freely the catheter may be
slightly withdrawn and light pressure made upon the bladder.

Before removing the catheter the nurse must locate the fundus and assure
herself that it is in a proper position. If it is pushed up or to one
side she will know that the bladder is still distended, and that more
urine must be withdrawn. After the bladder has been emptied the nurse
should place one finger over the open end of the catheter and remove it
slowly.

Another method of catheterization differs from the one just described,
in the preparation of the nurse’s hands. In this instance she simply
washes her hands well with soap and hot water and wears neither gloves
nor finger cots.

She bathes the vulva with pledgets and an antiseptic solution, using
forceps, and then separates the labia with two dry pledgets, one each
under forefinger and thumb of the left hand, and proceeds as above. It
will be observed that the nurse avoids touching the inner surface of the
labia or the meatus with anything but sterile pledgets and the sterile
catheter. The advantage of this procedure is that it is accomplished
quickly and with the minimum of disturbance to the patient.

A distended bladder may so easily occur unless the patient is carefully
observed during the puerperium that the nurse should charge herself to
watch for this complication. She should give the patient a bedpan every
four hours, note the contour of the abdomen and measure the urine during
the first week, remembering that the patient should void considerably
more than the average amount, both because of the amount of milk and
water that she is taking, and the fluid which she is eliminating from
her tissues. The importance of measuring the urine lies in the fact that
though the patient may void fairly regularly she may not empty her
bladder, and thus enough urine may accumulate to distend it.

=The temperature, pulse and respirations= are usually taken and recorded
every four hours for the first five or six days and then two or three
times daily, if normal. If the temperature is above normal at any time,
the nurse should take it every two hours until it becomes normal and
notify the doctor immediately if it goes as high as 100.4° F., or if the
pulse reaches 100.

=Care of the Perineum.= The best way of caring for the perineum, during
the first week or ten days after delivery, is a moot question, and the
nurse may find herself sorely perplexed by the widely divergent
instructions of different doctors who have excellent results, unless she
goes back of the details themselves and recognizes their purpose. She
will then see that there is entire agreement about the importance of
protecting the patient against infection, at this time, when infection
may so easily occur. And so far as the nurse is concerned, this means
cleanliness as to methods and appliances, when making perineal
dressings, and extreme precaution against conveying infection to her
patient. The minimum requisites for this are that the bedpan shall be
sterilized, by steam or boiling, at least once a day, and well scrubbed
and scalded after each time that it is used, and that the nurse shall at
least scrub her hands with soap and hot water before making each
perineal dressing, and apply only sterile pads.

After the perineum is bathed, immediately following delivery, the usual
practice is to apply a sterile pad, after which a fresh one is applied
as often as necessary at first, every four hours during the first week
and subsequently every eight hours. When the dressing is changed, and
after each voiding and defecation, the perineum is bathed with sterile
pledgets and some such antiseptic solution as bichlorid 1–2,000 or lysol
½ per cent. or 1 per cent. (Figs. 117 and 118.) The soiled pad must
always be removed from above downward and the bathing also directed
toward the rectum, each pledget being used for one stroke only. The
rectum is bathed last, a fresh sterile pad applied and the patient’s
hips and back thoroughly dried.

The nurse may be required to scrub and soak her hands, wear sterile
gloves and hold the pledgets in forceps when bathing the perineum, the
object of such precautions being, quite clearly, to avoid infecting the
patient from without, for the inner surface of the uterus is still
regarded as an open wound.

[Illustration:

  FIG. 117.—Preparation and draping of patient for post-partum dressing.
    Note rack of equipment on table; bag of dry, sterile pledgets at
    head of bed; paper bag on floor for used pledgets. The nurse has
    scrubbed her hands. (From photograph taken at The Manhattan
    Maternity Hospital.)
]

Some obstetricians believe that the perineal pad is a menace, since it
slips and moves about, and thus may transfer infective material from the
anus to the vagina. Accordingly, they forbid the use of all perineal
dressings and instead have large, sterile, absorbent pads slipped under
the patient’s hips to receive the lochia, the pads being changed as
often as necessary. This is the practice at the Brooklyn Hospital, for
example, where the nurse bathes the vulva with lysol 1 per cent.,
placing the patient on a sterile bedpan, using sterile forceps and
cotton swabs and wearing sterile gloves while making the dressing.

Another method is to place the patient on a sterile bedpan, remove the
pad and with gloved hands pour from a sterile pitcher a warm antiseptic
solution over the groin and outside of the vulva; then to separate the
labia and pour the solution between them, in some instances pressing a
dry, sterile pledgets to the vaginal orifice during the irrigation.

[Illustration:

  FIG. 118.—Equipment, in rack, used at The Manhattan Maternity Hospital
    in bathing perineum. A, pitcher of lysol, 1%. B, basin of pledgets
    in lysol. C, sponge-sticks in alcohol.
]

When the urine is being measured, as it frequently is during the first
week, the solution which is used for irrigating the vulva should be
measured beforehand and the contents of the bedpan measured after the
dressing, in order that the amount of urine passed, if any, may be
ascertained.

Another method of bathing the perineum, that employed at Johns Hopkins
Hospital, is simply to bathe the perineum with soap and warm water,
without separating the labia, using a clean wash cloth and afterwards
applying a sterile pad, the pads being changed every four hours, or
oftener if necessary. The theory upon which this procedure is based is
that the steady outward flow of the lochia constantly carries material,
infective and otherwise, away from the generative tract, and that if
nothing is introduced between the labia or into the vagina the patient
will not be infected.

In caring for the perineum, the nurse must remember also the real danger
of the patient infecting herself with her own fingers and should caution
her against taking this risk. The patient should be told that if she
feels uncomfortable, or thinks she is bleeding, she must lie quietly and
summon a nurse, but on no account to try to find out for herself what is
wrong. There is little doubt that cases of severe infection have been
caused by the introduction of organisms into the vagina by means of the
patient’s own fingers, after the most scrupulous precautions had been
taken by doctors and nurses to avoid that very disaster.

In most instances the care of the perineum is the same whether or not
there are stitches, and in any case the method employed will be
specified by the doctor. The nurse’s responsibility is to appreciate the
object of the care, whatever form it may take, and bring intelligence to
bear in giving it.

When there are perineal stitches, it is a wise and harmless precaution
to fasten a towel or bandage about the patient’s knees for a few days,
to prevent her pulling apart the uniting edges of the tear as she moves
about in bed.

=Douches.= In connection with perineal dressings, it may be well to
caution the nurse against giving douches without explicit orders.
Douches are seldom given early in the puerperium, for fear of carrying
infective material up into the uterus, except occasionally in cases of
hemorrhage, in which case they are given by the doctor.

Sometimes, however, a low vaginal douche is given daily for some time
after the patient gets up, with the idea of increasing her comfort and
promoting involution. About two quarts of some weak antiseptic solution
at 110° F. is given with the nozzle introduced just within the vaginal
outlet, and the container of the solution placed only slightly above the
level of the patient’s hips, in order that the stream may be very
gentle.

[Illustration:

  FIG. 119.—Sterile gauze held in place over nipples by means of
    adhesive strips and tapes. (From photograph taken at Bellevue
    Hospital.)
]

=The Care of the Breasts.= There is a wide difference of opinion about
the proper care of the breasts, also, but here again, although the
details vary, the ultimate objects of the care are always the same,
namely: to facilitate the baby’s nursing, promote the mother’s comfort
and prevent breast abscesses. These ends are usually accomplished by
keeping the nipples clean and intact and by giving support and rest to
heavy, painful breasts.

The patient who has cared for her nipples during the latter part of
pregnancy will usually have little or no trouble with them during the
period of lactation, if the care is continued. But this attention is
imperative.

It is very generally customary to have the nipples bathed before and
after each nursing with a saturated solution of boracic acid, in either
water or alcohol, using sterile pledgets and forceps, and to keep them
clean between nursings by applying sterile gauze. This gauze may be held
in place by means of a breast binder or by tapes tied through the ends
of narrow strips of adhesive plaster, four being applied to each breast.
(Fig. 119.) Strips of adhesive plaster about five inches long are folded
over at one end, two adhesive surfaces being in contact for about an
inch. Through a hole in the folded end a narrow tape or bobbin is tied
and the strips applied to the breast, beginning at the margin of the
areola and extending outward. The free ends of the tapes are tied over
squares of sterile gauze, between nursings, and untied to expose the
nipple at nursing time.

Lead shields are sometimes used to protect the healthy nipple and not
infrequently are applied to cracked nipples, being held in place by
means of a breast binder. The secretion of milk which escapes into the
shield is acted upon by the metal and the result is a lead wash which
continuously bathes the nipple. The shields should be scrubbed with
sapolio and boiled once daily.

Another method, and one widely employed, is to anoint the nipple after
nursing with sterile albolene or a paste of sterile bismuth and castor
oil, and apply squares of sterile paraffin paper. These bits of paper
are pressed into place and held for a moment by the nurse’s hand, the
warmth of which softens and moulds them to the breast after which they
remain in place. In some instances the bismuth and castor oil paste is
wiped off, with a sterile pledget, before nursing and in others it is
not.

In some hospitals, neither gauze nor paper is used, the nipples being
protected by putting sterile night-gowns on the patients.

The purpose of all of these methods is to keep the nipples clean, and
here again the patient must be cautioned against infecting herself. No
amount of care on the nurse’s part will protect the patient if she
touches her nipples with her fingers.

The nurse will appreciate the reason for all of this painstaking care if
she calls to mind the fact that the breast tissues are highly vascular
and excessively active at this time and therefore very susceptible to
infection, and also that the baby’s suckling is often very vigorous and
accompanied by a good deal of chewing and gnawing of the nipples. Unless
the nipples have been toughened, and sometimes even when they have, the
skin becomes abraded or cracked as a result of the baby’s suckling, thus
creating a portal of entry for infecting organisms, in addition to the
milk ducts which lead back into the breast tissues. Unless the nipples
are kept clean, constantly, they may become infected by organisms from
the baby’s mouth or on the patient’s hands, bedding or gown with a
breast abscess as a result. The important thing, then, is to keep the
nipples clean and not allow anything unsterile, excepting the baby’s
mouth, to come in contact with them at any time.

[Illustration:

  FIG. 120.—Protecting cracked nipples by having the baby nurse through
    a shield. (From photograph taken at Johns Hopkins Hospital.)
]

It is sometimes the practice to swab the baby’s mouth with boric soaked
cotton or gauze before each nursing, but many doctors hold that this is
injurious to the delicate mucous lining of the baby’s mouth. The
opinions for and against this routine seem to be about equally
prevalent.

[Illustration:

  FIG. 121.—Nipple shield used in Fig. 120.
]

If the nipples become painful or cracked, one can easily understand that
continued suckling would only aggravate the condition and increase the
danger of infection. But the baby must nurse, if possible, and so in the
majority of cases a nipple shield is used (Figs. 120–121) as a
protection, and after nursing the fissures or abraded areas are painted
with bismuth and castor oil paste; compound tincture of benzoin; balsam
of Peru; argyrol, silver nitrate or sometimes only alcohol. The
application is made with sterile swabs prepared by twisting a wisp of
cotton about the end of a toothpick. If the crack or abrasion is
extensive enough to cause bleeding, even nursing through a shield is
sometimes, but not necessarily discontinued, while the other treatment
is the same as for a nipple that does not bleed.

Sound, uninjured nipples, then, are to be kept clean and protected from
infection and those which are abraded or cracked are to be kept clean
and also protected against further injury.

=Lactation.= About the third or fourth day after delivery, when milk
replaces colostrum, the breasts become swollen, engorged and often very
painful, and not infrequently, a hard, sensitive lump or “cake” may be
felt. The growing tendency, now, is merely to support these heavy
breasts by means of a binder which has straps passing over the
shoulders, in order to hold them up without making pressure (Fig. 122)
and to apply ice caps or hot compresses to the painful areas. It used to
be customary to massage and pump caked breasts, to apply pressure and
various kinds of lotions or ointments. Though one, or all of these
measures are still employed, in some cases, the general practice is to
avoid manipulating the breasts but to empty them regularly by the baby’s
nursing; support them and allow Nature to make an adjustment between the
amount secreted and the amount withdrawn.

[Illustration:

  FIG. 122.—A simple method of supporting heavy breasts by means of
    three folded towels; one fastened about the waist, one over each
    shoulder, crossing front and back.
]

Free purging is sometimes employed and the amount of fluids reduced
until the engorgement and discomfort subside. This happy issue is
practically always reached if the baby nurses regularly and
satisfactorily, as there is a spontaneous adjustment between the amount
secreted by the mother and that withdrawn by the baby. But as abscesses
may follow in the wake of caked breasts, particularly if the nipples are
sore, it is of great importance that the nurse watch closely for the
first evidence of painful lumps. The prompt application of a supporting
bandage and ice bags (Fig. 123) or hot compresses will, in the majority
of cases, give speedy and complete relief. So widely is this believed
that many doctors regard the care of the breasts, including the
prevention of breast abscesses, as a nursing question, entirely, and
conversely are likely to regard the occurrence of a breast abscess as an
evidence of careless nursing.

[Illustration:

  FIG. 123.—Ice caps held in place on painful breasts by straight binder
    with darts pinned in under breasts and supported by shoulder straps
    of muslin bandage.
]

Certain it is that breast abscesses are almost never seen where the
nurses have this sense of responsibility, and habitually watch the
breasts closely and promptly use support and either heat or cold when
the breasts become heavy and sensitive.

There are innumerable bandages and methods for supporting heavy breasts,
any one of which is efficacious so long as it meets the two chief
requirements: to lift the breasts, suspending their weight from the
shoulders, and, while fitting snugly below to avoid making pressure at
any point, particularly over the nipples. One of the most satisfactory
and widely used supports is the Y-bandage, (Figs. 124, 125, 126),
another, the Indian binder (Fig. 127.)

[Illustration:

  FIG. 124.—Modified Richardson “Y” binder made of two strips of soft
    muslin, full width of material and 44 inches long, folded into
    strips of same width as distance from margin of patient’s breast to
    outer part of areola. One strip is folded in the middle at right
    angles and pinned to one end of the other strip as indicated. (Figs.
    124, 125, 126, with captions, are from The Maternity Hospital,
    Cleveland, by courtesy of Miss Calvin MacDonald.)
]

The nurse must on no account massage or pump engorged breasts on her own
responsibility, for there is a good deal of evidence to show that any
such manipulation tends to increase the amount of the secretion and this
in turn increases the engorgement and pain. It is possible, too, that
massage may bruise the breasts and thus make them more susceptible to
infection.

=Mastitis.= When infection occurs, the swollen, painful breasts may grow
hot and red, the patient may complain of chilliness and have a slight
fever, with or without there being an abscess. Even then the general
treatment is most frequently found to consist of support; ice or heat;
catharsis and restricted fluids, though in some cases the breasts are
pumped and nursing is discontinued.

[Illustration:

  FIG. 125.—Bandage in Fig. 124 applied. The long arm of binder is
    placed under patient’s shoulders, one end of the Y being brought
    around the top of the breasts and the other around the lower part,
    toward the nurse, crossed at right angles under the arm and pinned
    to long arm of bandage as indicated in Fig. 126. The nipples are
    covered with sterile gauze and the upper and lower parts of the Y
    fastened with a safety pin between the breasts. The remaining length
    of the long arm is brought across the breasts and fastened with a
    safety-pin to the opposite side. When the baby nurses this pin is
    removed as well as the one between the breasts. The entire binder
    should be snug and held in place by means of shoulder straps, pinned
    front and back.
]

When the inflammation so far progresses as to require that the breast be
opened and drained, the subsequent nursing care will be outlined by the
doctor to meet the needs of each case. It is a painful operation and
often a serious one, for the destruction of breast tissue may be
extensive enough to render the breasts valueless as milk-producing
organs. The healing is slow and altogether the occurrence is a most
lamentable one.

[Illustration:

  FIG. 126.—Y bandage in Fig. 125 seen from the opposite side.
]

The nurse’s part in preventing this complication is cleanliness and
gentleness in her attentions; unremitting watchfulness; immediate
application of a suspensory bandage and either heat or cold, upon the
first sign of engorgement and prompt reporting to the doctor.

[Illustration:

  FIG. 127.—Indian Binder used at The Montreal Maternity Hospital for
    supporting heavy breasts. The tapering ends tie in a knot in front.
]

If the patient’s nipples have not been toughened during pregnancy or if
flat or retracted nipples have not been satisfactorily brought out, it
may be necessary for the nurse to employ the treatment to these ends
which were described in the chapter on pre-natal care. In the meantime
the baby may have to nurse through a shield until the nipple is brought
out prominently enough for him to grasp it well.

=Stripping.= Sometimes in cases of depressed nipples, which the baby
cannot grasp, or when the baby is too feeble, to nurse at the breast,
milk is withdrawn from the breast by means of so-called “stripping.” The
nurse should scrub her hands thoroughly with hot water and soap and dry
them on a sterile towel before beginning. The breast is grasped by
placing the thumb and forefinger of the right hand on the areola on
opposite sides of the nipple but well below it. The nipple is then
raised from the breast by a quick, lifting and rolling motion of the
thumb and finger, accompanied by slight pressure. A sterile medicine
glass should be held in position to receive the milk which spurts from
the nipple, but the glass should not touch the breast. (Fig. 128.)

[Illustration:

  FIG. 128.—Position of thumb and finger below nipple on areola, in
    stripping breasts. (From photograph taken at The Long Island College
    Hospital.)
]

There is a knack about stripping and it requires practice, but those
doctors who advocate it feel that it empties the breast, when this is
necessary, with less disturbance than that caused by pumping, and as the
milk is projected directly from the nipple into the sterile glass,
without any of it running over the nipple or breast as may happen in
pumping, it has the additional advantage of always being sterile.

Extreme gentleness must be used; the openings of the milk ducts must not
be touched by the fingers, and the thumb and finger must not press
deeply enough to reach the glandular tissue itself. If done properly
stripping neither stimulates nor bruises the breast tissue nor does it
cause the patient even temporary discomfort.

=Abdominal Binders and Bed Exercises.= There is considerable difference
of opinion about the advantage of using abdominal binders upon the
puerperal patient while she is in bed, and the nurse will accordingly
care for the patients of some doctors who use them and for those of
others who do not.

The application of a moderately snug binder for the first day or two is
a fairly common practice, for multiparæ, particularly, are often made
very uncomfortable by the sudden release of tension on their flabby
abdominal walls; a discomfort which a binder will relieve. And during
the first few days after the patient gets up and walks about, she is
sometimes given great comfort by a binder that is put on as she lies on
her back, and is adjusted snugly about her hips and the lower part of
her abdomen.

But the continued use of a binder after the first day or two, while the
patient is still in bed, is not as general as it formerly was. Many
women ask for binders in the belief that they help to “get the figure
back” to its original outline, and some doctors feel that the use of the
binder is helpful in restoring the tone to the abdominal muscles, which
amounts to about the same thing. Both the straight swathe and the
Scultetus binder are used for this purpose and they are put on in the
usual manner; snugly and with even pressure, but not tight enough to
bind.

Those doctors who disapprove of the binder believe that it interferes
with involution and, by making pressure, tends to push the uterus back
and cause a retro-position, in addition to retarding instead of
promoting a return of normal tone to the abdominal muscles.

Accordingly, they instruct their patients to take exercises, instead of
wearing binders, and they have these exercises started while the patient
is still in bed. Their adoption, and the rate at which they are
increased, are entirely dependent upon the individual patient’s
condition, for they must never be continued to the point of fatigue.
There are, therefore, no definite rules laid down, concerning these
exercises, beyond a description of the positions and movements
themselves, and their sequence.

Those which are taught to the patients at the Long Island College
Hospital are so simple, and evidently productive of such happy results
that they offer excellent examples of this form of treatment. They are,
of course, taken only by the doctor’s order, but the nurse’s intelligent
supervision increases their effectiveness.

[Illustration:

  FIG. 129.


  Figs. 129 to 135, inclusive, are bed exercises taken during the
    puerperium.
  For description see text. (From photographs taken at The Long
  Island College Hospital.)
]

The general purpose of these exercises is to strengthen the abdominal
muscles, thus helping to prevent a large, pendulous abdomen; to increase
the patient’s general strength and tone, just as exercise benefits the
average person; to promote involution; to prevent retro-version and in a
measure, increase intestinal tone and thus relieve constipation. To
accomplish these much to be desired ends the exercises must be taken
with moderation and judgment; started slowly; increased very gradually
and constantly adapted to the strength of the individual patient.
Otherwise they may do more harm than good. In the average, uncomplicated
case in which the patient is doing well, she usually starts the
chin-to-chest exercise from twelve to twenty-four hours after delivery.
She should lie flat on her back and raise her head until her chin rests
upon her chest. (Fig. 129.) If she rests her hand upon her abdomen, she
will feel for herself that the abdominal muscles contract, and
accordingly will be disposed to continue the exercises with more
interest and confidence than she otherwise might. The movement is
repeated twenty-five times, morning and evening, every day, and
continued as long as the patient is in bed.

[Illustration:

  FIG. 130.
]

[Illustration:

  FIG. 131.
]

The familiar, deep-breathing exercise is ordinarily started on the third
or fourth day. The patient should lie flat, with her arms at her sides,
then extend them straight out from the shoulders (Fig. 130), raise them
above her head (Fig. 131) and return them to the original position. This
is repeated ten times morning and evening, daily, as long as the patient
is in bed.

[Illustration:

  FIG. 132.
]

The one-leg-flexion exercises are not done by patients with perineal
stitches, but in other cases they are usually started about the fifth
day. The thigh is flexed sharply on the abdomen and leg on thigh (Fig.
132), then extended and lowered to the bed. This is repeated ten times,
with each leg, morning and evening for one, or possibly two days.

The next exercise replaces the one-leg-flexion and is started after the
latter has been done for one or two days, according to the strength of
the patient, and it in turn is continued for only one or two days. Both
thighs are sharply flexed on abdomen and legs on thighs (Fig. 133), then
extended and lowered but not far enough for the heels to rest upon the
bed before being flexed again. This is repeated ten times morning and
evening.

[Illustration:

  FIG. 133.
]

[Illustration:

  FIG. 134.
]

Next is the exercise for which the leg-flexion exercises prepare the
patient, and which are discontinued when this one is adopted. It is
started, as a rule, about the seventh day, or three or four days before
the patient gets up. Both legs are slowly lifted to a position at right
angles to the body (Fig. 134) and slowly lowered, but not far enough for
the heels to touch the bed (Fig. 135), and the movement repeated. As
this exercise requires a good deal of effort, it must be taken up very
gradually, as follows: The legs should be raised on the first day, once
in the morning and twice in the evening; second day, three times in the
morning and four times in the evening; third day, five times in the
morning and six times in the evening and so on, if the patient is not
fatigued, until the exercise is repeated ten times each morning and
evening. It is continued for several months.

[Illustration:

  FIG. 135.
]

The knee chest position (Fig. 136) is intended to counteract the
tendency toward retroversion, from which so many women suffer after
childbirth. It is usually started about the seventh day and the patient
begins by remaining in that position for a moment or two, gradually
lengthening the time to about five minutes each morning and evening for
about two months.

[Illustration:

  FIG. 136.—Knee chest position.
]

[Illustration:

  FIG. 137.—Walking on all fours. (From a photograph taken at the Long
    Island College Hospital.)
]

Walking on all fours is violent exercise and has to be taken up very
gradually. Some patients are able to attempt it on the first day out of
bed, if they have been taking the other exercises, but as a rule it is
not started until the second or third day. The patient’s clothes should
be free from all constrictions; the knees should be held stiff and
straight with the feet widely separated, to allow a rush of air into the
vagina, and the entire palmar surface of the hands should rest flat on
the floor. (Fig. 137.) The patient should start by taking only a few
steps each morning and evening, gradually lengthening the walk to five
minutes twice daily and continuing it for about two months.

It is believed that as the patient walks in this position the uterus and
rectum rub against each other producing something the same result as
would be obtained by massage. The effect of the exercise is to promote
involution and diminish the tendency toward constipation and
retroversion, apparently preventing malposition entirely in a large
percentage of cases. Though not widely used, its beneficial effects are
unquestioned by those doctors who employ it.

In taking a general survey of the young mother and her needs, we realize
that in a broad sense she is not ill, in so far as no pathological
condition exists. But she is in a transitional state and may become
acutely or chronically ill if not carefully watched and nursed. In
general her mental, physical and nervous forces must be conserved and
increased, and this requires thoughtful and devoted attention from the
nurse. She must be scrupulously clean in her care of the nipples and
perineum, and in order to be able promptly to inform the doctor of any
departure from the normal in the patient’s condition, the nurse’s
watchfulness should embrace regular observations upon the following:

  1. The patient’s general condition; the amount and character of her
       sleep; her appetite; her nervous and mental condition.

  2. The temperature, pulse and respiration.

  3. The height and consistency of the fundus.

  4. The quantity, color and odor of the lochia.

  5. The persistence and severity of the after-pains.

  6. The condition of the perineum.

  7. The condition of the nipples and breasts.

  8. The functions of the bladder and bowels.

If all goes well and there are no complications, the patient will
usually be able to assume full charge of her baby by the sixth or eighth
week, and practically return to her customary mode of living, with the
difference that she now has the care of a baby which she did not have
before. The care of that baby requires certain, definite care of
herself, as a nursing mother, which will be described in detail in the
next chapter.

To sum up the general principles of nursing the young mother during the
puerperium, we find that just as during pregnancy and labor, the nurse
must first be familiar with the normal changes that occur in order that
she may recognize the abnormal. Then, as before, the nurse’s care of the
individual patient must rest unfailingly upon a foundation of
cleanliness in order to prevent infection; watchfulness, which implies
ability to recognize normal changes and unfavorable symptoms; adjustment
to the methods of the attending physician and to all of the
circumstances surrounding the patient, and the wisest and tenderest
consideration for her patient as an individual.



                              CHAPTER XVI
                           THE NURSING MOTHER


Not infrequently the nurse remains with her patient after the end of the
puerperium, and therefore she may have the care of the mother and baby
for several weeks, or even months. The most valuable single service
which she can perform in this capacity is to help in making it possible
for the mother to nurse her baby at the breast. For both the nurse and
the mother must realize that the breast-fed baby is much more likely to
live through the difficult first year, and is markedly less susceptible
to disease and infection than is the bottle-fed baby.

The first step is to convince the young mother of what it means to her
baby and her obligation to try to nurse him, since, excepting under very
rare and unusual conditions, she can nurse him if she wants to enough to
make the necessary effort and sacrifice.

The important contra-indications for attempting breast-feeding are
retracted nipples, tuberculosis, eclampsia, severe heart or kidney
disease and certain acute infectious diseases such as typhoid fever.

It seldom happens that the mother who has had average prenatal care,
followed by good care during and after delivery, is unable to nurse her
baby if she orders her life in the way that is known to be necessary to
promote and maintain lactation. The first essential is her real desire
to nurse her baby; next, her appreciation of the continuous care of
herself that is necessary and third, her whole-hearted willingness to
take this care for her baby’s sake.

It is safe to say that if the doctor and the nurse and the patient all
want the baby to nurse at the breast, and all do everything in their
power to make this possible, they will almost invariably succeed. This
assertion can scarcely be made too positively, and the nurse should
never lose sight of the fact that if the baby is not breast-fed he is
being defrauded, and in the vast majority of cases, because of
insufficient effort on the part of the doctor, nurse or patient, or all
three.

A favorable frame of mind and state of good nutrition in the mother are
the two indispensable factors in establishing breast-feeding and in
maintaining the secretion of an adequate supply of breast-milk. These
conditions, in turn, are both affected by her general mode of living, as
long as the baby nurses.

Women with happy, cheerful dispositions usually nurse their babies
satisfactorily, while those who worry and fret are likely to have an
insufficient supply of milk, or milk of a poor quality. And in addition
to this sustained influence, the temporary effect of a fit of temper; of
fright; grief; anxiety or any marked emotional disturbance is frequently
injurious to the quality of milk that previously has been satisfactory.
Actual poisons are created by such emotions and may affect the baby so
unfavorably as to make it advisable to give him artificial food, for the
time being, and empty the breasts by stripping or pumping, before he
resumes breast feeding.

A mother’s lack of faith in her ability to nurse is so detrimental in
its effect that she must be assured over and over, that she can nurse
her baby if she will persevere. If the nursing does not go well at first
she must not give up, but must continue to put the baby to the breasts
regularly, as this is the best means of stimulating them to activity.
His feeding should be supplemented with modified cow’s milk, if the
breast milk is inadequate, either in amount or quality.

=Method of Nursing.= The baby should be put to the breast for the first
time between eight and twelve hours after he is born. This gives the
tired mother an opportunity to rest and sleep, and the baby, too, is
benefited by being kept warm and quiet during this interval. His need
for food is not great as yet, nor is there much if any nourishment
available for him.

In preparing to nurse her baby, the mother should turn slightly to one
side, and hold the baby in the curve of her arm so that he may easily
grasp the nipple on that side. She should hold her breast from the
baby’s face with her free hand by placing the thumb above and fingers
below the nipple, thus leaving his nose uncovered, to permit his
breathing freely. (Fig. 138.) The mother and baby should lie in such
positions that both will be comfortable and relaxed, and the baby will
be able to take into his mouth, not only the nipple but the areola as
well, so as to compress the base of the nipple with his jaws as he
extracts the milk by suction.

[Illustration:

  FIG. 138.—Position of mother and baby for nursing in bed.
]

The nurse may have to resort to a number of expedients in persuading the
baby to begin to nurse, for he does not always take the breast eagerly
at first. He must be kept awake and sometimes suckling will be
encouraged by patting or stroking his cheek. Or if his head is drawn
away from the breast, a little, he will sometimes take a firmer hold and
begin to nurse. Moistening the nipple by expressing a few drops of
colostrum or with sweetened water may stimulate the baby’s appetite and
thus prompt him to nurse.

The young mother must be prepared to find very discouraging the early
attempts to induce the baby to nurse, but if the nurse will help her to
persevere in making regular attempts she will almost certainly succeed.

During the first two or three days the baby obtains only colostrum,
while nursing, but the regular suckling is extremely important, not
alone for the sake of getting him into the habit of nursing but for the
sake of stimulating the breasts to secrete milk.

Moreover, the irritation of the nipples so definitely promotes
involution of the uterus that this process goes on more rapidly in women
who nurse their babies than in those who do not. If the nipples are not
sufficiently prominent for the baby to grasp them, a shield will have to
be used while they are being brought out. But the shield should be
discarded as soon as possible for it is the baby’s suckling that
produces the physiological effects. If a shield is used, it should be
washed and boiled after each use and kept, between nursings, in a
sterile jar or a solution of boracic acid.

The length of the nursing periods and the intervals between them have to
be adjusted to the needs and condition of each baby; his weight, vigor,
the rapidity with which he nurses, the character of his stools and his
general condition, all of which will be considered in connection with
the care of the baby. The intervals between nursings are measured from
the beginning of one feeding to the beginning of the next, and are
fairly uniform for babies of the same age and weight. The length of the
nursing period itself is usually from ten to twenty minutes.

[Illustration:

  FIG. 139.—The Nursing Mother. (By permission from a pastel by Gari
    Melchers.)
]

The average baby nurses about every six hours during the first two days,
or four times in twenty-four hours. According to one schedule he will
nurse every three hours during the day for about three months, beginning
with the third day, and at 10 p.m. and 2 a.m., or seven times in twenty
four hours. From the third to the sixth month he nurses every three
hours during the day and at ten o’clock at night, or six times in
twenty-four hours, and from that time until he is weaned he should nurse
at four hour intervals during the day and at ten o’clock at night, or
five times daily, as follows:

 ─────────────────────┬──────────────────────────────────┬─────────────
                      │               Day                │    Night
                      │                                  │
 First and second days│     6     12      6              │    12
 First three months   │     6      9     12      3      6│    10   2 a.
                      │                                  │           m.
 Third to sixth month │     6      9     12      3      6│    10
 After the sixth month│     6     10      2      6       │    10
 ─────────────────────┴──────────────────────────────────┴─────────────

It is becoming more and more common to omit night feedings after 10
p.m., even during the first three months, with the average baby who is
in good condition. When this practice is adopted the baby not only seems
to do as well as he normally should, but to benefit by the long
digestive rest during the night. Certainly the mother profits by the
unbroken sleep which this makes possible.

As a rule the baby should nurse from one side, only, at each nursing,
emptying the breasts alternately, but if there is not enough milk in one
breast for a complete feeding both breasts may be used at one nursing.
Neither the mother nor the baby should be permitted to sleep while he is
at the breast, but he should pause every four or five minutes to keep
from feeding too rapidly.

After the mother sits up, she may occupy a low, comfortable chair while
nursing the baby. She should lean slightly forward and raise the knee
upon which the baby rests by placing her foot on a stool, supporting his
head in the curve of her arm, and holding her breast from his face, just
as she did while in bed. (Fig. 139.) She should nurse him in a quiet
room where she will not be disturbed nor interrupted and where the baby
and her breasts will be protected from drafts or from being chilled.
Many women prefer always to lie down when nursing the baby.

Before the nurse leaves her patient she should teach her how to care for
her nipples, including the preparation of boric solution; the importance
of washing her hands before bathing her nipples, and of keeping the
breasts covered with clean gauze between nursings.


                 PERSONAL HYGIENE OF THE NURSING MOTHER

The personal hygiene of the nursing mother should be virtually a
continuation of that which is advisable during the latter part of the
puerperium; a normal, tranquil kind of life which is unfailingly regular
in its daily routine.

But this is not quite as easy as it sounds, for during the puerperium
the young mother is still something of a patient and is regarded as
such, while during the months that follow she is simply a nursing
mother, who must live sanely and moderately for her baby’s sake, and at
the same time take her place among people who are not under compulsion
to place any special restrictions upon their daily lives. It is much
easier to take precautions and follow directions for a few days or
weeks, while the situation is novel, than it is to persist month after
month without help or encouragement. The young mother’s family often
fails to appreciate the difficulty of her problem and for this reason
she is sometimes unable to care for herself, as she should, with the
result that she cannot nurse her baby successfully.

As long as the nurse remains with her patient, therefore, she must try
to impress upon both the patient and the members of her household that
the most important single factor in the care of the new baby is the
sustained and regular care which the nursing mother should take of
herself. For it must be remembered constantly that it is not alone
breast feeding, but _satisfactory breast feeding_ that nourishes and
builds and protects the baby. Unsatisfactory breast milk may be
positively injurious, and irregularity and thoughtlessness in the
mother’s mode of living will usually produce milk of this character.

Therefore, for ten or twelve months after the baby is born, the mother
should discharge her responsibility and obligation to him by regulating
her own life to meet his needs.

=Diet.= Throughout the entire nursing period the mother’s diet must be
such that it will nourish her and also aid in producing milk which will
meet the baby’s needs. His needs are that the daily demands of his
growing body shall be supplied and that he shall be given those
materials which will build a sound body, with resistance against disease
and infection.

So important is this matter of nutrition, and the principles upon which
it rests, that it is discussed at considerable length in the succeeding
chapter. At this point, however, it may be stated briefly that the most
valuable article in the nursing mother’s dietary is milk, and that to
this should be added eggs and the vegetables which are designated as
“leafy,” and fresh fruits, particularly oranges. These foods are rich in
the materials which are essential to the baby’s nutrition, good health,
and resistance.

She should have a generous, simple, nourishing mixed diet, then,
consisting largely of milk, eggs, and leafy vegetables. She must
steadily guard against indigestion for if her digestion is deranged the
baby is almost sure to suffer. Rich and highly seasoned foods must be
avoided, as well as alcohol, strong tea and coffee or any articles of
food or drink that might upset her.

It becomes apparent that although the expectant mother does not have to
“eat for two,” the nursing mother does, in certain respects. She should
augment the nourishment provided by her three regular meals, by taking a
glass of milk, cocoa or some beverage made of milk, during the morning,
afternoon and before retiring.

The morning and afternoon lunches had better be taken about an hour and
a half after breakfast and luncheon, respectively, in order not to
impair the appetite for the meals which follow.

It is very important that the nursing mother shall take her meals with
clock-like regularity and enjoy them, but at the same time she must
guard against overeating, for fear of deranging her digestion. She must
drink water freely, partly for the sake of promoting intestinal
activity.

=Bowels.= The nursing mother’s bowels must move freely and regularly
every day, but she should not take cathartics nor even enemata without a
doctor’s order.

She will usually be able to establish the habit of a daily movement by
taking exercise, eating bulky fruit and vegetables, drinking an
abundance of water and regularly attempting to empty her bowels, every
day, preferably immediately after breakfast.

=Rest and Exercise.= The nursing mother will not thrive, nor will the
baby, unless she has adequate rest and sleep and takes at least a
moderate amount of daily exercise in the open air. She should have eight
hours sleep, out of the twenty-four, in a room with open windows, and as
fatigue has an injurious effect upon the character of the milk, the
average mother should lie down for a while every afternoon.

Her exercise will have to be adjusted to her tastes, customary habits,
circumstances and physical endurance, for it must always be stopped
before she is tired. Walking is often the best form of exercise that the
nursing mother can take, though she may engage in any mild sports that
she enjoys. Violent exercise is inadvisable because of the exhaustion
that may follow.

=Recreation.= Part of the value of exercise lies in the pleasure and
diversion which it gives, for a happy, contented frame of mind is
practically indispensable to the production of good milk. In addition to
some regular and enjoyable exercise, therefore, the mother needs a
certain amount of recreation and change of thought and environment. If
her life is monotonous and colorless, the average woman is likely to
become irritable and depressed; to lose her poise and perspective; to
worry and fret, and then, no matter what she eats nor how much she
sleeps, her digestion will suffer, her milk will be affected and the
baby will pay. This, of course, goes back to the question of her mental
state and the condition of her nerves as being determining factors in
the young mother’s ability to nurse her baby successfully.

For the sake of giving her an opportunity to go out, mingle with her
friends or enjoy some music or a play, it is often a very good plan to
replace one breast feeding, some time in the course of each day, with a
bottle feeding. The freedom which this long interval between two
nursings gives the mother for diversion and amusement, will usually
affect her general condition so favorably that the quality of her milk
is better than it otherwise would be, and the baby is benefited as a
result. This single supplementary feeding cannot be regarded lightly,
however, for it must be prepared with the same cleanliness and accuracy
as an artificial diet.

=Weaning.= One advantage in giving the baby a supplementary bottle, once
a day, is that it paves the way for weaning, when the time comes to make
this change. Under ordinary conditions, the mother begins to wean her
baby about the eighth or tenth month. Having started by replacing one
breast feeding, daily, with a bottle feeding, she should gradually
increase the number of daily artificial feedings until all of the breast
feedings are discontinued by the time the baby is eleven or twelve
months old. There are exceptions to this general rule, of course, and
under any conditions the weaning should always be directed by a doctor,
for the baby will suffer unless it is skillfully done.

If the mother’s milk is satisfactory and the baby is doing well, it is
often considered wiser not to discontinue the breast feeding entirely,
during the hot summer months, even though the weaning falls due at this
time.

It was formerly deemed advisable to wean the baby for any one of several
reasons, but at present the only indications for this step which are
generally accepted by the medical profession, are: pulmonary
tuberculosis, acute infectious diseases in the mother, and pregnancy.
Menstruation, which is normally suspended during lactation, was long
regarded as incompatible with satisfactory nursing, but it is now known
that if the mother is taking proper care of herself and is in generally
good condition, the effect of menstruation upon the milk is usually for
the duration of the periods only. It may be necessary to supplement the
breast feeding with suitably modified cow’s milk during menstruation,
but the baby should be put to the breast regularly, just the same, for
if the stimulation of the baby’s suckling is discontinued, the temporary
reduction in the amount of milk secreted will probably be permanent.

The state of pregnancy, however, is different, for though some women
nurse the baby satisfactorily for some months after becoming pregnant,
it is not considered advisable to subject a woman to the combined strain
of pregnancy and nursing. Moreover, the mother’s milk is usually
impoverished during pregnancy and the nursing baby suffers in
consequence.

=Drying up the Breasts= used to be a great bugbear. Lotions, ointments
and binders were employed and often a breast pump as well. Various drugs
were given by mouth and the patient was more or less rigidly dieted. It
is true that some of these measures are still employed and are followed
by a disappearance of the milk. But at the same time, the breasts dry up
quite as satisfactorily when none of these things is done, provided the
baby does not nurse. It is not known what starts the secretion of milk
in the mother’s breasts but certain it is that absence of the baby’s
suckling prevents it.

If the drying up of the breasts is left to the nurse, as it so
frequently is, her wisest course will be to do nothing beyond applying a
supporting bandage if the breasts are heavy enough to be uncomfortable.
She may rely absolutely upon the fact that the baby’s suckling is the
most important stimulation in promoting the activity of the breasts and
if this stimulation is not given, or is removed, the secretion of milk
will invariably subside in the course of a few days. It is true, that
the breasts may be engorged and very uncomfortable for a day or two, and
in addition to a supporting bandage the doctor may order sedatives, but
the discomfort subsides as the secretion disappears. This is true
whether the reason for drying up the breasts is that the baby is still
born or has died, or a live baby’s nursing is discontinued.

Naturally, the nurse will not press her patient to drink an extra amount
of milk if it is not desirable to promote the activity of the breasts,
but, unless otherwise ordered, there is no necessity for placing any
other restrictions upon her patient’s diet.

In thinking over the period of lactation, as a whole, it is apparent
that the most valuable service which the nurse can offer to the nursing
mother, is assistance in planning and living a simple, normal, tranquil
life; helping her to eat, sleep, bathe, and exercise and to nurse her
baby with unfailing regularity—all for the sake of providing her baby
with adequate nourishment. This must be the chief end and aim of her
existence.

Normal breast-milk is the ideal baby food and there is no entirely
satisfactory substitute. It greatly increases the baby’s chances of
living through the first year, and protects him from many diseases.

Quite evidently, breast-feeding is every baby’s right and the nurse can
and should help him to secure it.



                              CHAPTER XVII
                  NUTRITION OF THE MOTHER AND HER BABY


The importance of providing the expectant and nursing mother with
suitable food has been stressed so insistently in the preceding pages,
that it is advisable to explain to the nurse the reason for these
recommendations, in regard to certain groups of foods, and thus make
clear why a young mother may eat a large amount of food and have an
adequate amount of breast milk, and yet fail to nourish her baby
satisfactorily.

The following material is available in these pages through the interest
and generosity of Dr. E. V. McCollum and Miss Nina Simmonds, Professor
and Assistant Professor of Chemical Hygiene, School of Hygiene and
Public Health, Johns Hopkins University. This information is the result
of many years of research and experimentation on many thousands of
laboratory animals and of observations upon human beings as well. Dr.
McCollum and Miss Simmonds offer the fruits of their labors to
obstetrical nurses, in the belief that they are in a peculiarly
favorable position to aid in improving the nutritional state of the
coming generation.

In order that such a discussion may not seem irrelevant to obstetrical
nursing, the nurse must remind herself anew, that the object of
obstetrics to-day is not only to carry a woman safely through
childbirth, but to give her such care from the beginning of pregnancy
that she and the baby shall emerge from this experience, not merely
alive, but well and vigorous and with every prospect of continuing to be
so.

It is the acknowledged obligation of those engaged in obstetrical work
to strive toward improving the health of the race at its source—the
health of the mothers and babies. Malnourished mothers and malnourished
babies do not develop a hardy race.

It is probably safe to say that the two most influential factors in
creating and maintaining a satisfactory state of health are suitable
nutrition and prevention of infection; and although we shall concern
ourselves solely with nutrition in this chapter, it should be stated in
passing that a state of good nutrition goes far toward protecting the
individual from infection.

It will help in clarifying the subject to explain in the beginning that
a state of good nutrition is not necessarily evidenced by one’s being
tall nor by being fat. But it is evidenced by normal size and
development; sound teeth and bones; hair and skin of normal color and
texture; blood of the normal composition; stable nerves; vigor both
mental and physical; normally functioning organs and resistance to
disease, and above all that indescribable condition which is summed up
as a state of general well-being.

That this degree of nutritional stability is not as prevalent in this
country as might be desired is disclosed by reports upon findings of the
examining boards for army service, over a period of three years and
physical examinations of various groups of school children throughout
the country. It was found in the first case, that about sixteen per
cent. of the apparently normal young men who were inspected for military
service, were undernourished in some degree, and according to Dr. Thomas
W. Wood, Professor of Physical Education, Columbia University, “Five
million children in the United States are suffering from malnutrition.”
This army of undernourished children, which represents about one-third
of the children of the country, is on the broad highway to ill health,
invalidism of various kinds and degrees, instability and inefficiency.
They are certainly not developing into the clear-eyed, alert, buoyant
individuals that go to make up good citizenry.

The tragic aspect of this state of undernourishment is that though a
great deal can be done to nourish and build up the malnourished child or
adult, a certain amount of damage that results from inadequate
nourishment during the early, formative weeks and months cannot be
entirely repaired later on in life.

As the baby grows and develops, certain substances are needed at the
various stages of its progress, and if these are not supplied at these
stages, there will always be some degree of inadequacy in the adult make
up. It is much like the futility, when building a house, of using bricks
without straw for the foundation instead of firm, durable rock, and then
trying to make it substantial and secure later on by using good
materials when constructing the upper stories.

The solid foundation and substantial beams and girders for men and women
are put in during infancy and early childhood in the shape of good
material that forms good nerves, muscles, bones, teeth and general
physical stability. It is practically impossible to make up to the older
child or adult for damage caused by failure to supply sufficient
nourishment to the growing, developing, infant body.

              “The moving finger writes; and, having writ,
              Moves on; nor all thy piety nor wit
              Shall lure it back to cancel half a line,
              Nor all thy tears wash out a word of it.”

We see all about us the results of this form of neglect of babies, in
the bow-legged, knock-kneed, undersized, misshapen, chicken-breasted
adults and in those who are nervous and below par in endurance; are
susceptible to colds and other infections and may be summed up as being
“not strong.”

The reasons for much of the undernourishment among people in this
country to-day are to be found in certain widespread misconceptions of
long standing as to what constitutes a state of good nutrition or
malnutrition and the value and purposes of different foodstuffs. For
malnutrition does not necessarily describe a simple condition due to an
insufficient amount of food, but to any one of several complex
conditions due to a lack in the food of one or more essential
substances.

One may eat a large amount of food and even have a well-padded body and
yet be seriously in need of certain food factors—in other words, be
incompletely nourished in some particular.

That was possibly the first misconception—the belief that one simply
needed enough food, and accordingly was well nourished if three large
meals were eaten daily, irrespective of the composition of those meals.
A step forward was taken when housewives and people generally accepted
the fact that quantity alone was not enough to consider in providing
food, but that the dietary should consist of balanced amounts of the
five food materials: fats, carbohydrates, proteins, minerals and water,
in order to build and maintain the body in a state of health.

But this, too, was found to be an error, in so far as it was only a part
of the truth, for it was next ascertained that even provision for a
suitable balance of the five food groups was not enough to nourish us,
but that we must consider the heat and energy producing properties of
these component parts, as measured by the caloric unit, and each must
daily take in the requisite number of calories if we would keep our
engines going.

It is now known that even this is not enough, for we may eat food in
ample quantities, consisting of the properly balanced fats, proteids,
carbohydrates, minerals and water, and it may daily yield the required
number of calories, and still we may suffer from seriously faulty
nutrition.

Hess and Unger state in this connection, that, “in framing dietaries for
children and adults, our minds are still focused on insuring a
sufficient supply of calories in the food, and we have not yet reacted
in practice to the newer knowledge that ample carbohydrates, fats and
proteins may constitute a dangerously deficient diet.”[10]

We find an explanation for this fact in the comparatively recent
recognition of three substances, as yet not clearly understood, which
are contained in a certain few articles of food, each one of which is
essential to growth and normal health and well-being, though not
necessarily concerned in the production of heat or energy. Various terms
have been applied to these mysterious, but necessary substances, such as
vitamines, accessory food substances as applied to all, or fat-soluble
A, water-soluble B and water-soluble C to designate them separately.

A surprisingly small amount of each of these substances is sufficient to
meet the needs of an individual, but no one of these, even in this small
amount, can be safely dispensed with, for if the diet is deficient, or
lacking in one or more of them some form of nutritional disturbance will
result. It may be severe enough to be diagnosed as a disease, or it may
be only enough to keep the individual below a normal state of health.

When the disturbance is profound enough to produce a definite,
recognizable condition, it is designated as a deficiency disease, of
which there are three: scurvy, beri-beri and xerophthalmia. With these
are sometimes included rickets and pellagra. The exact cause of the two
latter disorders is not definitely known but both are associated with
faulty nutrition. Poor hygienic conditions may enter into the causation
of rickets, and infection may be a factor in the occurrence of pellagra,
but neither disease appears among those who are suitably fed while both
diseases may be produced by faulty diet and both may be cured with
suitable food.

But probably of graver importance to the public welfare than the well
defined nutritional disturbances, themselves, is the fact that between a
state of good health and the level upon which a disease is recognizable
is a long scale, along which are ranged an uncounted army of under-par,
half-sick people. These are the ones who are tired, nervous, susceptible
to infections, with feeble recuperative powers, and in general are more
or less ineffective in the business of life.

It is this borderline state, or as Dr. Goldberger terms it, “the
twilight zone,” which cannot quite be called disease but is not health,
that is serious to the masses, for diagnosed disease is given treatment,
but nervousness, lack of energy and endurance, weakness and inefficiency
are not treated; they are merely tolerated, as a rule. The sufferers
fail to reach their highest possible development and they fail to be of
highest value to society.

This is the condition which can be so largely prevented by giving the
baby a good nutritional foundation; this must be started during its
prenatal life, carried through the nursing period and then continued
throughout the rest of his life. Since the nurse is very likely to be
entrusted with the arrangement of the patient’s dietary, being told
merely to give a liquid, soft or light diet and possibly to avoid
certain articles, it will mean much to the coming generation if nurses
at large are able so to compose the various diets for the expectant and
nursing mother, that they will provide not only the requisite fats,
proteids, carbohydrates, minerals and water and yield the necessary
calories, but also contain all three protective substances: fat-soluble
A, water-soluble B and water-soluble C. It can be demonstrated that when
these food factors are not present in the mother’s diet, they will not
appear in her milk, and accordingly will not be supplied to her baby.

This is the crux of the whole matter. If the mother’s diet is faulty,
her milk will be faulty in the same respect and the baby will start life
with tissues which contain an inadequate amount of the substances that
are necessary to make them sound and promote health.

That is what we have in mind when we say that the mother’s milk must be
satisfactory not alone in quantity but in quality as well.

In order to make quite clear how damaging are the results of diets which
are deficient or lacking in these protective substances, we shall take
up, briefly, the deficiency diseases in turn.

=Scurvy= (scorbutus) is caused by a lack or deficiency of the substance
called water-soluble C, the most unstable of all the protective
substances, being easily impaired or destroyed by heating, drying or
aging. This anti-scorbutic substance is present in fresh milk, potatoes,
oranges, lemons, onions, and such fresh vegetables as lettuce, raw
cabbage and celery and in apples, pears, peaches, bananas and
cantaloupe. Tomatoes are rich in the anti-scorbutic substance and,
moreover, this form is but slightly injured by heating or aging, for
which reason canned tomatoes are frequently used both to prevent and to
cure scurvy.

Scurvy is a disease which develops slowly. The patient loses weight, is
anemic, pale, weak and short of breath. The gums become swollen, bleed
easily and frequently ulcerate; the teeth loosen and often drop out.
Necrotic areas in the bones may result. Hemorrhages into the mucous
membranes and the skin are characteristic. Large black and blue spots
develop in the skin, after trivial injury, or even spontaneously. The
ankles become edematous and in severe cases a hard, board-like condition
of the skin and subcutaneous tissues develops. There is sometimes severe
headache and in the later stages there may be convulsions and delirium.

Although scurvy has been known to exist for centuries, well developed
cases are not often seen among adults to-day, because experience has
taught the importance of including some fresh food in the dietary, and
present transportation facilities make this a fairly simple matter for
most people. The disease was doubtless limited almost entirely to
soldiers and pioneers until after the discovery of America. This event
marked the beginning of long sailing voyages, with diets of dried and
otherwise preserved foods, and scurvy began to take a heavy toll of life
among the mariners. It became known as “the calamity of sailors” because
of its frequency on shipboard. A notable instance in the history of the
disease was the voyage of Jacques Cartier, in 1536, when he lost
twenty-six of his party from scurvy, and only saved the remainder by the
use of an infusion of pine needles. The efficacy of fresh fruits and
vegetables in the prevention and cure of scurvy was discovered by common
experience; when it became customary to administer lime- or lemon-juice
to all sailors, scurvy practically disappeared from the service.

Although we seldom see actual cases of the disease among adults to-day,
it is believed that there are large numbers of border-line cases among
people who subsist largely on meats, canned and dried vegetables and
canned fruits, the meat-bread-and-potato type of diet, for several
months at a time, as during the winter season.

“Every individual requires a certain amount of anti-scorbutic substance
in his dietary, or to put this statement in a broader way, every nation
has need for a per capita quota of foodstuffs containing this necessary
food factor, if scurvy is to be avoided.”[11]

=Infantile scurvy= is seen among babies who are fed solely on milk that
has been heated, boiled, pasteurized or canned, since the anti-scorbutic
substance in milk is practically destroyed by heating or aging. The
disease is characterized by malnutrition, pain, typical changes in the
structure of the bones and hemorrhage in various parts of the body, most
frequently in the gums and beneath the periosteum. The disease develops
slowly, the first symptoms appearing between the seventh and tenth
months. Tenderness or pain in the legs is perhaps the most common
symptom and may be detected first by the baby’s crying when its diaper
is changed or its stockings are put on. And a baby that previously has
been cheerful, playful and active will prefer to lie quietly and will
cry whenever it is touched. He grows pale, listless and weak and fails
to gain in weight or length. The large joints are likely to be swollen
and tender; the swollen gums may bleed; the urine may be diminished in
amount and contain blood and there also may be edema. But it is quite
possible for a baby to be in serious need of an anti-scorbutic and still
not present well defined symptoms of scurvy, or it may suffer from the
latent or subacute type of the disease. In the latter case there may be
stationary weight; fretfulness; a muddy complexion; rapid pulse and
respirations; edema over the tibiæ with perhaps tenderness of the bones
and tiny hemorrhagic areas over the body.

Scurvy may be both prevented and cured by giving orange juice, potato
water, or tomato juice to a baby whose diet consists of milk that has
been heated and is therefore lacking in water-soluble C. Many doctors
believe that an anti-scorbutic should be started as early as the end of
the first month, with babies fed on pasteurized milk, for the disease
develops so slowly that severe damage may be done if the administration
of this material is delayed until symptoms appear.

Scurvy, itself, does not often cause death among babies, but its
occurrence is serious since it renders the infants very susceptible to
infection, particularly nasal diphtheria and “grip.” Recovery from even
severe attacks is amazingly rapid, sometimes being complete in a week or
ten days as a sole result of giving orange juice.

It is sometimes recommended that modified milk, for infant feeding, be
made up with potato water, instead of barley water, since the latter has
no anti-scorbutic properties, while potatoes are somewhat protective
even after being cooked.

Spinach water is sometimes given, but there is doubt in some minds about
its anti-scorbutic value, which seems to be more damaged by heat than
that of potatoes and tomatoes.

Canned tomatoes are valuable because of being inexpensive and preserving
their anti-scorbutic properties, even after heating. It is the opinion
of many pediatricians that babies tolerate canned tomatoes very well,
and in some cases may be given as much as four, six, or even eight
ounces daily, without causing trouble.

Infusion of orange peel also is used in the prevention and treatment of
scurvy and has the advantage of being inexpensive since the orange
itself may be used for other purposes.

But orange juice and lemon juice are generally accepted as being the
most valuable of all anti-scorbutics. Orange juice may be started early,
and to be of value as a preventive, must be started early or scurvy will
have started to develop. The common practice is to give a dram, daily,
at three months, increase it to an ounce by the sixth month and two
ounces when the baby is a year old. It should be diluted with water and
given in two doses, midway between two morning and afternoon feedings.

To sum up: Scurvy in infants or adults is the result of a diet which is
deficient or lacking in the anti-scorbutic substance, called
water-soluble C, and may be prevented or cured by adding to the faulty
diet those articles of food which contain this substance, namely, fresh
milk, oranges, leafy, green vegetables, cabbage, onions, potatoes or
tomatoes. Although scurvy is seldom seen in breast-fed babies it is
believed that an infant nursing at the breast of a woman whose diet is
poor or lacking in the anti-scorbutic substance may suffer a certain
degree of starvation for this food factor.

Recent work at the University of Minnesota has shown that milk from cows
on dry feeds is very much lower in anti-scorbutic properties than milk
from cows on green pasture. This provides a strong argument for giving
orange juice to all artificially fed babies, for one cannot always know
how the cows, from which the milk is obtained, are fed.

=Beri-beri= is a deficiency disease, chiefly characterized by paralysis
and caused by a diet which is lacking or poor in water-soluble B. The
foods which entirely lack this substance are polished rice, starch,
sugar, glucose, and the fats and oils from both animal and vegetable
sources, while those which are poor in it are the products of
degerminated cereal grains, such as tapioca, hominy, cornmeal, macaroni,
spaghetti and the muscle cuts of meat, such as steak, roast, chops, ham
and fish and fowl muscle. Foods which are rich in water-soluble B are
beans, peas, the root vegetables as beets, carrots, white and sweet
potatoes, leafy vegetables, fruits, milks, eggs and the glandular organs
such as liver, kidneys and sweet breads.

The early symptoms of beri-beri are fatigue and depression; numbness and
stiffness in the legs; more or less edema of the ankles and face,
followed by tenderness of the calf muscles, and tingling or burning
sensations in the feet, legs and arms. There are two types of the
disease, the dry and the wet. In the dry type, wasting anesthesia and
paralysis are the chief symptoms, while the most marked evidences of the
wet type are the edema, which may be excessive, affecting the entire
body. The death rate from beri-beri is usually high.

We are accustomed to thinking of this disease as occurring chiefly among
the Orientals, for it was long confined to Southern China, Japan, the
Dutch East Indies and the Malay Peninsula. But it may occur among any
people whose diet is poor in those foods containing the particular
substance which protects against it. It is common in Newfoundland and
Labrador and certain parts of South America and among people who eat
little aside from staple, non-perishable, cereal products, wheat bread
made from bolted flour, fish and salt meats. An evidence of this near at
home was an outbreak of typical beri-beri, in the jail at Elizabeth, N.
J., in 1914, caused by the faulty diet of the inmates.

The disease may be prevented or cured only by including in the diet such
food as milk, eggs, fresh fruit and vegetables.

=Xerophthalmia= is a deficiency disease characterized by eye lesions and
due to a lack of, or deficiency in the diet of the protective substance
which has been designated as fat-soluble A. This substance is absent in
polished rice, and present in but small amounts in barley and other
cereals; in muscle cuts of meat; in peas, beans and other vegetables
excepting those described as “leafy.” It is contained in cod-liver oil,
butter, cream, egg yolk, liver, kidneys and the leafy vegetables.

In the early stages of the disease the eyes are inflamed and the lids
badly swollen. If the diet is wholly lacking in fat-soluble A, the
disease progresses rapidly, the eye balls frequently rupture and the
lens and vitreous humor are expelled, with total and permanent blindness
as the tragic result. On the other hand, the malady clears up in a very
spectacular manner if, in the early stages, the patient is fed those
foods which contain the mysterious, but indispensable fat-soluble A.

[Illustration:

  FIG. 140.—This baby is totally blind in the left eye as a result of
    ulcers, due to a long continued diet of cereals with a little
    skimmed milk; in other words, a diet poor in fat-soluble A. The
    right eye became involved but administration of cod-liver oil was
    followed by speedy recovery and partial vision was saved. There is
    little doubt but that the baby would have been totally blind had the
    faulty diet been continued. (From the Newer Knowledge of Nutrition,
    by E. V. McCollum.)
]

Well developed xerophthalmia is not common in this country but one sees
inflamed eyes and corneal ulcers in young children which clear up with
little local treatment after a mother has been persuaded to give the
patient more fresh milk, butter and green vegetables.

Mori reports upon about 1500 cases occurring in Japan, in 1905, among
children between the ages of two and five years. He states that the
disease does not occur among the fisher folk but among people whose diet
is largely composed of rice, barley, cereals, beans and “other
vegetables,” but he does not state what the other vegetables are. Prompt
relief of the eye symptoms was observed when cod-liver oil, chicken
livers and eel fat were administered.

Bloch describes cases of xerophthalmia among infants under one year of
age, in the vicinity of Copenhagen, during the years of 1912 and 1916.
(Fig. 140.) The babies were also suffering from malnutrition and the
skin was dry, shrivelled and scaly. Their diet consisted largely of
separator skimmed milk, which was, therefore, practically fat-free,
oatmeal gruel and barley soup. The milk was pasteurized and then cooked
in the home before being fed to the babies. Such a diet was so faulty
that the infants in question may well have been border-line cases of
scurvy and beri-beri, as well as developed cases of xerophthalmia. It is
also evident that the children were unquestionably suffering from
rickets.

It is believed that the condition known as night-blindness is related
to, or a mild or early form of xerophthalmia. It occurs in Newfoundland
and Labrador, among men in lumber camps and elsewhere, whose diet
consists chiefly of wheat flour, beans, meat, fish, molasses, raisins
and coffee. Such a diet is made up of those parts of the plant or animal
which have good keeping qualities, but these qualities do not compensate
for the poverty of the protective substance.

Dr. Anna Strong, who has had experience as a medical missionary in
India, observes that night-blindness is common in the vicinity of
Calcutta, and it is said to occur frequently in Russia during the Lenten
fasts. The popular treatment for this condition consists of poulticing
the eyes with fresh goat’s liver and giving the liver as a food as well;
while in Japan the efficacy of eating liver to cure night-blindness has
been recognized from early times.

=Pellagra= is a disease of obscure origin, associated with faulty
nutrition, which involves the nervous and digestive systems and the
skin. Usually one of the first symptoms is soreness and inflammation of
the mouth, then a remarkable, symmetrical eruption appears on parts of
the body, which, with weakness, nervousness and indigestion form the
most characteristic picture of the disease.

There are some indications that infection may be the immediate cause,
but the strong evidence is that a faulty diet is the chief predisposing
cause of the disease. Certain it is that pellagra is both prevented and
cured by a diet containing liberal amounts of milk, eggs and leafy
vegetables. On the other hand, those who live during the winter months
on a diet chiefly derived from bolted white flour, degerminated
cornmeal, polished rice, starch, sugar, molasses and fat pork, furnish
the victims of this dreaded disease in the spring.

Pellagra was discovered in Northern Spain, by Cassal, in 1735, but for
many years it had been of common occurrence in parts of Italy, and
during the last century has been prevalent in parts of France, the
Balkans, especially Roumania, and for a lesser time, in Egypt. In
America the disease was not recognized with certainty until 1908, but
from that year its incidence apparently increased, until by 1917 there
were 170,000 cases of pellagra recorded in the United States,
principally located in the Southern States.

In 1914, Dr. Joseph Goldberger, of the United States Public Health
Service, began an investigation of the factors concerned in causing
pellagra. After he had studied its prevalence in various orphanages in
the South, and had relieved the situation by improving the diet with
milk, fresh vegetables and meat, he was anxious to know whether the
disease could be produced by a faulty dietary, of the type common among
pellagrins. He planned an experiment to this end, which would restrict
men to a diet similar to that which had been supplied in the
institutions where pellagra had been endemic, and where it had been
relieved by the improvements in the food supply which have been
mentioned. This type of diet was also very characteristic of that used
in the homes of the cotton mill workers throughout the South, where
pellagra was so common. The Governor of Mississippi offered pardon to
any of the healthy white men in the state prison who would submit
themselves as subjects for the experiment, and eleven actually underwent
the test.

The men were put upon a diet consisting of articles made from white,
wheat flour, degerminated cornmeal (maize), polished rice, starch,
sugar, molasses, pork fat, sweet potatoes, coffee and very small
quantities of collards and turnip greens—so small as to furnish
inadequate protection against a certain degree of undernourishment. At
the end of five and a half months six of the eleven men developed the
skin lesions characteristic of incipient pellagra.

As a result of his investigations, Dr. Goldberger points out the
important fact that when milk, eggs, meat, fresh fruit and vegetables
are included in the diet, pellagra does not develop, also that the
disease may be cured by giving these articles of food to the afflicted
person.

[Illustration:

  FIG. 141.—Rachitic baby and normal baby of the same age, showing
    dwarfism and deformities caused by rickets. (By courtesy of Dr.
    Leonard Findlay, Glasgow, Scotland.)
]

=Rickets.= The actual cause of rickets is not definitely known, but the
disease apparently results from wrong proportions between calcium and
phosphorus, and to unfavorable amounts of these two substances in the
food. Accordingly, it may be said to be due to a faulty diet—one which
is rich in carbohydrates and poor in fats and possibly some substance as
yet unrecognized—and it may be both prevented and cured by what is now
regarded as suitable feeding.

The chief characteristics of the disease are arrested growth and
softening of the bones, with dwarfism and deformities as a result. (Fig.
141.) It is essentially a disease of infancy, occurring as a rule,
between the fourth and eighteenth months but some of its unfavorable
effects, such as bone deformities and poor resistance to disease, may
persist throughout life.

Although babies rarely die of rickets alone, it is one of the most
serious of all health problems and obstacles to normal development and
stability, since it predisposes to such diseases as bronchitis,
pneumonia, tuberculosis, measles, and whooping cough and in general
greatly enfeebles the powers of resistance and recuperation.

It is common among babies who are fed solely or continuously on heated
milk, either boiled or canned, and on proprietary foods and sweetened
condensed milk. There has been some speculation about the possible
relation between rickets and fat-soluble A, but no definite conclusions
have yet been reached. It is known, however, that rickets may develop
among nursing babies whose mothers are on faulty diets, and that the
disease may be prevented and cured by the administration of cod-liver
oil, which is rich in fat-soluble A. Sunshine, also, seems to have a
pronounced effect in preventing and in curing the disease.

[Illustration:

  FIG. 142.—Exterior of thorax of normal rat and rachitic rat of same
    age. The latter shows dwarfism and deformities resembling pigeon
    breast so frequently seen in human beings suffering from rickets.
    (From The Newer Knowledge of Nutrition, by E. V. McCollum.)
]

=Symptoms.= The common symptoms of rickets which appear early are
irritability; restlessness particularly at night; a tendency toward
convulsions from very slight cause; digestive disturbances and profuse
perspiration about the head. The baby may be fat, but is likely to be
flabby and to have a characteristically white, “pasty” color. The
fontanelles are large and late in closing; the abdomen is large and the
chest narrow; dentition is usually delayed and the teeth may be soft and
decay early. But the most conspicuous effect of rickets is upon the
entire bony skeleton, due to the inadequacy of the lime deposit. The
bones are soft, easily bent and broken and often misshapen. Their growth
is likely to be retarded and the ends of the long bones may be enlarged,
giving the familiar swollen wrists and ankles, while the nodules which
form at the junction of the ribs and sternum, produce the beaded
appearance so commonly called a “rickety rosary.” The bones in the arms
and legs may become curved as the baby lies or sits in its crib, making
him either bow-legged or knock-kneed. The deformity is increased by
walking because the soft bones are easily bent by the weight of the
body. The spinal column may be curved or too weak to permit the baby to
sit straight or stand alone. The entire chest wall is often deformed
(Figs. 142, 143) producing the familiar “chicken breast,” as well as a
serious decrease in the size of the thoracic cavity, and through loss of
rigidity of the bony wall, the respiratory movements may be seriously
impaired. The forehead is prominent and the whole head looks square and
larger than normal, while the pelvic deformities in girl babies often
give rise to very serious obstetrical complications later in life, as
has been previously explained.

[Illustration:

  FIG. 143.—Interior of specimens in Fig. 142 showing nodules, due to
    rickets, protruding into thoracic cavity and encroaching upon space
    occupied by heart and lungs. This is a factor in the respiratory
    diseases which frequently complicate rickets.
]

Although lack of fresh air and sunshine seem to be factors in producing
rickets, it has been observed that the disease does not develop in poor
surroundings if the diet is suitable or if cod-liver oil is given to
babies fed artificially, or on unsatisfactory breast milk; but that it
may occur in the presence of satisfactory hygienic conditions if the
diet is faulty in certain respects. For children under a year old, the
desirable food is good breast milk, or, lacking that, fresh, certified
cows’ milk, with fruit juices, scraped beef, eggs and strained vegetable
purées, started as early and increased as rapidly as the baby can digest
them.

=Treatment.= Cod-liver oil and sunshine, together with proper food, are
the essentials in treating rickets. When cod-liver oil is given to a
baby whose diet is faulty, it exerts a marked tendency toward enabling
the bones to develop satisfactorily even when the mineral content of the
food is unfavorable. The use of sunshine, either by moving the baby from
a dark to a light house, or by exposing his body to the direct rays of
the sun is found to be of pronounced therapeutic value. These factors,
in addition to general good care constitute the treatment, but it is a
long slow process, taking from three to fifteen months, and it is
doubtful if the damage which the disease works can ever be entirely
repaired.

Rickets is more common during the cold months of the year, winter and
spring, than during the milder summer and autumn seasons. A possible
explanation for this lies in the higher value of the cows’ food during
the warm months when green things form the diets of animals. Since it is
now recognized that milk is not a constant product, but that its
properties vary with the food of the animals that produce it, cows’ milk
would be favorably influenced by their being put to pasture.

Similar evidence of such an influence is seen in the fact that although
rickets is not seen among breast-fed babies whose mothers are on
satisfactory diets, it may and does occur in breast-fed babies who are
nourished by mothers who are, themselves, on dietaries which are poor in
milk and fresh fruit and vegetables.

Drs. Hess and Unger made a study of the occurrence of rickets among
colored babies in a section of New York City and the value of cod-liver
oil as a preventive of this disease. In commenting upon their findings,
they state, “This tendency is so marked that it may be safely stated
that over ninety per cent. of the colored babies have rickets, and that
even a majority of those that are breast-fed show some signs of this
disorder.” They ascertained that the average diet of the mothers of
these rickety babies was largely made up of carbohydrates and proteins,
being poor in fats, although the diets yielded a daily quota of calories
which represented almost the requisite amount for their individual
weights. But they took little fresh milk or fresh fruit or vegetables,
using canned and dried products freely.

It is important to note here that it is a diet of heated milk, rich in
carbohydrates but poor in fats, that produces rickets in a bottle-fed
baby—almost the same type of diet which in a nursing mother results in
rickets in a breast-fed baby.

In an endeavor to prevent rickets among these incompletely nourished
babies, Drs. Hess and Unger carried on a definitely organized
experiment. “Our plan,” they report, “was to give infants under
six-months one-half teaspoonful of oil three times daily and older
infants twice this amount. It was found that almost all babies can take
cod-liver oil, although it may disagree temporarily and may have to be
discontinued for short intervals when there is digestive disturbance.
Infants of from two to three months tolerate the oil in half-teaspoonful
doses, and younger ones may be given still smaller amounts.” In
commenting upon the tabulated results of this interesting study they
say: “It is seen that we were able to prevent the development of rickets
in more than four-fifths of the infants who received the oil for six
months, and in more than half of those who were given it for four
months. This result must be considered satisfactory when we note that,
of the sixteen infants who did not receive the oil, fifteen showed signs
of rickets, though all of them lived under the same conditions and many
in the very same families. No other treatment was given, nor was a
change of diet or mode of life attempted which could account for the
difference in the results between the two groups of cases.” The poor
quality of the breast milk of these inadequately nourished mothers is
suggested by the further statement: “Table two shows that the cod-liver
oil proved to be a more potent factor than breast feeding in warding off
rickets, and that almost all the colored babies developed rickets even
though nursed.”

It may seem like a far cry from scurvy among sailors, on shipboard,
xerophthalmia among lumbermen in Labrador, and beri-beri among the
Orientals to the nursing mother and her baby in our care.

But when we gather all of these apparently unrelated threads together
and consider them in their possible relation to this same nursing mother
and her baby, right here at hand, the following facts stand out as being
of insistent importance to their well-being:

  1. There are five recognized diseases resulting from faulty nutrition,
       which may be both prevented and cured by a diet which contains
       the protective substances which are now regarded as essential to
       normal growth, development and well-being.

  2. These essential substances are not necessarily provided in adequate
       amounts by a diet that is satisfactory in bulk or in its balance
       of fats, carbohydrates, proteins, salts and water or that yields
       the requisite number of calories. The familiar diet of meat,
       potatoes, peas, beans, bread, pie and coffee is so far from
       providing complete nourishment that those who are limited to it
       are in a state of partial starvation.

  3. The diseases resulting from a lack or deficiency of the protective
       substances, fat-soluble A, water-soluble B and water-soluble C,
       respectively, are xerophthalmia, beri-beri and scurvy. With these
       are often included pellagra and rickets, the causes of which are
       not definitely known but result from diets that are poor in
       certain respects. The serious aspect of the deficiency diseases,
       however, does not lie entirely in those conditions which are well
       enough developed to be recognizable, thus prompting treatment;
       but also in the wide prevalence of malnutrition, of some form,
       which is not severe enough to be diagnosed as disease, and which
       is caused by a sustained diet that is poor in one or more
       essential food factors. This condition is serious because it
       produces a legion of individuals who are spoken of as being “not
       strong.” They are tired, nervous, susceptible to infections, have
       poor recuperative powers and in general fall short of a normal
       state of health and efficiency.

  4. Although the breast tissues are capable of converting into milk
       certain substances which they extract from the blood, and may,
       for example, convert poor proteins into proteins of higher value,
       they cannot create the protective substances which we have been
       considering. They can merely excrete these substances if they are
       contained in the mother’s diet. The absence, or shortage of these
       food essentials in the mother’s diet, and therefore in her milk,
       may result in rickets or other malnourished conditions in the
       baby, or in a degree of faulty nutrition which is not marked
       enough to be diagnosed, but enough to keep him frail. Enough to
       give him the poor start that is so likely to put him, ultimately,
       in the class of those adults who are more or less unfit, though
       not actually ill.

We must see to it, therefore, that our selection of food for the
expectant and nursing mother provides those substances which are
necessary to promote growth and development and preserve health, if we
are to live up to our claim that the aim of obstetrical nursing is to
aid in building a strong, vigorous and buoyant race.

The nurse may find herself feeling a bit dismayed at the prospect of
trying to remember at all times which foods contain fat-soluble A, for
example, and which are poor in water-soluble C, but she can remember in
general, that milk and leafy vegetables are the great protective foods
and that any diet which is poor in these is incapable of nourishing
satisfactorily; and by calling to mind the deficiency diseases,
previously described, she will be impressed anew by the seriousness of
faulty nutrition.

By _milk_ we mean, in addition to fresh milk, cream, butter,
butter-milk, cream-soups and sauces, custards, ice-cream and all dishes
and beverages made of milk.

By _leafy vegetables_ we mean lettuce, romaine, endive, cress, celery,
cabbage, spinach, onions, string beans, asparagus, cauliflower, Brussels
sprouts, artichokes, beet greens, dandelions, turnip tops and the like.

Other foods which are rich in protective substances are fresh fruit,
egg-yolks and glandular organs.

Nearly all of the common foods are deficient in some respect, but
as the shortcomings of the various groups are different, we can
arrange entirely satisfactory diets by combining foods which
supplement each other’s deficiencies. This explains to us why the
meat-potato-peas-beans-bread-and-pie type of meals fails to supply
adequate nourishment. These foods belong in the same general group
and are deficient in about the same kind of food factors, thus
tending to duplicate, rather than supplement each other.

If such a fare is enriched by the addition of the protective foods, milk
and leafy vegetables, we have a well rounded diet in which the
deficiencies of one group of foods are supplied by the properties of the
other groups. In fact, it is only by such a supplementing combination
that an entirely satisfactory diet can be secured.

Dr. McCollum points out that the mother on a faulty diet cannot nurse
her baby to his advantage. “The mammary gland,” he says, “picks up from
the blood both of the chemically unidentified food essentials,
fat-soluble A and water-soluble B, and passes these into the milk, but
it is unable to produce either of these substances anew. When one or the
other of these is absent from the mother’s diet it is not found in the
milk. We have shown the possibility of producing milk, poor or lacking
in each of these substances and therefore not capable of inducing
growth.”[12]

Dr. W. E. Musgrave gives dramatic accounts of the effect upon nursing
babies of faulty nutrition among mothers in the Philippines, as follows:
“Infant mortality in Manila,” he writes, “is greater than it is in any
other city from which we have records. The underdeveloped and
undernourished condition of the great masses of the Filipino people is
due to a number of causes, the principal one being insufficient quantity
and injudicious variety of foodstuffs employed. The cause of the
enormous influence of the faulty nutrition of the mothers upon infant
mortality directly and indirectly is one of the most important subjects
within the scope of any investigation of this character. The mortality
in breast-fed children is higher than it is among children artificially
fed. This condition so far as we know is peculiar to the Philippines.
The logical, and we believe, the correct explanation of this is the
deficiency in quality and quantity of the mother’s milk. There are not
in history more pathetic examples of unavailing self-sacrifice than are
daily seen in our large clinics of poor, half-starved, undernourished
mothers attempting to supply from their breasts food enough for one or
more children, when their own metabolisms are in a starved condition.
When asked the direct question as to the supply of foodstuffs these
mothers almost invariably state that they have plenty to eat and the
pathetic part of the story is that they believe that they are stating
facts. These abnormal premises are the result of a peculiar
unexplainable psychology that is of very wide application in this
country that the administration of food is more to satisfy hunger than
to produce flesh and blood, and that the cheapest way in which hunger
may be satisfied produces a satisfactory form of existence.”

It is generally agreed that the two big problems of babyhood are proper
nutrition and the prevention of infection, but nutrition is perhaps the
greater problem, since any form or degree of malnutrition lessens the
baby’s powers to resist and to recover from infection. Whether
breast-fed or bottle-fed, therefore, it is imperative that the baby be
nourished in the complete sense of being given all of the food materials
which are essential to normal growth, development and protection against
disease.

If the baby is artificially fed on milk that has been heated, his diet
needs to be augmented by such protectives as cod-liver oil and orange
juice, since the protective properties of milk are impaired by heating.
If he is breast-fed, the mother will be able to supply to her baby the
requisite nourishment and protective substances only if she, herself, is
adequately nourished and in good condition.

That is the point of this entire discussion: The nursing mother must be
on a satisfactory diet or she cannot satisfactorily nurse her baby. And
by satisfactorily nursing her baby we mean, to give him from the
beginning, through her milk, the materials necessary to build well and
firmly that temple, in the shape of his body, which he will occupy
throughout life; a structure so securely built, from the foundation up
through each stage, that it will be able to withstand the attacks of
disease and weather the inevitable storm and stress of life.


                              BIBLIOGRAPHY

  McCollum. The Newer Knowledge of Nutrition, 2nd edition. New York,
    1918.

  McCollum and Simmonds. The American Home Diet, Detroit, 1919.

  McCollum. Newer Aspects of Nutrition, Proceedings of the Institute of
    Medicine of Chicago, 1920, iii, 13.

  Musgrave, W. E. The Philippine Jour. of Science, Series B, vol. 8,
    1913, 459.

  Goldberger, J. Jour. Amer. Med. Assoc., 1916, lxvi, 471.

  Hess, A. F. and Unger, L. J. Prophylactic Therapy for Rickets in a
    Negro Community.



                             CHAPTER XVIII
                    COMPLICATIONS OF THE PUERPERIUM


The most important of the complications of the puerperium are
subinvolution and malpositions of the uterus; breast abscesses;
hemorrhage and infection.

The importance of these to the nurse lies in their preventability, by
means of the clean and efficient care which she helps to give during
pregnancy, labor and the early weeks after the baby is born.

The nurse’s part in prevention and treatment of subinvolution,
malpositions of the uterus and breast abscesses is so bound up in the
daily care of the young mother that it was described in the preceding
chapter.

=Hemorrhage.= Under ordinary conditions, a patient may lose as much as
500 cubic centimetres of blood during or immediately after labor,
without serious results, but a loss of 600 cubic centimetres or more is
regarded as a hemorrhage and as requiring speedy attention.

According to Dr. Williams, severe hemorrhage occurs only once in every
few hundred labors, and with proper treatment, should not result fatally
in more than one out of every 2000 or 2500 cases.

The severe hemorrhage due to a partially separated placenta occurs
during the third stage of labor and was discussed in that connection. As
the danger of hemorrhage, after labor is completed, is greatest during
that critical hour immediately following, it is practically routine the
country over to watch the patient closely during this period, both for
the sake of preventing bleeding and detecting its early evidence, should
hemorrhage occur, thus making prompt treatment possible.

The causes of post-partum hemorrhage are: Deep cervical tears, retained
portions of the placenta, and atony of the uterus.

The treatment of hemorrhage due to tears of the generative tract is
suturing the torn edges.

Since the retention of even a small piece of placental tissue will
prevent the uterus from contracting firmly, the treatment of hemorrhage
from this cause is immediate removal of the retained fragment. It is to
obviate this occurrence that the placenta is carefully inspected after
its expulsion. If it is not intact, the obstetrician may introduce his
finger and remove the retained portion, thus making it possible for the
uterus to contract properly and close off the open blood vessels.

Atony, or impaired tone of the uterine muscles, may result in hemorrhage
because of failure of the muscle fibres to constrict the vessels. Quite
evidently, the first step toward controlling hemorrhage from this cause
is to stimulate the muscles to contract; this is done by means of
massage and the administration of pituitrin and ergot. Elevation of the
foot of the bed and application of ice-bag to the abdomen are also
employed.

In severe cases, the doctor may give an intra-uterine douche of hot,
sterile salt solution and if this fails he may pack the uterus tightly
with sterile gauze. The douche and pack represent operative maneuvers
and, therefore, are never to be undertaken by the nurse. Her assistance
is important, however, as strictest asepsis is imperative and she will
have to prepare the patient and the necessary articles with the greatest
care.

Should bleeding become profuse during the doctor’s absence _the nurse
must stay with the patient and massage the fundus_ and have some one
else elevate the foot of the bed on the seat of a straight chair or upon
firm blocks and summon the doctor. In anticipation of such an emergency
the nurse must always have an understanding with the doctor about the
administration of pituitrin and ergot. If there has been no
understanding, and the doctor is delayed or the bleeding becomes
alarmingly profuse, the nurse will usually be upheld if she gives 1
cubic centimetre of pituitrin, hypodermically and a dram of ergot by
mouth.

It is, of course, definitely understood that nurses do not give
medicines without orders, but a single dose of pituitrin and ergot upon
the occurrence of a profuse hemorrhage can scarcely do harm and may
actually save the patient’s life. Such a situation is an emergency
fortunately a rare one, and the nurse will have to be quick-witted and
use the best judgment she is capable of.

The patient is usually more or less shocked by the time the bleeding has
been controlled and needs the rest, quiet and stimulation that are
ordinarily employed in such cases. She should be well wrapped in
blankets and surrounded with hot water bottles _placed outside the
blankets, watched constantly and moved frequently_; salt solution or
strong coffee are sometimes given by enema, or saline infusions or
intra-venous injections may be given. The patient must be kept warm and
quiet and pressed to drink large amounts of fluids.

But above all the nurse must remember that severe hemorrhage from a
relaxed uterus can almost always be prevented if the fundus is kept
hard, by massage when necessary, during the first hour or so after
delivery.

=Puerperal infection= is usually regarded as a condition which results
from the entrance of infective bacteria into the female generative tract
during labor or the puerperium, to distinguish it from other infections
which may occur coincidently with the puerperal state, but not
necessarily be related to it.

Puerperal infection is one of the most destructive and most dreaded of
the complications which may overtake the obstetrical patient, and has
evidently been so considered since the days of Hippocrates. Until recent
years this veritable scourge was so utterly baffling that it was
regarded as more or less of a dispensation of a Divine Providence and
therefore to be accepted with the same philosophical resignation as
earthquakes and cyclones.

In dramatic contrast to this unresisting attitude is the present
knowledge concerning the cause and prevention of this disease, and the
general belief that it is a wound infection and therefore practically
preventive; that it is to be ascribed to the carelessness of mankind
rather than to the indifference of Providence.

This change is due very largely to the devoted work of three men who
were deeply stirred by the tragic frequency with which young women laid
down their lives in so-called “child bed fever.” These men were Ignaz
Semmelweiss, Oliver Wendell Holmes, better known to Americans as poet
and humorist, and Louis Pasteur, each contributing his own special
observations to the sum of knowledge which was to mean so much to
mothers of the future. Also the theories of Lister concerning antisepsis
and the inauguration of the use of sterile rubber gloves by Dr. Halsted,
of Johns Hopkins Hospital, has had the same life-saving effect upon
obstetrical patients as upon all surgical patients.

In 1843, Oliver Wendell Holmes read a paper before the Boston Society
for Medical Improvement, entitled “The Contagiousness of Puerperal
Fever.” In this paper he presented striking evidence that in many
instances, something was conveyed by doctor or nurse, from an ill person
to a maternity patient with puerperal fever as a result. He was attacked
and ridiculed for his theories and some of the leading obstetricians
declared that it was an insult to their intelligence to expect them to
believe that creatures too small to be seen by the naked eye could work
such havoc.

In 1847 Ignaz Semmelweiss, of the Vienna Lying-in Hospital, decided as a
result of some of his investigations that puerperal infection was a
wound infection, and that the infecting organisms were introduced into
the birth canal on the examining finger of the doctor or nurse, after
contact with an infected patient or cadaver. Accordingly he required
that all vaginal examinations be preceded by washing the hands in
chloride of lime, after which precautions the mortality from infection
dropped from 10 per cent. to less than 1 per cent. In 1867 Semmelweiss
offered his theories and conclusions in a masterly work on this subject,
the title of which may be translated as “The Etiology, Conception and
Prophylaxis of Child-Bed Fever,” but the actual cause of the disease was
still unknown.

But about 1879 Pasteur demonstrated what is now known as the
streptococcus, in certain patients suffering from puerperal fever.

  “Pasteur,” wrote M. Roux, “does not hesitate to declare that that
  microscopic organism (a microbe in the shape of a chain or chaplet)
  is the most frequent cause of infection in recently delivered women.
  One day, in a discussion on puerperal fever at the Academy, one of
  his most weighty colleagues was eloquently enlarging upon the causes
  of epidemics in lying-in hospitals; Pasteur interrupted him from his
  place. ‘None of those things cause the epidemic; it is the nursing
  and medical staff who carry the microbe from an infected woman to a
  healthy one.’ And as the orator replied that he feared that microbe
  would never be found, Pasteur went to the blackboard and drew a
  diagram of the chain-like organism, saying: ‘There, that is what it
  is like!’ His conviction was so deep that he could not help
  expressing it forcibly. It would be impossible now to picture the
  state of surprise and stupefaction into which he would send the
  students and doctors in hospitals, when, with an assurance and
  simplicity almost disconcerting in a man who was entering a lying-in
  ward for the first time, he criticised the appliances, and declared
  that the linen should be put into a sterilizing stove.”[13]

Slowly, but very slowly, the teachings of these earnest men were adopted
by the medical profession, with the result that in well-conducted,
modern hospitals the precautions which have been described in preceding
chapters are rigidly observed. And to-day, one woman in about 1,000 in
such hospitals dies of puerperal infection, instead of one in ten, as in
the early days. In the year 1864, 23 per cent. of the patients at the
Maternité, in Paris, died of puerperal infection.

But unhappily, the decline in the occurrence of puerperal infection, in
this country is largely confined to the hospitals, for in the homes
throughout the land the disease is almost as common as it was in the
days of our fathers, or even grandfathers. Of approximately 20,000
deaths from childbirth in this country during 1920, about one-half, or
possibly 10,000 were from puerperal infection.

To the nurse there is considerable significance in Pasteur’s
characterization of the infected young mother as an “invaded patient,”
for the nurse’s preparation for labor and her care of the patient during
the puerperium should be enormously influential in preventing this
“invasion.” In this connection she may well ponder Miss Nightingale’s
assertion that “The fear of dirt is the beginning of good nursing.”
Certainly the obstetrical patient cannot be well cared for unless the
nurse has this fear in her heart.

Puerperal infection, then, in the light of present information, is
regarded as a wound infection caused by the streptococcus, gonococcus,
colon bacillus, gas bacillus or any other pus producing organism. Of
these, the streptococcus infection is the most frequently seen and is
also the most serious, about 10 per cent. of such infections resulting
fatally; while the gonorrheal infection, though seldom ending in death,
usually causes sterility.

Infection during the puerperium occurs most often in the uterus, and, if
mild, may amount to nothing more than endometritis, or inflammation of
the uterine lining. In more serious cases, the inflammation may spread
to the tubes and ovaries; may cause abscesses in the broad ligament and
general peritonitis. A streptococcus infection may spread through the
lymphatics and cause general septicemia.

Infection of the raw and bleeding placental site may occur at any time
during labor or the ten days following, though the danger of infection
decreases steadily after the first day postpartum.

=Symptoms.= The symptoms vary greatly according to the infecting
organism and according to the site and extent of the inflammation. In
mild types of infection, the patient may be entirely normal for the
first three or four days and then complain of chilliness or even have a
chill; her temperature will be slightly above normal, finally reaching
about 101° F., where it hovers for ten days or two weeks, after which it
drops again to normal and the patient recovers.

The severe type, which is so dreaded, is the one in which the patient is
normal until the third or fourth day when she complains of tenderness,
chilliness, weariness, and of being generally wretched. She may complain
of chilliness but more often has a chill.

The pulse is usually rapid and the temperature goes up somewhat
abruptly. (Chart 3.) The condition of the lochia depends upon the
infecting organism. In streptococcal infection the lochia is often
greatly decreased in amount and almost odorless, while in colon bacillus
infections the lochia is profuse and foul-smelling. The attack may be
very acute and result fatally in a few days, or it may gradually subside
and the patient recover.

[Illustration:

  CHART 3.—Chart showing rise in temperature about 3rd day after
    delivery in a _streptococcus infection_.
]

[Illustration:

  CHART 4.—Chart showing rise in temperature about 7th day after
    delivery in _gonorrheal infection_.
]

In gonorrheal infections the temperature does not go up until later,
from the sixth or to the tenth day, as a rule. (Chart 4.) The patient is
not usually very ill and generally recovers. But the gonococcus is very
likely to produce an inflammation of the tubes and to close up the
fimbriated opening. Thus it is impossible for ova thereafter to enter
the tube and gain access to the uterus and accordingly the patient
cannot again become pregnant. Unlike other infections, gonorrhea is not
conveyed to the patient during or soon after labor on instruments or
examining fingers, but is already present in the vulvo-vaginal glands
and from them may travel to the uterine cavity and to the tubes.

=Treatment and Nursing Care. Preventive.= There is so little that can be
done toward curing a patient suffering from puerperal infection that the
greatest effort should be made to prevent the disease. The nurse’s part
in preventing this complication is an important one and consists of
making such preparation for labor that it may be conducted with absolute
cleanliness; maintaining the same asepsis during delivery as she would
throughout a major surgical operation and protecting the perineum from
infection after delivery.

=Curative.= The curative treatment for puerperal infection resolves
itself largely into good nursing care. The patient should be kept warm
and quiet and as comfortable as possible; elimination is promoted, her
strength is saved and her general resistance increased in every way
possible. The head of the bed is frequently elevated, to promote
drainage; the windows are kept open to provide plenty of fresh air; the
diet is light and nourishing and the patient is encouraged to drink an
abundance of water. Ice caps to the head and abdomen are frequently used
to make the patient more comfortable; also cold sponge baths when the
temperature is high.

A patient suffering from puerperal infection should be conscientiously
isolated. If the nurse who cares for her is forced to come in contact
with other patients, she should wear gloves and a gown while attending
the infected woman and thoroughly scrub and soak her hands after each
attention.

It was formerly the practice to curette the patient suffering from
puerperal infection, and give intra-uterine douches, but it is now
pretty generally believed that neither of these procedures does any
appreciable good, but on the other hand may do harm. The objection to
curettage is on the ground that by this means the protective wall which
Nature has developed to prevent the further invasion of bacteria into
the uterine tissues, is removed and a new bleeding area is provided for
further and easy development of the inflammation.

Antiseptic douches seem to be useless, for if they are strong enough to
be germicidal they are likely to injure the tissues and also do harm by
being absorbed into the system; while weaker solutions will not destroy
the organisms but are likely to carry more infective material up into
the uterus. In cases of putrid endometritis, however, if the doctor
cleans out the uterus with his finger, a douche of sterile salt solution
is often given for the purpose of removing any putrefactive material
which may have been left behind.

=Phlegmasia alba dolens or “milk leg.”= In some cases of puerperal
infection, thrombi are formed in the veins of the pelvis, from which
particles may be broken off and carried to various parts of the body and
cause phlebitis or even abscesses. If thrombi lodge in the large vessels
of the thigh, the interference of the venous circulation results in
swelling and tenderness of the leg which is often referred to as “milk
leg.” This condition is rather rare and does not usually appear until
the second or third week after delivery.

The swelling ordinarily starts at the foot and gradually extends up to
the thigh. The patient complains of pain in the calf of her leg and she
may have an elevated temperature, rapid pulse and the general
wretchedness associated with an infection.

The main feature of the treatment is rest in bed; the patient should be
kept there for at least a week after her temperature becomes normal; her
leg should be elevated, wrapped in cotton batting and the bedclothes
held from it by means of a bed cradle or some sort of a light frame. The
nurse should never rub the affected leg, and the patient should also be
cautioned against this for fear of dislodging a particle of the thrombus
and causing an embolism elsewhere, possibly in the lungs. For the same
reason, the patient must be warned not to make sudden or violent
movements for some time after she is allowed to be up and about, but to
walk and move rather slowly. The swelling and discomfort may subside in
a few weeks or they may persist for months.

=Puerperal Mania.= A word about extreme mental unbalance during the
puerperium is worth while at this point because the nurse will
frequently hear of this distressing condition, and will almost
inevitably come in contact with it at some time. It was formerly
believed that there were certain mental disorders which were peculiar to
pregnancy and the puerperium, but this belief has given way before the
present knowledge of psychiatry.

The puerperal patient is sometimes delirious and violent for longer or
shorter periods of time, but apparently these conditions are due to
toxemia or fever, or a mental unbalance has resulted from her reaction
to the idea of motherhood, just as it would have resulted from an equal
strain of some other character.

In other words, the young mother may suffer mental derangement from the
same causes that would produce this state in any other person, but not
from causes or conditions which are peculiar to the puerperium.

If the excitement or delirium are due to a toxemia, they are relieved by
treating the cause, while from the nurse’s standpoint the care would be
the same as for any delirious patient. The patient should not be left
alone and she should be protected against doing herself any injury.

A mental disturbance which is due to the patient’s inability to adjust
herself to the state of motherhood, and all that that implies to her, is
a different matter, and is discussed in the chapter on mental hygiene.


  “Sympathy with, interest in the poor so as to help them, can only be
  got by long and close intercourse in their own houses—not
  patronizing—not ‘talking down’ to them—not ‘prying about’—sympathy
  which will grow in insight and love with every visit.”—FLORENCE
  NIGHTINGALE.



                                PART VI
                 THE MATERNITY PATIENT IN THE COMMUNITY


  CHAPTER XIX. ORGANIZED PRENATAL WORK. Mortality in Childbearing. Aims
    of Prenatal Care. Difficulties: Educational, Economic, Social,
    Professional. Prenatal Work in Other Countries. Progress of Prenatal
    Work in this Country. The Women’s Municipal League of Boston.
    Maternity Centre Association of New York. Routine and Methods.
    Results. The Situation in the Country as a Whole. Prenatal Care in
    Rural Communities. Forms and Routines used by Maternity Centre
    Association, New York City.

  CHAPTER XX. HOME DELIVERIES AND CARE OF THE YOUNG MOTHER BY VISITING
    NURSES. Forms and Routines of the Philadelphia Visiting Nurse
    Society.



                              CHAPTER XIX
                        ORGANIZED PRENATAL WORK


The foregoing discussions of prenatal care and the principal
complications of pregnancy, and the dangers to which expectant mothers,
young mothers and their babies are exposed, bring us sharply face to
face with the questions, “What can be done about it?” “What is being
done about it?” and, “Is anything more possible?”

We have considered the problem, and the remedy, at very close range;
that is, from the standpoint of the individual patient. We are now
concerned to know whether or not the remedy, in the shape of care and
supervision during pregnancy, may be extended in proportion to the
enormous multiplication of the problem, when instead of one patient we
must think of millions. In other words, is country-wide prenatal care,
with all that it implies, practicable? And if so, by what means or
method?

Let us review the problem for a moment, and acknowledge the pathos and
tragedy of it.

Child-bearing is so dangerous, under present conditions in this country,
that it stands second only to tuberculosis as a cause of death among
women between the ages of 15 and 44. The discharge of woman’s supreme
function is apparently very hazardous.

Dr. Dublin summarizes as follows the rate at which mothers die
throughout the country at large:

  1. “More than seven women die from disorders of pregnancy or
       childbirth out of each 1,000 confinements. This is equivalent to
       one maternal death out of every 140 confinements. (About 20,000
       in 1920.)

  2. “Forty-five babies out of every 1,000 births, or one out of every
       22, are born dead. (About 112,000 annually.)

  3. “Forty babies out of every 1,000 born alive, die before they are
       one month old. (About 100,000 annually.)

     “Such are the dangers to mother and infant at the present time.”

And then, as though in answer to our question, “What can be done about
it?” he states that, “among women who receive prenatal and maternal care
under skilled direction:

  1. Only _two_ women instead of _seven_ die out of every 1,000
       confinements.

  2. Only _twelve_ babies, instead of 45, are still-born in every 1,000
       births.

  3. Only _ten_ babies, instead of 40 per 1,000 born alive, die before
       they are one month old.”

Obviously, then, only a few—too few—American women are receiving the
minimum of care that makes child-bearing a reasonably safe adventure.

Perhaps it will be well for the nurse to pause just here for a fresh
reminder that the end really to be desired through prenatal care is not
so much the mere prevention of death among mothers and infants, as the
promotion of health, as well; our charges must be not only saved but
saved to mental and physical health, vigor and well-being, capable of
being useful, productive citizens. Happily, both life and health are
conserved by the same measures, and effort toward either end helps to
accomplish both.

Although the inhabitants of a prosperous country like the United States
should be a hardy people, the results of medical examinations by the
draft boards, during the war, gave us a rude awakening to the fact that
they are not.

An appallingly large number of young men who were passing in every day
life as normal were found to be physically unfit for military service.
And we know that a large part of this unfitness resulted from inadequate
care, of some kind, during the weeks and months that comprise the
beginning of life.

It can scarcely be doubted that the most critical period in the life
history of the individual is the first ten months—the nine months of
intra-uterine life and the first month after birth. Good care, then,
during this critical period is indispensable in the building of a
healthy race. The difficulty in the way of giving this care, at present,
seems to be fourfold: educational, economic, social and professional,
and may be summed up somewhat as follows:

  1. From the educational standpoint, almost universal ignorance of the
       need of skilled obstetrical care.

  2. From the economic standpoint, financial inability of the average
       woman to afford such care.

  3. From the social, or administrative, standpoint, a fairly general
       failure on the part of public authorities to recognize the
       situation as one of grave national importance.

  4. From the professional standpoint, inadequacy of available
       obstetrical service, both medical and nursing.

In many of the large cities women have access to excellent obstetrical
and prenatal care; both those who can pay for it and also the poor woman
who cannot, though very many in both groups still fail to take advantage
of the opportunities that are open to them.

But the city women of moderate means, and those in small towns and rural
communities are in general unprovided for. And it is their babies who
grow up and later constitute the backbone, weak or strong, of the
nation.

Certain foreign countries which have evinced more concern for the
welfare of mothers and babies than has the United States have
demonstrated that widespread prenatal care is entirely possible and
practicable, and they regard it also as an imperative measure toward
promoting the national welfare.

The actual origin of this prenatal care is somewhat difficult to locate.
There are the consultations for pregnant women instituted in Paris
several years ago by Dr. Budin. But Dr. Ballantyne, of Edinburgh, is
generally regarded as the father of the prenatal work because of his
work on abnormalities of pregnancy and his insistence upon the
importance of what might be accomplished through intelligent care and
supervision of all women, not alone abnormal cases, throughout
pregnancy.

In England for nearly twenty years the supervision and instruction of
expectant mothers has been an integral part of the work of midwives who
are trained, registered and controlled by government authority. Of late
the work among mothers and babies has been so extended that during the
war, always a destructive period for babies, the infant death rate was
reduced to the lowest figure in the country’s history. This was
accomplished partly through a maternity benefit which helped the mother
to pay for obstetrical care, and partly through indirect government aid,
in the form of: compulsory notification of births; a great increase in
the number of “health visitors” and welfare centres, and government
grants to local authorities which defrayed half the expense of giving
prenatal, natal and postnatal care and of instructing mothers in the
care of themselves and their babies. Especial effort has been made to
help the mothers in rural sections; more small hospitals being
maintained, more physicians being provided and assistance given in
caring for older children, during the mother’s absence, if she was
obliged to go to a hospital at the time of delivery.

New Zealand also has made marked progress in its work of saving the
lives and promoting the health of its mothers and babies, having at
present the lowest infant death rate in the world. This has been brought
about largely through the efforts of the “Society for the Health of
Mothers and Children,” an organization employing visiting nurses, called
Plunkett Nurses, in honor of the family by that name which has greatly
aided the work.

The outstanding features of this work are educational and preventive;
the mothers being instructed from early in pregnancy about the care of
themselves and the preparation for, and subsequent care of their babies.
Prenatal clinics are maintained and the facilities for hospital care are
being steadily increased and improved.

One is impressed by the spirit animating this organization, as expressed
in a statement of its “functions,” one of which is as follows: “To
uphold the sacredness of the body and the duty of health, to inculcate a
lofty view of the responsibilities of maternity and the duty of every
mother to fit herself for the perfect fulfillment of the natural calls
of motherhood, both before and after childbirth, and especially to
advocate and promote the breast feeding of infants.” Work based upon
such idealism could not but be effective.

The New Zealand undertaking is regarded as patriotic, rather than
philanthropic, and mothers who are visited and cared for are accordingly
encouraged to pay for this service, if financially able to do so. The
Government supervises and warmly supports the work of this Society and
also aids by enforcing the most perfect system of birth registration in
the world, without which the results of the work could not be accurately
gauged.

England and New Zealand, as countries, have pointed the way toward
accomplishing a nation-wide reduction of maternal and infant mortality
and morbidity by making provision for widely organized prenatal care.
They recognize the problem as one of public concern. They get at the
heart of it: ignorance on one hand and poor or inadequate care on the
other. They apply a practical solution, comprising a system of
preventive, instructive prenatal care, together with improved and
increased facilities for medical and nursing care at the time of
delivery and afterward.

This country has been strangely laggard in making widespread, organized
effort along these lines, to safeguard its mothers and babies, through
prenatal care. But sporadic, volunteer effort has been made in certain
cities, and has been crowned with brilliant success.

The first of these attempts in this country was made in Boston, in 1909,
with a maternity nurse working under the auspices of the Women’s
Municipal League. The work, which was established by Mrs. William Lowell
Putnam, was designed to show what could be accomplished by intensive
work in a small group of city mothers, and suggest the feasibility of
its extension to larger numbers.

“The routine, which has been evolved through a five-year experiment by
the Prenatal Committee of the Women’s Municipal League,” says Mrs.
Putnam, “has reduced the infant deaths, among those cared for by a third
to one-half, as compared with cases not receiving this care.
Still-births have been cut in half. Premature births have been reduced
to seven-tenths of one per cent. These results were obtained by
supervision during pregnancy only, and at a cost of less than $3.00 per
patient; an expense which the patients were always encouraged to meet if
possible.

“The success of this venture proved to be so satisfactory that the
Boston workers have gone still further toward supplying the needs of
mothers and babies by adding to the prenatal care, care at the time of
birth and afterwards until the mother is again on her feet. Through the
courtesy of one of the largest Boston hospitals, a clinic is held weekly
in its Out-Patient Department. The hospital is in no way responsible for
the clinic, simply lending the room in which the clinics are held. The
medical care at the clinic and in the patients’ homes is given by
obstetricians from the staff of the Boston Lying-in Hospital. Medical
examinations are made during pregnancy at the clinic, and a nurse visits
and instructs the patient during the period of expectancy, always under
the direction of a physician. The delivery is performed in the home by a
physician connected with the clinic, at which the nurse also is in
attendance. She visits the mother and baby twice daily for three days
subsequent to the delivery, gradually making her visits less frequent
thereafter. The doctor pays from two to four postnatal visits, as may be
needed. For this prenatal, natal and postnatal, medical and nursing
care, $40.00 is the entire amount charged, and the work is
self-supporting with the nurse’s time filled. Prenatal care, alone, is
given if desired by a physician and with visits at the clinic included;
the charge for this service is $10.00.”

I refer to the work in Boston, particularly, as its inauguration by Mrs.
Putnam marked the beginning of this branch of public-health work in this
country, though to-day the same kind of service is available to
expectant mothers in many of the large, and some of the smaller cities.
Visiting nurse associations, the country over are giving postnatal and
infant care (in some instances, excellent prenatal care, too), often
providing for or assisting with the deliveries, and effecting an
enormous saving of life and health by so doing. But the number of
patients who are cared for by each organization is relatively so small
that even the aggregate of the work done reaches a pathetically small
proportion of the mothers and babies in the country as a whole who need
care.

The first comprehensive effort, in the United States, to meet the need
of all expectant mothers in an entire community, was inaugurated in New
York City, in 1918, by the Maternity Centre Association, the chief
function of the organization being to coordinate the work of agencies
already in existence.

This Association was formed as a result of the work of the Maternity
Protective Committee of the Women’s City Club and the Maternity Service
Association of Physicians and Hospital Superintendents.

The form of organization, purpose and methods of work of this
association may be studied with profit, for having been started on a
small scale as an experiment, it now constitutes a demonstration of how,
through co-ordinated effort, prenatal and obstetrical care may be
extended almost indefinitely to expectant mothers in urban districts,
and at a low cost.

The purpose and scope of the work are described by Miss Anne Stevens,
its former Director, who tells us “that it is the aim of the Association
to cover completely the need for maternity care, prenatal, delivery and
postnatal, in a given community, by providing for every woman in that
community, medical supervision and nursing care from the beginning of
her pregnancy until her baby is one month old. This is being attempted,
not by establishing another medical and nursing agency, but by
establishing a centre through which the maternity work of every
hospital, private physician, midwife and nursing agency in the community
may be co-ordinated and developed to its fullest extent; a centre at
which there will be a complete record of every pregnancy in that
district; a centre from which the whole community may be educated to
realize the need of and to demand adequate medical supervision and
nursing care for every woman and her baby before and after birth.”

It is not, then, an experiment in prenatal clinics, many of which have
been conducted, both in New York and elsewhere; but it is an experiment
in its attempt to provide adequate care for every pregnant woman in the
community from the beginning of her pregnancy until her baby is a month
old.

Standards for adequate prenatal care, upon which to base the work, were
formulated by the Maternity Service Association of Physicians. The
nurses worked with these standards as a guide and gradually developed
detailed routines, as a result of frequent conferences over the
difficulties and problems arising in the course of their daily work
among the patients.

These various adaptations were, of course, approved and authorized by
the Medical Board of the Association. Because these routines meet the
doctor’s requirements so satisfactorily, and have been evolved out of
the experience of many nurses, concentrating their best efforts upon
this work, they are copied on pages 423 to 436 with the belief that they
will be suggestive, and perhaps save time and effort for those who may
wish to inaugurate similar work.

Every effort is made by the Association to reach all of the expectant
mothers in the ten zones into which, for the purposes of the work, the
Borough of Manhattan was divided by the preliminary committee[14] called
by Dr. Haven Emerson, who at that time was Commissioner of Health for
New York City. This Committee was called for the purpose of surveying
the obstetrical facilities of Manhattan, and offering suggestions as to
how they might be utilized in an effort to decrease the persistently
high infant mortality.

Patients are reported for care by hospitals, dispensaries, clinics,
relief agencies, church clubs, settlements and the like and are
discovered in various ways by the nurses on their rounds.

The nurse’s first visit to a patient is little more than a friendly one.
In fact, she may have to make several such calls before she is able to
so far win the patient’s confidence and friendship that she will consent
to place herself under supervision. For in addition to obtaining her
verbal consent, the establishment of this sympathetic relationship is
found to be necessary before the nurse can feel sure that the patient
will freely tell of her symptoms and follow the advice given.

Before making plans, or talking to the patient about prenatal care, the
nurse ascertains what arrangements, if any, the patient herself has made
for care at the expected confinement. She finds that the expectant
mothers fall into four groups:

  1. Those who have registered with a hospital.

  2. Those who have arranged to be cared for by a physician.

  3. Those who have arranged to be cared for by a midwife.

  4. Those who have made no arrangements of any kind.

The nurse’s relation to a patient registered with a hospital for
delivery depends upon the scope of the work of that particular
institution. Some hospitals will register patients early in pregnancy,
and assume the entire medical and nursing care and supervision from that
time until after the baby is born. The Maternity Centre nurse,
obviously, has no responsibility for these patients. But she does give
nursing care and instruction to patients registered with hospitals which
have not facilities for prenatal clinics or visiting nurses to send into
the patients’ homes. The hospital resident, in these cases, assumes
responsibility for medical supervision of the patients and receives a
report from the Maternity Centre upon each nursing visit; and the nurse
in turn urges the patient to return to the hospital, periodically, to
see the doctor, in accordance with instructions received from the
hospital.

This form of co-operation has proved to be so satisfactory that many
hospitals now do not wait for the Maternity Centre nurses to discover
patients registered with them, but each day notify the nurses of newly
registered patients and ask that they be given the routine nursing care
and supervision by a Maternity Centre nurse.

When a nurse finds, upon her first visit to a patient, that she has
engaged a physician to attend her at the time of confinement, she gives
no advice, but sends to the doctor a form letter, prepared by the
Medical Board, offering to nurse that patient according to the routine
of the Maternity Centre Association if he wishes, and to report to him
upon each nursing visit. A very small percentage of physicians refuse
this offer of assistance, the majority accepting it with eagerness.
Patients who have engaged their own physician for delivery, naturally,
are not asked to go to the Maternity Centre clinics for medical
examination or advice, but are invited to go for the nurse’s
instructions, and to attend the group conferences that will be described
later.

If the patient belongs to the third group, having engaged a midwife, the
nurse goes in person to see the midwife, as letters are usually of
little avail. She asks the midwife to bring her patient to the clinic,
explaining that, though midwives are taught to conduct deliveries, they
are not taught to make the examinations that are now known to be so
important to the future welfare of mothers and babies, but that such
examinations can be made at the clinic by the doctor. If the initial
examination discloses any abnormality, this fact is explained to the
midwife and also that the rules governing her practice forbid her caring
for such a patient. The nurse, midwife and patient then plan for
adequate care at the time of delivery. In this way the nurses win and
retain the confidence and good will of the midwives; and since these
women exert a powerful influence over their patients and their families,
their co-operation is of considerable value in persuading the patients
to accept more skilled care than midwives can offer.

If, on the other hand, the initial examination does not disclose any
abnormality, the midwife is simply asked to allow the nurse to visit the
patient at regular intervals, in a supervisory way, and to have the
patient report to the clinic doctor for his periodic observations and
advice. The intelligent midwives, who speak English, are usually
co-operative, but the others are sometimes suspicious and persuade their
patients to refuse the nurse’s supervision.

For the patients in the fourth group, those who have made no arrangement
for care at the time of delivery, the nurse is even more responsible.
The plans for these patients include three fundamental requirements: a
complete physical examination; the correction of physical defects, so
far as is possible, and a study of the environment and social status of
the patient; this in order to adapt the care during pregnancy and at the
time of delivery to each individual’s condition and circumstances.

From time to time the nurse explains to the patient, as much as she can,
about pregnancy and the changes that accompany it and the reasons for
the advice that is given, in order to secure her intelligent
co-operation. Experience has taught that it is not enough to advise the
patient to do thus-and-so because the doctor thinks best. But if she
understands that examination of her urine, for example, may disclose
conditions that can be cured, but which if neglected may cause
headaches, or convulsions, she is much more likely to provide a specimen
for examination than if she is asked for one without explanation.

The care of each patient is a tactful adjustment of the prescribed
routine to the condition, habits and temperament of that patient. It is
carried on through a combination of visits which the nurse makes to the
patient’s home and visits which the patient makes to the nurse at the
Maternity Centre in her district. The advantages of this combination of
visits are, that the nurse first knows the patient in her own home, and
can help to plan for the desired care with the conditions of this home
in mind, and perhaps evolve from the patient’s simple belongings the
equipment needed for her care; also that at the Centre it is possible to
assemble the patients and give them a certain amount of informal group
instruction. There is at each Centre a doll model of a baby; a model of
a baby’s bed (Fig. 144), showing that a box or a basket may be used with
entire satisfaction; a model of the mother’s bed, prepared for delivery
at home and protected with newspaper pads; a complete layette (Fig. 145)
to show the mothers how simple such an outfit can and should be;
patterns for making each garment and some one to help the women to make
them; a breast tray (Fig. 146) and a baby’s toilet tray (Fig. 147), so
complete and yet so simple that no woman with a few chipped or cracked
cups to spare need be dismayed.

[Illustration:

  FIG. 144.—Separate bed for the baby improvised from a market basket.
    (By courtesy of the Maternity Centre Association.)
]

In the course of this group instruction the women are taught how to
prepare for, and later care for their babies. One week, the nurse
demonstrates to the group how to handle the baby, dressing and
undressing or bathing it; or explains the reason for making each article
in the model layette, or the purpose and use of each article on the
toilet tray, and shows them how to make boric acid solution and swabs.
In short, each detail in the care of the baby is gone over. Every
alternate week the mothers demonstrate to the nurse. They dress and
undress the doll model; explain and demonstrate how to make boric acid
solution; how to prepare sterile water and give it to the baby. Many of
the mothers attend the classes for several weeks in succession, and
frequently a mother returns with her three-week-old baby to make sure
that she has not forgotten any of the details of infant care which the
nurse tried to teach her before the baby came.

[Illustration:

  FIG. 145.—Layette recommended to patients by Maternity Centre
    Association:

  A. Flannel binder.
  B. Knitted band with straps.
  C. Shirt.
  D. Petticoat.
  E. Dress or nightgown.
  F. Diaper.
  G. Pad for basket-bed.
  H. Flannel square.
]

[Illustration:

  FIG. 146.—_Breast tray_ improvised from articles to be found in any
    home, contains: Jar of cotton pledgets; bottle of liquid petrolatum;
    soap on saucer, covered with cup for water to bathe nipples. (By
    courtesy of the Maternity Centre Association.)
]

A patient is not asked to go to the Centre for any reason if she seems
very reluctant to go; or if her going is inadvisable for physical
reasons or if it would entail great hardship, because of young children
who would have to be taken with her, or left at home alone. But when
they can go, it simplifies the work and enables each nurse to supervise
a larger number of patients than if she did all of the traveling and
visiting.

[Illustration:

  FIG. 147.—_Baby’s toilet tray_ equipped with jelly glasses, bottles,
    celluloid hair receiver for cotton, and a soap dish, containing:

  1. Safety pins sticking in cake of soap.
  2. Jar for sterile nipples.
  3. Jar of sterile water.
  4. Jar of boracic acid solution.
  5. Nursing bottle.
  6. Sterile water to drink.
  7. Nursing bottle for water.
  8. Small tooth pick swabs.
  9. Liquid petrolatum.
  10. Gauze mouth swabs.
  11. Absorbent cotton.
  12. Soap.

  (By courtesy of the Maternity Centre Association.)
]

Each patient is seen by a doctor or a nurse every two weeks until the
seventh month of pregnancy, and once a week after the seventh month. At
each visit the nurse follows as much of the prescribed routine as is
possible; this routine consists of testing for albumen in the urine;
taking the systolic blood pressure; listening to the fetal heart;
questioning the patient and looking for the objective symptoms of
complications. During these visits to the homes the nurses are able also
to help their patients assemble entirely satisfactory outfits for the
care of their nipples, consisting perhaps of jelly glasses, cheese jars,
or handleless cups. And they help to find a place on the shelf where
this little equipment may be kept undisturbed and always ready for use.
When it comes to the measuring of urine, they explain that the regular
size tomato can holds just a quart, and is therefore quite as
satisfactory for that purpose as a costly graduated glass measure.

No patient is dismissed for failure to follow advice; the nurse
continues her visits, unless the patient positively refuses to admit
her, and she continues to advise, adjusting and modifying the ideal
routine and persuading the patient to do as much as she can, or will.

If abnormalities develop during pregnancy, the nurse arranges for
immediate medical care, either at the patient’s home or in a hospital.
If the clinic doctor feels that the patient should have hospital care,
but she will not or cannot go to a hospital, she is persuaded to engage
a doctor, and a nurse from the Centre helps, as a visiting nurse, to
take care of the patient in her own home.

The next responsibility of the nurse is to advise the patient in
arranging for care at the time of delivery, this advice being based upon
the patient’s physical condition, the circumstances of her home life and
the available facilities for care. Although hospital care may be the
ideal for all patients, from an obstetrical standpoint, the mother
cannot always be removed from her home with safety to the family circle.
Her physical and social conditions therefore are considered together; if
there is no complicating home problem, it is usual to advise hospital
care for primiparæ and for all patients who have, or develop
abnormalities, or have a history of previous difficult labors,
complications or abnormalities.

Patients who, the doctors think, give promise of having complicated
labors and who prefer to remain at home are advised to engage a doctor,
and to arrange with the Henry Street Settlement for nursing care at the
time of delivery and during the puerperium, as the Maternity Centre
nurses do not perform this service.

At one time, however, the Centre provided assistance to patients
delivered at home, in the shape of a working housekeeper to discharge
the mother’s household duties while she remained in bed the necessary
length of time after the baby was born, or in some cases, while she took
much needed rest during the latter part of pregnancy. For this purpose
the nurses had a list of women who were good housekeepers and clean
workers and whose own children were partly grown. These women were glad
of an opportunity to do part time work and earn a little extra money.
They were paid thirty cents an hour, twenty-five cents for lunch and
whatever their carfare amounted to, the patient paying whatever she
could afford toward the fund, provided by the Women’s City Club, from
which these working housekeepers were paid. This service, which in no
wise replaced the nurse’s care, has been temporarily discontinued
because of lack of funds, but proved to be so valuable that it will be
resumed as soon as possible.

Supervisory postnatal visits are paid to patients, not under the care of
the visiting nurse service, who have been under Maternity Centre
Association care during pregnancy, as well as to those who have not had
this care but are referred to the Centre, by hospitals, upon their
discharge. The nurse first visits to satisfy herself that the mother is
able to care for her baby and to give any instructions that seem to be
necessary. She then visits the patient, or the patient visits the nurse,
when she is able, until the baby is a month old, when she is urged to
register the baby at a baby health station.

The importance and value of birth-registration is explained to the
mother and the nurse endeavors to have a copy of a birth certificate in
the mother’s hands before the case is dismissed.

The importance of post-partum examinations, not later than six weeks
after delivery, is also impressed upon the patient. Patients who are not
to be examined by the doctors who delivered them are given a post-partum
examination by a doctor at the Maternity Centre, to make sure that they
are dismissed in good condition, or are referred to the proper agency
for further care, this being the first step in prenatal care for the
next baby.

Is all of this elaborate organization and detailed care worth while?

A recent statement issued by the Maternity Centre Association replies
convincingly that it is. It says that during 1920 among women in the
Borough of Manhattan not under Maternity Centre supervision:

  1. One mother died for every 205 babies born. (One out of 14 for the
       rest of the country.)

  2. One out of every 26 babies born, died under one month of age.

  3. One out of every 21 babies was born dead.

Whereas, among women in Manhattan who were supervised by the
Association, during the same period:

  1. One mother died for every 500 babies born.

  2. One out of every 51 babies born, died under one month of age.

  3. One out of every 42 babies was born dead.

The Association does not usurp nor supplant, but endeavors to give
impulse to public and private agencies alike in affording the best
possible supervision and care for expectant and parturient mothers and
their babies.

Thus has the stupendous problem in New York been attacked with courage
and with gratifying results. Much might be accomplished in smaller and
less complex communities with proportionately less difficulty.

But all of the foregoing relates to city dwellers. What about the
expectant mothers in isolated and rural communities?

I wish we did not have to say.

Prenatal care is practically unknown among them and there is scarcely
any provision for obstetrical care, either. The nearest physician may
live miles away and even though one were near, country women and their
husbands do not always feel that the expense of employing a doctor, for
mere childbirth, is justifiable.

In certain Northern and Western communities, that were considered fairly
representative of those sections, conditions have been studied at some
length by agents of the Federal Children’s Bureau. They found that about
half of the mothers in those communities had no medical attention
whatever in childbirth. Untrained women, friends or neighbors,
frequently someone’s grandmother, were in attendance. Or husbands or
workmen were pressed into service. A few women were entirely alone in
their hour of trial. Scarcely a mother among them received prenatal care
and instruction worthy of the name.

In the Southern states, the proportion of women delivered by physicians
seems to be even smaller than in the North and West, and in some of the
mountain regions the conditions are distressing. From one such locality
we learn that when a woman goes into labor the first passing teamster is
hailed, or perhaps a member of the family hurries down the road for the
nearest tanner or blacksmith, or any one else, who in total ignorance
will fearlessly rush in to meet the great emergency. The results of this
practice—dismembered infants and badly injured or dead mothers,—are too
sickening to describe, but may be imagined by any nurse who has seen
good obstetrical work and appreciates its value.

From another mountain region in the South comes the contrast in accounts
of the work done by Miss Lydia Holman, founder of the Holman
Association, as evidence of what skill and desire may accomplish.
Something more than twenty years ago this nurse started volunteer
visiting nursing among the mountain people, with no precedent to follow
and no Board to direct or advise. But there were sick people all about,
people needing care, and Miss Holman was not only trained but eager to
nurse them, and after all these qualifications are the chief requisites.

After all these years of self-sacrificing, pioneer work, of which
American nurses may justly be proud, Miss Holman has the enviable
satisfaction of knowing that she has lessened the perils of childbirth
for some 600 women and saved practically all of their babies. Much of
this in the simplest, most meagerly equipped mountain homes. She has
even managed to have some of the mothers taken to a nearby town for the
repair of lacerations which occurred during labor. And she has a little
hospital now up on the mountain top, with doctors and nurses, not only
caring for sick people, but, among other things, teaching women and
girls how to care for infants and children.

A complete maternity service for rural communities would evidently
include small hospitals for primiparæ and abnormal cases and to serve as
centres from which nurses and doctors would carry on prenatal
supervision and instruction, and give skilled attention at birth;
followed by visiting nursing of the young mother and her baby. The
prenatal supervision in sparsely settled districts might leave much to
be desired, because of the impossibility of seeing each patient as often
as is wise. But even a little care would be an improvement upon present
conditions. In some localities, it has been found possible to teach some
of the more intelligent of these rural mothers a good deal about their
own supervision. One nurse tells of a very isolated woman who could only
be visited at long intervals whom she taught to test her own urine for
albumen, explaining its possible significance and seriousness. One day
the report card that came by mail indicated that the last test showed
albumen. But the card also carried the remark, “Don’t worry about this.
I am drinking lots of water, taking nothing but milk for food and will
be in to see the doctor on Tuesday.”

This hints at some of the possible adjustments that must be made in
meeting the needs of the patient in unusual circumstances. For we are
constantly facing the unalterable fact, that no matter where she is, nor
what conditions surround her, the individual woman needs care and
supervision, and though conditions vary, the general needs of expectant
mothers are the same.

This survey of the situation in cities and rural communities gives us a
glimpse of what _can_ be done about it—this problem of mothers and
babies who need care—and also what _is_ being done, and we begin to
sense an answer to the question, “Is anything more possible?”

It is clear that a wide extension of provisions for prenatal care is
necessary if all mothers are to be reached; rich, middle-class and poor;
in cities, small towns and rural districts alike. We believe that it is
possible; and we are sure that wherever provision for prenatal care is
made, the achievement of its fine purpose will depend very largely upon
the spirit of the individual nurse.

What does it bring to the individual nurse—this survey of the problem as
a whole, with the suggestion for its possible solution? The appeal of
not a few mothers and babies, only, but of a legion, and of uncounted
homes and family circles in danger of being broken. And it brings a
suggestion of the immeasurable comfort and influence which the maternity
nurse may carry into each home that she enters. For she helps to save
lives and health, and through them, homes and family groups, and these
are the building blocks of the nation.

For the nurse whose imagination is touched by this appeal, it will exact
much—the best and most that she has to give—but in return she will find
a deep and enduring satisfaction in her work.


   FORMS AND ROUTINES USED BY MATERNITY CENTRE ASSOCIATION, N. Y. C.

  ROUTINE FOR PRENATAL VISITS:

  _First Visit._—Get acquainted with the patient and get her
  confidence. Learn if she has made any arrangements for her care at
  time of delivery. If a doctor or midwife has been engaged
  communicate with him or her. If the patient is registered with a
  hospital, or is under other nursing care, note that on your record,
  also on slip sent to Central Office. Always ask to see patient’s
  hospital or clinic card, or any card which she may have been given
  by any nurse or other visitor. Give patient pink card.

  Explain simply the reason for an expectant mother seeing a doctor
  and nurse early and regularly. Invite the patient to come to the
  Center. Ask her in a general way about herself, when the baby is
  expected, other pregnancies and deliveries, and illnesses; other
  members of her family. Direct your conversation so as to get as much
  data as possible without asking a direct question. Do not attempt a
  full nursing visit unless the patient meets you more than half way.
  Every patient is to be encouraged to come to the Center for as much
  of the nursing care as is possible for that individual woman. In the
  care of all patients it is the nurse’s responsibility to make every
  effort to solve (by working with every existing agency) such home
  problems as might effect the health of the mother or baby or disturb
  the mother’s peace of mind.

  _Complete Nursing Visit._—Ask the patient about any aches, pains,
  troubles of any kind, directing your questions to cover all items on
  record. Select a table, chair, machine top, or end of mantel, to use
  as work table, and place on it:

                   Newspaper for protection
                   Paper napkin as cover
                   Nurse’s soap, hand scrub and towel
                   Watch
                   Fountain pen
                   Maternity Record
                   Thermometer
                   Tycos

                   Bottle for specimen or

                   {Test tube and holder
                   {Urinometer
                   {Litmus paper
                   {Acetic Acid—2%
                   {Sterno
                   {Matches

  Take temperature, pulse, respirations and blood pressure (to take
  blood pressure adjust sleeve, get radial pulse, pump until
  obliterated, let out air and read dial at moment pulse returns. See
  Tycos Manual, sample No. 2, for full detail.) Wash thermometer
  thoroughly with soap and water, dry and return to case. Scrub hands.
  Inspect or demonstrate the care of nipples; to be done daily after
  the fifth month, not before. Use cotton ball (or soft toothbrush
  previously scalded and kept for this purpose). Thoroughly scrub each
  nipple with warm water and white soap and dry with a clean towel.
  Apply albolene, pulling out the nipple. Do not handle breasts.
  Listen to the fetal heart. If unable to hear make note on record
  n.h. If fetal movements are felt by nurse put an “x”; if patient
  says she feels the baby move, put “xx” in space on record for
  recording fetal heart rate. Look for edema, varicose veins; do not
  take the patient’s word for these symptoms. Apply bandage for
  varicose veins (patient to pay 70 cents for bandage, or bandage to
  be lent to patient as long as needed, to be washed and returned),
  and teach patient right-angle position. Get specimen of urine,
  either to take to the station for examination or to examine at once
  for specific gravity, reaction and albumen, in accordance with
  instruction given on page 30, Laboratory Technique—Wood, Vogel and
  Famulener. Have the patient cleanse vulva before voiding, and void
  in clean vessel. Teach patient proper disposal of urine, emphasizing
  why kitchen sink is not to be used. If any abnormality in amount,
  color, specific gravity, or trace of albumen, report to the doctor,
  midwife or hospital in charge of the patient, if the patient has
  engaged one; if not, use every effort to get the patient under care
  of doctor.

  Teach patient to measure amount of urine voided in 24 hours. Tell
  her to void in toilet on getting up in A.M.; then for the rest of
  that day and night and the following A.M. to void in a suitable
  vessel and measure in a tomato can (if no suitable vessel, void in a
  tomato can) and keep count of how many times she fills the can.

  On an early visit examine teeth and show how to keep clean. Where
  possible urge a visit to the dentist or dental clinic for
  prophylactic treatment. Explain that it is not wise to have
  extractions done during pregnancy without consulting a doctor, but
  that cleansing and temporary fillings may be done with much saving
  of teeth.

  On one visit, as early as possible, ask to see the layette, and
  advise about it, going over the list of baby supplies. Urge the
  patient to visit the center to see the model layette, and get help
  in the choice of materials and patterns. Note on the record if
  layette is not complete by the eighth month. Demonstrate the
  preparation of bed for the baby, made from clothes basket, soap box,
  or in a baby carriage similar to the model at the center. If the
  patient is to be delivered at home, some time after the seventh
  month ask to see the mother’s supplies, going over the list. The
  patient should be advised against the use of oilcloth from the
  kitchen table as a bed protector, and especially urged to prepare
  newspaper pads like the model at the center. Note on the report if
  the mother’s supplies are not complete by the eighth month. Advise
  about the arrangement of the room for delivery, and demonstrate the
  preparation of the mother’s bed like the model at the center.

  No treatment or medicine to be advised except in accordance with
  standing orders, private physician’s orders, hospital orders and
  Maternity Centre Association routine (note on record which).

Form letter signed by the head of the medical board sent to doctors who
have been engaged by patients for delivery:

  My dear Dr. ......:

  Mrs. ...... who has engaged you for her care at delivery, has been
  referred to this association for nursing care.

  In order to make the work of the nurses of this association of a
  uniformly high standard, the Medical Board has adopted the enclosed
  routine for the nurses to follow.

  May we not have your cooperation in our effort to teach the women of
  the community the need for, and value of, medical supervision
  throughout their pregnancy?

  May we have your permission to instruct our nurses to visit Mrs.
  ...... in accordance with our routine, and report each visit to you?

  A prompt reply on the enclosed slip will be greatly appreciated.

                            Cordially yours,

 Form for report sent after each nursing: visit to the patient’s doctor,
           either privately engraved or the hospital resident.

                            PRENATAL VISITS

 Name of patient,                         District,                        Date,

 Address,                             Nurse,                             Agency,

 T P R,     Nipples: Erect, Flat or inverted,     Edema: Face,    Feet,    Legs.

 Varicose veins, Dyspnoea, Spots before eyes, Nausea or vomiting, A.M., All day.

 Headache, Constipation, Diarrhea,  Vaginal discharge: White, Yellow, or Bloody.

 Vaginal Soreness.  Fetal Heart Rate.  Urinalysis: Sp. Gr.,  Reaction.  Albumin.

 Quantity in 24 hours.        Blood pressure:        Diastolic,        Systolic.

 Instructions followed.             Patient,             Husband, still working.

 Occupation changed, Patient,               Husband,              Weekly income.

 Remarks:  (Treatment, advice, change in occupation, housing, etc.)


                            MATERNITY RECORD

The Maternity Record upon which a complete history of each case is
recorded is divided into four parts, the first section for the social
data about the patient, the second for other pregnancies and observation
of patient during this pregnancy, the third records delivery and
postpartum care, the fourth, post-natal care. (See insert for form.)


               LEAFLET OF INSTRUCTIONS GIVEN TO PATIENTS


                           ADVICE FOR MOTHERS

Motherhood is natural and normal. If you do as the doctor and nurse ask
you to, you have no reason to worry about having your baby.


                                 _DIET_

Eat the food you are used to. Do not eat what you know gives you
indigestion. Do not eat too much at any one meal.

Drink 8 glasses of water every day.

Drink all the milk you can.

Do not drink any beer, whiskey, wine or other alcohol. These hurt the
kidneys and thus may poison the baby.

Eat meat, meat-soup or eggs and drink tea or coffee only once a day.


                                _SLEEP_

At least 8 hours every night with windows open.


                               _EXERCISE_

Do your regular house work, but lie down several times a day, if only
for five minutes. If possible take a walk out of doors. Fresh air is
good for your baby. If you cannot get out, keep the windows open while
you work indoors. Do not do heavy work; it will hurt your baby.


                               _BATHING_

Wash all over every day with warm (not hot) water, but do not get into a
tub after the seventh month.


                               _GARTERS_

Do not wear round garters or any tight bands. The nurse will show you
how to make suspender garters.


                             _CONSTIPATION_

If you are constipated, drink a cup of coffee (no cream or sugar) before
breakfast, hot milk (not boiled) with breakfast, go to the toilet at the
same time every day (after breakfast best). During the day eat coarse
bread, green vegetables, stewed fruit, drink no tea, but all the water
you can, at least 8 glasses, hot or cold. Cook 2 tablespoonfuls of senna
leaves with a pound of prunes and eat four to six prunes every day. If
you have hemorrhoids (piles) hold a cold compress to anus for five
minutes after bowels move and do not let yourself get constipated. Never
take any cathartics unless your doctor, midwife, or nurse tells you to.


                              _IMPORTANT_

Do not have any sexual intercourse after the 8th month. If you have
severe headache, vomiting, spots before your eyes, if your face, hands
or feet swell, let your hospital, doctor or midwife and nurse know at
once.

Labor begins with pains in back or abdomen; with bleeding or watery
discharge. If you have any labor pains or bleeding before the time you
expect your baby, go to bed and send word to your hospital, doctor or
midwife and nurse at once.

If you are going to the hospital, have ready after the 8th month one set
of baby clothes, to take with you to put on the baby when you bring him
home. Do not take anything else with you, the hospital will supply all
you need. As soon as labor begins, go to the hospital.

If you are to be confined at home, as soon as labor begins send for the
doctor or midwife. If the doctor is one of the hospital doctors, follow
the directions on your card from the clinic.

While waiting for the doctor, boil a large quantity of water in a
covered vessel and set aside to cool. Prepare your bed as the nurse has
shown you, take a warm sponge bath, braid your hair in two braids, get
out a set of baby clothes ready for the nurse to dress the baby. Get out
supplies needed for yourself.


                           MOTHER’S SUPPLIES

 2 gowns.
 1 pair white stockings.
 4 sheets.
 6 bed pads.
 Vulva pads or supply of freshly laundered old muslin.
 Cotton (absorbent).
 2 wash-cloths.
 2 towels.
 4 oz. lysol.
 1 bedpan.

The bed pads are made from 6 thicknesses of newspaper open to full size
and covered with freshly laundered old muslin tacked in place. No other
protection for bed is necessary. As a precaution, when possible, the
entire mattress may be covered with oilcloth put on under the bottom
sheet. See model at center. All washable supplies for mother and baby
should be freshly laundered and put away in pillowcases or clean, ironed
paper until they are needed.


                            BABY’S SUPPLIES

The following is a list of the complete outfit of baby clothes and
toilet necessities. It may be modified as to material, quantity and
quality to suit the individual taste and pocketbook.

  12 Diapers 18″ × 18″.

   3 Bands 6″ × 27″.

   3 Shirts, size 2, cotton and wool.

   3 Petticoats.

   3 Slips.

   2 Squares 36″ × 36″.

     Note: The squares are used instead of coat and bonnet until the
       baby is more than 2 months old. See model at the center.

   1 Oilcloth or rubber 12″ × 18″.

  12 large safety pins.

  12 small safety pins.

   1 Basket or box for bed 15″ × 30″.

   1 Felt pad or folded blanket for mattress.

   1 Oilcloth case for mattress.

   2 Muslin pillow-cases for mattress.

   2 Crib blankets, small size.

   2 Towels.

   2 Wash-cloths, old pieces of linen.

   1 piece Castile soap.

   8 oz. boric acid powder.

   1 package absorbent cotton.

   1 quart oil—sweet or albolene.

   1 package toothpicks.

Tray—fitted with:

     Glass jar for boric acid solution.

     Glass jar for nipple swabs.

     Glass jar for oil.

     Glass jar for small toothpick swabs.

     Dish for soap.

     Cake of soap to stick pins in instead of a pin cushion.

     Hair receiver for absorbent cotton.

     Newspaper cornucopias for waste.

     Bottle and nipple for giving baby water.

     Covered pail with borax water for soiled diapers.

     Jars for tray may be empty cheese, candy or jelly jars.


                             CLINIC ROUTINE

The nurse is urged so to conduct her clinic as to assure privacy to each
patient examined, and the same treatment which the patient would receive
if she were the only patient in the office of one of our best
obstetricians.

Nurse is to wear her graduate uniform during clinic and during her
office hours.

=Nurse’s Duties=

=1—Preparation of Clinic Room=

Pads of doctor’s record, return visit to doctor, post-partum
examination; pencil; examining table; side tables; sterilizers; basins;
instruments; supply of clean dry gloves; Department of Health material
for taking Wassermanns, cultures and smears; cotton balls; tampons;
throat sticks; sheets; pillow cases; sounding towel; adequate supply of
clinic drugs; solutions; thermometer, in glass of 50 per cent alcohol;
glass of cotton; to be ready one-half hour before the time set for
clinic.

=2—Preparation of Patients’ Dressing Room=

Screens or curtains arranged to form individual dressing rooms; a
sufficient number of clean clinic gowns; separate chair provided for
each patient to leave clothes on, unless room is provided with racks or
hooks.

=3—Preparation for Urinalysis=

Unless the urinalysis is made so near the toilet that the waste urine
may be thrown directly into the toilet, a covered pail is to be provided
one-fourth full of 1 per cent lysol solution. All waste urine and
washings from the test tubes to be thrown into this pail, and under no
circumstances is waste urine to be thrown into any sink or wash basin,
even though the basin is not used as a wash basin.

Test tubes, sterno, litmus, acetic acid, funnel, filter paper, test tube
holder, vessel for collecting specimen, basin of 1 per cent lysol
solution and cotton balls for patient to cleanse vulva before voiding,
basin for used cotton balls, provision for patient to wash hands, to be
in readiness one-half hour before the time set for clinic.

=4—Preparation of the Patient for Examination=

Each patient to completely undress, except her shoes and stockings, and
to put on clean gown supplied by the clinic. Her shoes to be unfastened
so that the doctor can examine her ankles for edema, her temperature to
be taken and a urinalysis made _before_ the patient is seen by the
doctor.

=5—Assisting Doctor in Examining Room=

Make notes on record pad at the doctor’s dictation, reminding her
tactfully of any omissions made in her dictation. Conduct examination in
the following order: Head, chest, breasts, blood pressure, abdominal,
fetal heart, measurements, ankles, vaginal, Wassermanns or smears when
necessary.

_Note_: Preparation for vaginal examination. Sponge vulva with 1 per
cent lysol solution. Give doctor fresh gloves for each patient.

The nurse is responsible for the technique in the clinic room, not the
doctor.

If the doctor wishes to do a vaginal examination on a patient more than
eight months pregnant, or one who is bleeding, take same precaution as
though examining a patient in labor; clip; scrub with green soap and
water; then 1 per cent lysol; give doctor freshly boiled, sterile
gloves.

=6—Arrangement of Examining Room After Clinic=

Soiled linen in laundry bags; fresh linen on tables, tables covered; all
used instruments to be washed, scrubbed when necessary, boiled five
minutes, dried and put away; all gloves used to be washed in cool water
and green soap and thoroughly rinsed, wrapped in towel, dropped in
boiling water and boiled for five minutes, then dried, powdered and put
away in a clean towel ready for use at next clinic; solution basins to
be emptied, washed and dried; all waste to be securely rolled up in
newspaper and put in a house garbage can; supply of drugs to be checked
up and replenished when necessary.

=7—Records=

All “Doctor’s Record” cards to be written up and filed; reports mailed
to the central office; reports on the condition of patient sent to
nursing agencies caring for the patient and other agencies working on
the case; maternity records to be filed in date file before the nurse
goes off duty.

=Doctor’s Duties as Outlined on Doctor’s Record=

  1. One complete physical examination including heart, lungs, breast,
       blood pressure, abdominal examination, fetal heart, pelvic
       measurements, vaginal examination and a Wassermann and G.C. smear
       on all patients with a suspicious history. Notes on this
       examination to be dictated to the nurse.

  2. Blood pressure; abdominal; urinalysis; on return visits and
       provides space for notes on such other observations as she may
       wish to make.

  3. One post-partum examination on every patient; including a statement
       on general condition; examination of breasts; vaginal; uterus;
       perineum; and note results of any intercurrent disease.

  4. Recording advice given to patient.

  5. Instructing patients when to return to see the doctor. _Note_: All
       patients not registered with a hospital or private doctor, to be
       seen by the clinic doctor once a month up to the seventh month,
       and once in two weeks, or oftener as the case demands,
       thereafter.

=8—Duties of Clinic Assistants=

At those clinics where a lay woman acts as assistant to the nurse, the
following duties (and no others without special permission) may be
assigned to the assistant:

  1. Greeting patient; and from name on her pink card, getting her
       maternity record from file and sending to nurse.

  2. Taking temperature, a record of which is sent in to the nurse on a
       scratch pad and copied by her on her clinic record.

  3. Urinalysis.

  4. Helping patient dress and undress.

  5. Care of any children who may come with patient.

  6. See that patient understands when to return and has her pink card
       so marked before she leaves.


                       CLINIC EQUIPMENT STANDARD

=Requirements=:

Room for examining, and dressing room, screens, running water, gas, near
a toilet, urinalysis facilities, good light,

 Chair                                                                 1
 Desk                                                                  1
 Blotting pad                                                          1
 Blotter                                                               1
 Ink-well                                                              1
 Penholder                                                             2
 Pens,
 Erasers,
   Ink                                                                 1
   Pencil                                                              1
 Red Pencil                                                            1
 Rubber bands

 =Office=:

 Clips
 Ruler                                                                 1
 Waste basket                                                          2
 Hand blotters                                                        12
 Ink, Red and Black
 Charities Directory                                                   1
 Map of Manhattan in Sanitary areas                                    1
 Report on vital statistics                                            1
 Babies’ Welfare directory                                             1
 Guide Cards Baby Health Station                                       1

 =Examining Room=:

 Table                                                                 1
 Pad                                                                   1
 Pillow                                                                1
 Foot bench                                                            1
 Shelves or side table for supplies, etc.                          1 set
 Garbage pail                                                          1
 Pelvimeter                                                            1
 Tape measure                                                          1
 Stethoscope                                                           1
 Tenaculum                                                             1
 Scissors                                                              1
 Bivalve speculum                                                      1
 Uterine Dressing Forceps                                              1
 Blood Pressure machine (Tycos)                                        1
 Thermometers                                                          3
 Thermometer Glasses (1 for cotton)                                    2
 Enamel jars for tampons and pledgets                                  2
 Large basin                                                           1
 Small basin                                                           1
 Erlenmeyer flasks for green soap and Lysol                            2
 Medicine Glass                                                        1
 Hand Scrub                                                            2
 Rubber gloves, No. 7½                                             6 pr.
 Absorbent cotton                                                  1 lb.
 String                                                           1 ball
 Spatulæ                                                             100
 Hemoglobinometer (Tahlquist)                                          1
 Needles (skin)
 Wassermann Set from D. of H.                                          1
 G. C. Smear Set from D. of H.                                         1
 Culture tubes from D. of H.

 Bandages (Ace)                                                        6
 Sterilizer                                                            1
 Sterilizer burner                                                     1
 Metal Shelf or table for Gas sterilizer
 Scott Tissue Towels                                                   6
 Urinalysis outfit                                                     1
 Test tube rack                                                        1
 Test Tubes                                                           12
 Test Tube holder                                                      1
 Urinometer                                                            1
 Sterno
 Matches
 Enamel Measure                                                        1
 Dish (Chamber)                                                        1
 Litmus
 Acetic Acid 2%
 Toilet paper
 Funnel                                                                1
 Filter paper
 Covered pail

                                =Linen=:

 Sounding towels (for use in listening to F. H.)                       6
 Sheets                                                                6
 Pillow cases                                                          3
 Doctor’s gowns                                                        2
 Dusters                                                               6
 Gown’s for patients                                                  12
 Covers for tables                                                  q.s.
 Laundry bags                                                          2
 Towels                                                                6

                              =Sewing Bag=:

 Cotton 70
 Cotton 30
 Needles, assorted
 Thimble
 Tape measure
 Tape
 Safety Pins
 Plain Pins

                                =Drugs=:

 K Y
 Lysol
 Green soap
 Boro Glycerin
 Alcohol
 Iodin
 Albolene

                             =Breast Tray=:

 Castile soap in dish
 Small bowl
 Bottle of albolene
 Jar of cotton balls
 Soft toothbrush

                           =Exhibit on Table=:

 Patterns for baby clothes.
 Complete layette. Slip and petticoat open in back.
 Basket for baby bed.
 Pad (of felt or hair mattress).
 Rubber.
 Pillow cases.
 Blanket (crib).
 Doll (baby) dressed.
 Suspender garter for mother—abdominal support with garters.
 Patient’s bed prepared for time of delivery, newspaper pads.

                             =Toilet Tray=:

 Jar of boiled water (for washing mother’s nipples).
 Jar of oil (mineral oil best).
 Jar of boric acid—2% for baby’s eyes.
 Jar of breast swabs.
 Jar of small swabs.
 Absorbent cotton in container (hair receiver).
 Soap in dish.
 Soap with safety pins, instead of pincushion.
 Jar for clean nipples.
 Bottle and nipple, or cup and spoon for giving baby water.
 Bottle of boiled water (day’s supply boiled fresh each day) and
   kept corked.
 Newspaper cornucopia for waste.

=Contents of Nurse’s Bag=:

Any nurse may remove from her bag any article not necessary in her
district or for any one day’s work, provided she makes note of same on
card, which is left in bag pocket, stating where removed articles may be
found.

 1 mouth thermometer
 1 rectal thermometer
 1 baby scale
 Acetic acid—2%
 1 test tube
 1 test tube holder
 1 test tube brush
 1 blue litmus
 1 urinometer
 1 sterno
 1 matches
 2 specimen bottles
 Paper napkins
 Soap and hand scrub in bag
 1 flashlight
 1 fountain pen
 1 Babies’ Welfare Directory
 1 Board of Health Station card
 1 Sounding towel in envelope
 1 abs. cotton in envelope
 1 scratch pad
 Addressed postals
 Advice to mothers
 Letterhead memo pad and envelopes
 Pink cards
 Maternity Records for patients to
 be visited
 Blank Maternity Records
 Prudential Ins. Co. Baby Primer
 1 Tycos Blood Pressure apparatus
 3 Ace Bandages
 1 Street directory


              MATERNITY CENTRE STANDING ORDERS FOR NURSES

These standing orders may be used at the discretion of the nurses when a
patient is under no other medical supervision. When patients are
registered with a midwife, may be used with her consent.

=Ante-Partum Orders=

 Cathartic:            After hygiene, diet, prunes and senna have ailed,
                         use either

                       Cascara, grains 5, or,

                       Licorice Powder, beginning with drams 2 and
                         reducing dose gradually.

                       For neglected constipation use one-half pint warm
                         oil (sweet oil, albolene or olive oil) enema,
                         followed in one-half hour by soap suds enema
                         (this treatment to be given by the nurse).

 Heart Burn:           After advice as to diet, water, habits,
                         constipation, use Soda Bicarbonate tablet,
                         grains 10 (do not advise or allow Baking Soda).

 Binder:               Abdominal binder like pattern P.R.N. for heavy
                         abdomen, backache.

 Brassiere:            Brassiere for breast support P.R.N. (Debevoise
                         tape best if patient can afford; if cannot
                         afford have patient make one like sample
                         support at Center).

 Toxemia:              Until medical attention can be secured advise:

                       1. Mild—as much rest as possible; force water 8
                         to 10 glasses a day.

                       Diet—milk, cereals, vegetables, stewed fruits and
                         oranges (no peas or beans).

                       Eliminate all salt and condiments.

                       2. Severe—patient in bed. No vegetables; diet of
                         milk and cereals only.

                       3. With edema. Reduce water to 3 or 4 glasses for
                         three days, after that force water and follow
                         2.

=Post-Partum Orders=:

 Breasts:              For all cases instruct mothers to leave breasts
                         alone, no pumping, no massage. Supporting
                         binder P.R.N. (brassiere best).

                       For engorgement, follow preceding, and restrict
                         so-called milk-making foods, but not water. To
                         dry up milk, follow preceding and advise sodium
                         phosphate daily in frequent small doses (about
                         drams 1).

                       For cracked nipples, apply paste of Bismuth
                         Subnitrate and Castor Oil, equal parts each.
                         Use nipple shield. If not healed report to
                         Central Office.

                       Cathartic, Cascara grains 5, or mineral oil ½
                         dram, or licorice powder drams 2. For neglected
                         constipation, use enema as described for
                         ante-partum patients.

=Post-Natal Orders=:

 Thrush:               Solution of Soda Bicarbonate (1 tablespoonful to
                         1 glass of water); apply to spots with swab
                         before and after nursing. If not effective send
                         baby to dispensary or doctor.

 Constipation:         Olive Oil and Glycerin, equal parts of each,
                         minims 5–15 to dose.

 Circumcision:         If penis is not thoroughly healed, dress with
                         Aristol powder.

 Excoriated Buttocks:  Castor Oil and Bismuth Paste, equal parts of
                         each.

 Oozing Umbilicus:     Cleanse with alcohol on swab, dust with Aristol
                         powder, apply dry sterile dressing.

 Protruding Umbilicus: If dry, strap with well covered button or coin,
                         using wide adhesive tape.


                    ROUTINE FOR POST-NATAL FOLLOW UP

=Hospital Cases=

See patient as soon after she is dismissed as possible, to make sure she
understands how to care for baby. Urge her to take baby to nearest baby
health station (see Blue Card) when baby is three weeks old. Telephone
health station to see if she does register. Urge her to bring baby to
your own station when one month old. At that time arrange for
post-partum examination: if it is the practice of the hospital, at which
the patient was delivered, to instruct patient to return for post-partum
examination, urge her to go at time set by hospital; if not, urge her to
come to your station for such examination. If she fails to come, visit
her to learn condition of baby, and to urge post-partum examination. If
during the post-natal follow-up work, any abnormality is discovered in
baby or mother, report that at once to the resident of the hospital,
where patient was delivered, and carry out his orders as to whether
patient is to return to him or be referred to gynecological or baby
clinic.

=Patient Delivered at Home=

Urge all pre-natal cases to send you post card when baby is born. When
postal is received, visit as soon as possible to see that everything is
all right; arrangements made for care of home and children so as to keep
mother in bed proper time, etc. If a Henry Street nurse is doing
post-partum bedside nursing, make no other visit but urge mother to
bring baby to see you at station when the baby is one month old. If a
practical nurse or a midwife case, visit every day or so, but do not
interfere with her conduct of the case. If you find it necessary to
report any irregularity to the Department of Health communicate with the
midwife before doing so. After she has dismissed the case follow the
routine outlined above. Make special effort to get all midwives’ cases
to come for post-partum examination, and also private physicians’ cases
if they dismiss case before baby is six weeks old.



                               CHAPTER XX
             CARE OF THE MOTHER AND BABY BY VISITING NURSES


The preventive value of post-partum care is now so generally recognized
that maternity care by visiting nurses is given not only in the larger
cities, but is being extended even to rural communities. The routine of
the Visiting Nurse Society of Philadelphia, under the direction of Miss
Katharine Tucker, may be taken as an example of effective post-partum
care, in which daily visits by a nurse bring to large numbers of
patients the minimum of necessary attention. As the same kind of work is
effective and possible in smaller communities, the routines and
instructions used by the Philadelphia Society are reproduced on pp. 439
to 445. These include

  1. The equipment of the nurse’s bags.

  2. Delivery routine.

  3. Routine technique in caring for mother and baby.

In normal maternity cases, a visit is made once a day for eight days.
After that time, if the mother is up and about and the baby is in good
condition, the nurse visits at least once a week for supervision until
the fifth week, when the case is transferred automatically to the Child
Welfare Nurses under the City. If, however, there is any complication
with either the mother or baby, the nurse continues daily visits or
twice daily as indicated by the condition, until both mother and baby
are normal. Instruction to the mother in the care of the baby is one of
the important phases of the maternity nurse’s program.

The points observed and recorded on the bedside cards are: condition of
breasts, urination, condition of bowels, character of lochia, position
of uterus, T.P.R. or any abnormality. If there is any rise in
temperature or other abnormality noted, the physician is called by
telephone and the situation reported.

Any one can call the nurse—children, husband, neighbor, doctor, social
worker,—and a nurse is sent out on every call. A doctor must be in
charge of every case, and if one has not been engaged when the nurse
gets there, she sees to it that one is procured. The only exception is
in cases delivered by midwives, in which instances the nurse gives any
necessary care and supervision, having it clearly understood that if any
abnormality occurs, she will first notify the midwife and then the
midwife or the nurse will immediately call a doctor.

The doctor ordinarily brings his own equipment for delivery. The
contents of the nurse’s bag is the same for delivery as for post-partum
care, except for the addition of the nurse’s gown, extra towels and
silver nitrate. Perineal pads, cotton, boric solution, etc., are
supplied at cost, or free of charge if the patient is unable to pay. Bed
linen, nightgowns, layettes, etc., are provided for patients who cannot
procure them.

The cost per visit to maternity patients averages one dollar and the
cost for services at the time of confinement averages five dollars. Miss
Tucker says of the maternity work:

  “A complete maternity service which includes prenatal work, service
  at time of confinement, post-partum care and subsequent supervision
  of mother and baby is essential if adequate results are to be
  accomplished. Anything less than this complete service does not give
  full protection to the life of the mother and the baby. The
  Philadelphia Visiting Nurse Society has found that the inclusion of
  service at time of confinement has given a tremendous stimulation to
  both their prenatal and postnatal service. In the branches where a
  delivery service has been added, the prenatal service has increased
  fourfold. Both doctors and patients are enthusiastic and see far
  more reason for instruction and supervision from a nurse who is
  going to see the case through than from one who drops out at the
  crucial moment. It certainly has strengthened our whole maternity
  service, both as to results accomplished and in our relationship to
  the doctor and to the community.”


     FORMS AND ROUTINES FOR MATERNITY WORK, VISITING NURSE SOCIETY
                              PHILADELPHIA


                           EQUIPMENT FOR BAGS

     Bottles containing:

  1. Alcohol.

  2. Licreolisis.

  3. Green soap.

  4. Mouth wash.

     Jar with boric acid crystals.

     Jar with cord powder.

     Jar containing vaseline.

  1. Hypodermic syringe.

  2. Tongue depressors.

  3. Two thermometers: rectal and mouth.

  4. Toothpicks.

  5. Adhesive plaster.

  6. Fountain syringe or funnel and tube in linen bag.

  7. Gauze and bandages in linen bag, cord dressing and cord tape.

  8. Cotton and p.p. pads in linen bag.

  9. Paper napkins on which to lay articles.

 10. Granite pan.

 11. Two towels.

 12. One apron.

 13. Hand-brush.

     Instrument case containing:

     Scissors, forceps, 2 artery clamps, glass catheter, rubber
       catheter, colon tube, connecting tube, glass nozzle, medicine
       dropper.

     Folder containing:

     Records.

     Fee slips.

     Literature.


                           ROUTINE TECHNIQUE

=1. Uniforms.=

Except in the case of substitutes during their first six months and
staff nurses during their probation period, all the nurses are required
to wear the uniform of the Society.

 Prescribed hat and coat.
 Sensible black shoes.
 Plain dress of prescribed material.

=2. Bags.=

 Lining to be changed once in two weeks.
 Bottles to be kept neatly labelled.

Lost articles to be replaced at the expense of the nurse.

New equipment may be obtained only in exchange for the worn-out one.

Notebooks, charts, other papers, and pencils to be kept in the long
pocket.

Instruments to be boiled before and after dressings.

Brush to be boiled twice a week and after all infectious cases.

=3. Thermometer Disinfection.=

To be washed before and after using in running water if possible.

After using wrap in cotton soaked in alcohol and leave until the work is
finished. Then wash with green soap under running water.

=4. Routine in the Home.=

=General Care=:

  A. Remove hat and coat, folding coat right side out and placing on
       chair away from wall. Place bag on chair or on table with
       newspaper underneath.

  B. Ask nature of illness, doctor’s orders, etc.

     Ask family for a kettle of boiling water; pitcher of cold water;
       basin, soap and soap dish; pail for the waste; tumbler; towels
       and wash cloth; bath blanket or sheet; clean gown and necessary
       bed linen; newspapers; comb and brush.

  C. Open the bag; put on apron; roll up sleeves; take from bag
       necessary articles, placing on clean newspaper or napkin. Wash
       hands and thermometer. Take everything needed from the bag at
       once to prevent unnecessary handling. Take and record T.P.R. of
       all cases except chronics of long standing.

  D. Place newspapers-one on chair, one under edge of bed for soiled
       linen, one for utensils (kettle, pitcher, etc.)

     Make cornucopia of newspaper for waste and pin to the side of bed.

  E. Bath. Cover patient with blanket or sheet.

     Remove upper bed clothes, fold and place on chair.

     Soiled linen should be placed on paper with the stains turned in.

     Avoid unnecessary exposure of the patient at all times.

     Give thorough bath, using plenty of soap and rinsing carefully.

     Change water at least once.

     Bathe upper half of body, give local bath, change water and bathe
       lower half.

     Put on nightdress before completing bath.

     Clean teeth and nails.

     Comb hair, protecting pillow with towel.

     In making the bed be sure that there are no wrinkles under the
       patient and that the bed clothes are neatly tucked in.

  F. Clear room of articles used. Empty basin. Wrap soiled linen in
       paper.

     Burn cornucopia before leaving the house.

     Wash hands.

     Complete bedside record, sign receipt for fees, and place in an
       envelope.

     Instruct the family to give it to the doctor.

  G. Instruct the Family

     1. To have hot water and necessary articles ready for the next
       visit.

     2. To keep room clean and well ventilated and emphasize the
       importance of damp dusting and sweeping.

     3. To have table cleared for patient’s use.

     4. About the care to be given between visits.

     Choose most suitable member of the family and instruct carefully.

  H. Observe general health of other members of family and the hygienic
       conditions of the home.

=Partial Care=:

     Prepare as for general care.

     Bathe the patient’s hands, face, neck, axilla, and breasts, and
       give local bath. With maternity cases do post-partum dressing.

     Cleanse the mouth.

     Make bed as in general care.


                            DELIVERY ROUTINE

Extra articles to be carried in bags: gown, 2 towels, clamps, 2% silver
nitrate solution.

The doctor should be called at the same time as the nurse. This should
be ascertained when call is taken over telephone.

If the nurse arrives first, she should judge from the progress of labor
whether an urgent call should be sent for the doctor and how much time
she will have to spend in preparation for the delivery. Unless directed
otherwise by doctor, the nurse should proceed as follows:

Have a supply of boiled water and pour some in covered vessel to cool.

Take necessary articles from bag, wash hands, put on gown.

Prepare patient by giving enema, sponge bath, braiding the hair, putting
on clean white stockings and a gown which can be rolled up around waist.

Make bed with tight sheet, oilcloth and draw sheet, protect with pads
made of many thicknesses of newspaper, covered with old muslin.

Protect floor with newspapers, and place basin for placenta. On bedside
table, place alcohol, green soap, glass of boric acid solution, silver
nitrate, basin containing scissors, clamps, catheter, medicine dropper,
cotton gauze, cord tape and dressing, perineal pads, hypodermic,
thermometer. Basin of lysol within reach. Prepare a place for baby by
covering pillow with blanket and placing hot water bottle. Have olive
oil (warmed). Get baby clothes, also gown and binder for mother.

Scrub hands and cleanse patient locally with green soap and water and
put on sterile pad.

Assist doctor in any way possible during delivery.

Ask doctor whether he wishes to instill silver nitrate into baby’s eyes.
This should be followed by normal salt solution and boric acid.

After delivery, cleanse vulva with warm lysol, put on fresh pad and
binder, and make patient as comfortable as possible, giving her
something hot to drink.

Weigh, oil, cleanse, dress baby. Unless doctor orders otherwise,
instruct mother to nurse every three hours and to cleanse nipples with
boric acid solution before and after nursing. The following additional
information is to be written on the medical history card of patient
attended at delivery:

  1. Time nurse arrived.

  2. Time baby was born and sex and weight.

  3. Presentation.

  4. Instrumental—high or low.

  5. Laceration.

  6. Repair, kind and number of sutures.

  7. Hemorrhage.

  8. Prophylactic used for the eyes.

  9. Number of hours in labor.

 10. Condition on discharge—fundus and lochia.

This technique is given as a general standard but the nurse is expected
to use her own discretion in adapting it to the condition of patient,
the home surroundings and the wishes of the doctor.


                         ROUTINE AFTER DELIVERY

=Care of the Baby=:

=A.= Make preparations as for general care.

Have everything ready before the baby’s bath.

Have separate basin for the baby whenever possible.

Test temperature of water with the elbow.

If the room is cold bathe in the kitchen.

Use table whenever possible for the baby’s bath.

If not possible sponge on lap beside the mother’s bed so that she can
observe technique.

When cord is off, tub.

Place on paper napkin on third chair, table, or corner of dresser, glass
of boracic acid sol., olive oil, warmed, cord powder, and dressings,
safety pins, band, absorbent cotton, rectal thermometer, vaseline and
alcohol. Have baby’s clothes within easy reach. Protect lap with blanket
or bath towel.

Remove clothing.

To protect cord dressing, unpin but do not remove band.

Take temperature first and last visit, and when indicated.

Weigh baby on first and last visit.

Examine carefully for any abnormalities and note when found.

=B. Eyes.=

Unless there is a secretion, let the eyes alone.

When secretion or redness, wash eyes gently with 2% Boric acid sol.
using separate pledget for each eye.

=C. Mouth.=

Examine mouth.

No treatment unless required.

If necessary to cleanse use cotton wrapped around little finger and
dipped in boracic acid.

=D. Nose.=

No treatment unless required.

If necessary use piece of twisted cotton and boracic acid sol.

Never use toothpicks.

=E.= Wash face and ears gently with wash cloth or absorbent cotton and
dry.

Soap head with hands, rinse with cloth and dry carefully. Soap body with
hands, rinse with cloth and pat dry with soft towel. Fold binder across
abdomen, protect with hand and turn baby on stomach. Bathe the back.
Fold diaper and place under buttocks.

=F.= Genitals should be carefully cleansed.

In the case of boys, the foreskin should be gently pushed back once in
every two or three days, and the parts underneath bathed carefully with
absorbent cotton and boracic acid sol., removing the white pasty
material which causes irritation.

In the case of girl babies, carefully bathe genitalia. If deposit is
difficult to remove, soften with olive oil.

=G.= On first visit wash umbilicus with 70% alcohol and apply dry
sterile dressing. Do not remove this dressing except when soiled. After
the first time dress with cord powder. Put on clean binder, pinning on
side with safety pins. Oil under arms, buttocks and all creases.

Put on shirt.

Pin diaper.

Petticoat and dress should be drawn on over the feet.

Use hot water bottle filled with warm, not hot, water.

If necessary beer bottle, tightly corked, is a good substitute.

Clear away articles used for the baby.

=H.= Points to be observed, recorded and reported to the physician if
urgent:

  1. Condition of cord.

  2. Eyes; discharge, swelling or redness.

  3. Urination and stools.

  4. When foreskin is very tight and in every case when it cannot be
       easily pushed back.

=I. Instruct the Mother=:

  1. To nurse every three hours unless otherwise ordered.

  2. To cleanse nipples with boracic acid sol. before and after nursing,
       and to keep the breasts covered with clean cloth.

  3. To give cooled, boiled water at least twice a day between feedings.

  4. If fluid appears in the baby’s breasts, caution the family not to
       touch.

=J.= Do not discharge the baby until cord is off, umbilicus is in good
condition and no further nursing care required. Premature babies should
be oiled and wrapped in cotton. Premature jackets can be secured from
the V.N.S. for 35 cents.

=Care of Mother=:

Make preparations as for general care.

Extra articles needed:

  1. Pitcher for solution.

  2. Glass for boracic acid.

  3. Absorbent cotton.

  4. Dressings.

  5. Binder.

Take T.P.R.

Give complete bath.

Post-partum dressing:

  1. Make sol. of lysol in pitcher (or glass jar) which has been washed
       and scalded.

     Directions for lysol Sol.: Use ½ teaspoon lysol to 1 quart hot
       water.

  2. Place paper napkin on table or chair at side of bed and on it
       pledgets of cotton, and clean pads.

  3. Arrange sheet or bath blanket to avoid exposure.

  4. Place soiled pad in cornucopia.

  5. Place clean douche pan or basin under patient.

  6. Scrub hands with green soap and brush under running water.

  7. Pour sol. over vulva. Use pledgets for cleaning vulva, wiping
       always towards rectum.

     Dry thoroughly with pledgets.

  8. Remove pan.

     Turn patient on side and wipe from perineum back over rectum with
       pledget. Dry.

     Dry back and put on pad.

     While in this position place binder and draw sheet.

  9. Wash hands.

 10. Binder.

     Locate fundus.

     Draw edges of binder together and begin pinning from fundus down.

     Then pin from fundus up, taking dart in either side.

     Fasten pad to binder, front and back.

     Unless especially ordered the binder may usually be replaced by a
       T-binder on the fourth day.

 11. Complete as in general care.

     Points to be observed and recorded on bedside notes if necessary:

  1. Condition of the breasts.

  2. Urination.

  3. Condition of bowels.

  4. Lochia.

  5. Position of uterus.

     Record any abnormal conditions.

     Do not massage breasts unless ordered.

     Full post-partum care to be given on first visit if possible.

     Give general care every other day.

=Douche.=

When douche is ordered boil nozzle before and after using.

Boil douche bag before using and wash afterwards—use boiled water.

When sutures, instruct the family how to irrigate after urination and
movement of the bowels.

Normal maternity cases should be visited daily until after the 8th day
of puerperium and at least once a week for supervision until the 5th
week. The case is then transferred to Child Welfare nurse.

Additional visits should be made if the patient is still in bed and
there is no intelligent adult to give care, or if the baby’s condition
is not satisfactory.


                       A SUGGESTION FROM MONTREAL

Ingenuity, resourcefulness, and quick wit on the part of an intelligent
nurse can almost always apply hospital ideals to circumstances which
would at first seem hopeless. It is the nurse’s knowledge of obstetrical
nursing and principles, rather than her equipment, that counts in saving
lives. The following directions given to visiting nurses, by Cecil A. K.
Dawkins, R.N., Supervisor of the Outdoor Department of the Montreal
Maternity Hospital, indicate the possibility of clean, efficient care in
conditions far from ideal:


“MATERNITY CASE CONDUCTED IN A HOUSE WHERE THERE IS VERY LITTLE TO WORK
                                  WITH

“=Appliances You Are Likely to Find in Any House=:

“Bed, table, chair, two boxes, basin, pail, kettle, saucepan, plate, two
cups, spoon, several fair sized bottles, sheet, two towels, pillow,
pillow case, handkerchief, newspapers, old clean rags, small package
boracic powder, small bottle vaseline, soap, baby clothes.

“Doctor’s bag will usually contain towel, clamps, scissors, ergot,
chloroform, creolin, rubber apron, hypodermic syringe, nail brush.

 “1. I would take a look at the fire. Put on the kettle to boil, also
       saucepan containing scissors, clamps, hypo (cord ligatures),
       clean rags to use as sponges, if absorbent is not available. I
       would put several pieces of clean rag (some small for cord
       dressings, others large for vulva pads) on a plate in the oven to
       bake. This will only take a minute.

 “2. Attack the bed. Strip it, place a good pad of newspapers where the
       patient is to lie. Then the sheet. Cover this all over with
       newspapers, particularly where the patient lies. Here I would
       form a Kelly pad, rolling the paper up at the top and bottom and
       left side, the right side falling over the edge of the bed into
       the pail. Cover with clean rag. Paper under the pail.

 “3. Place basin, towel, soap and nail brush on table. Wash up and
       prepare patient. Braid her hair. Put on a clean nightdress.

 “4. Clip away the pubic hair with scissors, if razor not available to
       shave. Give S.S. enema, provided you have the time to do it in,
       and the syringe to do it with. Wash the vulva well with soap and
       water. Put on pad, rag wet with disinfectant.

 “5. The instruments, swabs, etc., should be boiled by this time. Place
       scissors and clamps on plate, and swabs in basin. Get hypo ready.
       Water for ergot. Boracic for baby’s eyes. Baby’s clothes
       together,—also warm cloth to wrap baby in. Fold handkerchief
       crosswise, and make funnel for chloroform mask.

 “6. When baby comes, wrap him up warmly, and place on the right side in
       a safe place. If no other place available, pull bureau drawer
       half open and put him in, but be careful not to close it again.

     The plate that has held the scissors and clamps may be used for the
       placenta.

 “7. To clean up the bed and make the patient comfortable, roll her on
       her right side, rolling the paper up to her back. Wash her and
       turn her on her left side, removing paper. Put on a clean pad and
       “T” binder.

 “8. A jug of boiled water left to cool would be useful in emergency,—as
       also several glass bottles filled with hot water for case of
       shock. The boxes may be used for raising the foot of the bed.”


              Yet it is but a little human babe,
              Given at last into his reaching arms
              And carried to the hollow of her breast!
                                    MARGUERITE WILKINSON.



                                PART VII
                          THE CARE OF THE BABY


  CHAPTER XXI. CHARACTERISTICS AND DEVELOPMENT OF THE AVERAGE NEW-BORN
    BABY. New Functions. Description. Growth and Development. Weight.
    Height. Head and Chest. Fontanelles. Teeth. Stools and Urine. Skin.
    Tears. General Behavior.

  CHAPTER XXII. NURSING CARE OF THE NEW-BORN BABY. Mortality of First
    Months and Year of Life. Preventable Causes. Dangers of Babyhood.
    Essential Features of Early Care. Daily Schedule. Bath. Clothes.
    Fresh Air. Exercise. Training the Baby. Bowels. Thumb-sucking.
    Ear-pulling. Crying. Ruminating. Feeding: Breast Feeding. Artificial
    Feeding. Necessary Characteristics of Artificial Food. Requirements
    for Milk Used. Articles Needed in Preparing Food. Preparation of
    Milk. Pasteurization. Boiling. Giving the Bottle. Ingredients of
    Food. Percentage Feeding. Average Formulae. Mixed Feeding.
    Commercial Baby Foods. Proprietary Foods, Canned Milks, Milk
    Powders. Other Articles of Food Sometimes Included in Baby Diet.
    Travelling. The Premature Baby. Summer Care of the Baby.

  CHAPTER XXIII. COMMON DISORDERS AND ABNORMALITIES OF EARLY INFANCY.
    Malnutrition, Marasmus and Inanition. Diarrheal Diseases: Acute
    Gastro-enteritis. Symptoms. Treatment and Nursing Care. Acidosis.
    Colic, Constipation, Convulsions, and Vomiting. Infections:
    Ophthalmia Neonatorum. Symptoms, Treatment, and Nursing Care.
    Syphilis. Thrush, or Sprue. Impetigo. Pemphigus. Vaginitis.
    Abnormalities: Icterus or Jaundice. Cephalhematoma. Club Foot.
    Engorgement of Breasts. Hare Lip. Cleft Palate. Hernia.



                              CHAPTER XXI
      CHARACTERISTICS AND DEVELOPMENT OF THE AVERAGE NEW-BORN BABY


Before undertaking the care of the new-born baby the nurse should stop
and consider him for a moment and review in her mind just what he
represents; what he has been through; what struggles and dangers are
ahead of him; what are the weaknesses of his equipment to meet these
perils and what must be the character of her service to him if she is to
do all in her power to help him safely over that most hazardous period
in the entire span of his existence: the first month of his life.

That little new-born baby is quite as helpless and appealing as he
looks, for his chances for present and future health lie very largely in
the hands of those who care for him during these early weeks, and any
injury which is done at this time, either through acts of omission or
commission, can never be entirely repaired.

At the time of birth, the baby makes the most complete and abrupt change
in his surroundings and condition that he will make during his entire
lifetime.

He has existed and evolved as a parasite for nine months, during which
time he has been protected from injury; kept at the temperature which
was best for him, and above all has been furnished with exactly the
proper amount and character of nourishment necessary for his growth and
development.

Suddenly he emerges from this completely protecting environment into a
more or less hostile world, where he must begin life as a separate
entity with a frail little body that in many respects is only
imperfectly developed. And yet the baby must not only continue the
bodily functions and activities that were begun during his uterine life,
but must also elaborate and establish others which were imperfect or
were performed for him. Otherwise he will not live.

The nurse will recall that the fetus received its nourishment and
oxygen, and gave up waste material, through the placental circulation;
that the lungs were not inflated and that most of the blood flowed
through the foramen ovale instead of through the pulmonary vessels, as
it does after birth. The digestive tract, excretory organs and nervous
system were not needed during fetal life and therefore are imperfectly
developed at birth and are capable of functioning only within very
narrow limits.

The pulmonary circulation usually is established immediately after
birth, and when the baby cries vigorously the lungs are expanded and
filled with air and the respiratory function is inaugurated. The ductus
arteriosus, ductus venosus and two hypogastric arteries are gradually
obliterated, as the normal circulation of the blood becomes established
and the foramen ovale is closed. See Figs. 28 and 29.

The other functions are established more slowly and the care of the baby
must be such that the immature, unused organs will not be overtaxed, and
yet that their development will be promoted through activity.

The new-born baby weighs 3250 grams, or 7¼ pounds, and is about 50
centimetres, or 20 inches long. The body is well rounded and the flesh
firm. The skin is a deep pink, or even red, and is covered with a white,
cheesy substance, the vernix caseosa, which is likely to be thickly
deposited in the folds of the skin, in the creases of the thighs and
axillæ and over the back. Some babies still have the fine, downy lanugo
hair over parts or all of the body.

The head and abdomen are relatively large, the chest narrow and the
limbs short. The legs are so markedly bowed that the soles of the feet
may nearly or quite face each other, but they finally assume a normal
position. The bones are largely cartilage and the entire body is
therefore very flexible. Some of the bones, which are separate at birth
unite later in life and the adult skeleton finally becomes firm and
rigid.

Most babies have faded blue eyes at birth, the permanent color appearing
gradually, while the amount and color of the hair varies greatly, some
babies being bald and others having abundant hair from the beginning.

The shape of the baby’s head is sometimes distorted at birth, being so
elongated from chin to occiput as to give the parents deep concern. But
they may be confidently assured that in the course of a few days the
head will assume the lovely rounded contour, so characteristic of
babyhood. The temporary deformity is caused by a moulding and
overlapping of the bones of the skull as it is forced through the birth
canal, and sometimes also to a collection of fluid under the scalp,
called the _caput succedaneum_, and which, too, is due to pressure
during birth. Both the anterior and posterior fontanelles may be felt at
birth.

GROWTH AND DEVELOPMENT. The progress during the first year, of average,
normal babies who are satisfactorily nourished and cared for, is fairly
uniform and the accepted average is suggested by the following schedules
which are based upon observations made upon a large number of normal,
healthy infants.

=Weight.= The average baby boy weighs at birth, 7¼ to 7½ pounds and
girls a little less, as a rule. There is an initial loss of from six to
ten ounces during the first week, through body waste and the passage of
meconium and urine, before the full amount of nourishment is taken and
assimilated, large babies losing more than small ones. (Chart 5.) From
this time the gain is usually from four to eight ounces, each week,
during the first five months, after which it is only about half as
rapid, or at the rate of from two to four ounces weekly. At six months,
therefore, the average baby weighs from fifteen to sixteen pounds, or
double the normal birth weight of 7½ pounds, and at twelve months, from
twenty to twenty-two pounds, or three times the average birth weight.
The weight is perhaps the most valuable single index to the baby’s
condition, that we have, but at the same time, it must be remembered
that a baby whose food is rich in carbohydrates may be of normal weight,
or over, but be incompletely nourished and very susceptible to
infection. Other babies who are small and seem to gain unsatisfactorily
are sometimes very well and vigorous. And very commonly there are
periods in the lives of entirely normal babies when there is little or
no gain in weight. This may occur during the period from the seventh to
the tenth month, for example, or during very warm weather. But the
baby’s weight should be watched carefully, for a loss or prolonged
failure to gain may be an evidence of faulty nutrition or disease.

[Illustration:

  CHART 5.—Weight chart showing average weekly gain during first year of
    life.
]

=Height.= The average height at birth is 20 inches, though boys may
measure a little more and girls a little less; at six months, 25 to 25½
inches and at one year, 28 to 29 inches.

=Head and Chest.= The circumference of the head and chest are about the
same at birth, the chest being possibly a little smaller. Both measure
about 13½ inches, increasing gradually to about 16½ inches at six months
and 18 inches at the end of the first year.

=Fontanelles.= The posterior fontanelle usually closes in six or eight
weeks but the larger, anterior fontanelle is not entirely obliterated
until the baby is eighteen or twenty months old. Closure of the
fontanelles is usually late in rickets, cretinism and hydrocephalus and
early in cases of malnutrition and microcephalus.

=Teeth.= Although it occasionally happens that a baby has one or two
teeth at birth, the average infant has none until the sixth or seventh
month, when the two lower, central incisors appear. After a pause of a
few weeks the two, upper, central incisors appear, followed by the two
lateral incisors in the upper jaw. At the end of the first year,
therefore, the average baby has six teeth, or eight, if the lower,
lateral incisors have come through by the first birthday, as they
sometimes do. (Fig. 148.) This is the usual course of dentition during
the first year, but there are wide variations among entirely well and
normal babies, the first tooth sometimes not appearing before the tenth,
eleventh or even twelfth month. But as a rule if no teeth are cut by the
time the baby is a year old, it is regarded as an evidence of faulty
nutrition, perhaps bordering on rickets.

The baby who is properly fed and cared for cuts his teeth with little or
no trouble, in spite of the widely current belief that a teething baby
is a sick baby. We have no way of estimating the number of babies who
die needlessly from infections and digestive disturbances because of
this fallacious conviction. For if the baby is sick while teething, the
disturbance is all too frequently accepted as a normal occurrence and
nothing is done until too late.

Frail, delicate babies may have convulsions each time that a tooth is
cut and if a baby is having digestive trouble it is likely to grow worse
while he is teething. But dentition is a normal physiological process
and the healthy, properly fed baby suffers little or no inconvenience at
this time.

[Illustration:

  FIG. 148.—Diagram of first or deciduous teeth and ages at which they
    usually appear.
]

The care of the baby’s teeth should begin when the first tooth appears.
It should be wiped, front and back, with a piece of gauze or cotton
dipped in a solution of boracic acid, or sodium bicarbonate or some
other weak alkaline wash, to neutralize the acid secretions of the mouth
which start decay. After the baby has five or six teeth, the use of a
very soft brush, with tooth paste, is often advised, the teeth being
brushed with a circular motion or from the gums toward their edges. The
teeth should be wiped, or brushed, morning and evening and after
feedings. The reason for such close care of the temporary teeth is that
they serve as a mould or brace to hold the jaws in proper shape for the
permanent teeth which appear later. If the “milk” or deciduous teeth
decay or crumble away before the jaws are developed to the point when
the permanent teeth appear, these second teeth are likely to be crooked
and uneven.

=Stools and Urine.= During the first two or three days, the stools are
of dark green, tarry material called meconium. Meconium consists of
cast-off cells from the skin and intestines, fat, mucus, hairs and bile
pigment. In the course of two or three days, the stools begin to grow
lighter and shortly the normal, milk-feces appear, being bright yellow,
of a smooth pasty consistency and having a characteristic odor. During
the first month or six weeks the baby’s bowels may move three or four
times daily, but after this they usually move but once or twice in the
course of twenty-four hours. As the diet is increased, the stools grow
somewhat darker and firmer and finally become formed.

[Illustration:

  FIG. 149.—Appearance of umbilical cord immediately after birth.
]

The new-born baby’s bladder usually contains urine which may be voided
immediately after birth or not until several hours later. After the
first voiding the bladder may be emptied five or six times a day, or
oftener. The nurse should watch for the first evacuation of the bowels
and bladder, and if they do not occur during the first few hours, the
fact should be reported to the doctor, as the omission may be due to an
imperforate anus or meatus.

[Illustration:

  FIG. 150.—Appearance of umbilical cord, four days after birth.
]

[Illustration:

  FIG. 151.—Appearance of umbilicus immediately after separation of
    cord.
]

[Illustration:

  FIG. 152.—Appearance of a well healed umbilicus.
]

=Cord.= Within a few days after birth the stump of the umbilical cord
begins to shrivel and turn black, and a red line of demarcation appears
at the junction of the cord with the abdomen. By the eighth or tenth
day, as a rule, the cord has atrophied to a dry black string, when it
drops off and leaves an ulcer, or small granulating area which heals
entirely in a few days. (Figs. 149, 150, 151, 152.) Before the days of
sepsis, infections of the cord were not uncommon and babies frequently
died of tetanus, streptococcus and other infections. But at the present
time an infected cord is a rare, and, it may be added, an almost
inexcusable occurrence.

=Skin.= By the end of the first week any lanugo remaining usually
disappears and there is frequently a scaling of the superficial layers
of the skin which lasts for two or three weeks, while a delicate pink
tint replaces the deeper color of the skin in the course of ten days or
two weeks. The baby does not perspire until after the first month, as a
rule, when insensible perspiration begins, gradually increasing until
perspiration is free by the time the baby is a few months old.

=Tears.= There are no tears at birth and opinions differ as to whether
they appear in the course of two or three weeks, or three or four
months. The absence of the lachrymal secretion is one explanation for
the necessity of bathing the baby’s eyes during the early days and
weeks, for if dust or other foreign material gains entrance it is not
washed out by the tears as it is later.

=General Behavior.= During the first few weeks the average baby sleeps
most of the time: that is from nineteen to twenty-one hours daily. He
gradually sleeps less, as the special senses develop and will sometimes
lie quietly for an hour or more with his eyes open, sleeping only
sixteen or eighteen hours daily at six months and fourteen to sixteen
hours at the end of a year.

The baby begins to make noises and “coo” at about two months and to
utter various vowel sounds when about six months old. By the end of a
year these indefinite noises and sounds become distinct words. At about
the fourth month, he grasps at objects and smiles and very soon even
laughs. He holds up his head at about the third or fourth month; sits up
and also begins to creep at six or seven months; while sometime between
the ninth and twelfth months he will stand by holding to some one’s hand
or the furniture, and will begin to walk with assistance.

These degrees of development at different ages are not to be taken as
the only measure of normal progress, for many well babies mature more
rapidly and others more slowly than at the rate which is found to be the
average.

In addition to these fairly specific evidences of the baby’s condition
and progress, such as weight, height and muscular development, there are
other and less definite indications of his well-being which the nurse
must watch for and accord a very high value.

The baby who is well and is being properly fed in all respects, will
have good color; his flesh will be firm; he will take his nourishment
with a certain amount of eagerness and seem satisfied afterward. He will
sleep for two or three hours after each feeding; will sleep quietly at
night, and while awake, unless he is wet or uncomfortable for some other
good reason, he will seem contented, good-natured and happy.



                              CHAPTER XXII
               NURSING CARE OF THE AVERAGE NEW-BORN BABY


It is estimated that out of every thousand babies born alive, in this
country, forty die during the first month of life, and that more than as
many again, or about eighty-five all told, perish before reaching the
first birthday.

So hazardous is this period of early infancy, in the United States, that
our annual loss of baby life is between seven and eight times as great
as was the yearly toll of our young men during the war, for upwards of
200,000 babies less than a year old die each year. That the first month
of life is fraught with greater danger than any which follow is shown by
the fact that about 100,000 of these deaths occur during the first four
weeks.

The tragedy of these figures is made darker by the knowledge that at
least half of the babies who are lost die from preventable causes. In
other words, they die from lack of proper care.

That is the significant fact for the obstetrical nurse, since more and
more frequently she has the young baby in her care during the crucial
first month and inevitably plays an important part in increasing his
chances to live. She does this by helping to keep the well baby well,
rather than by nursing a sick baby.

The dangers which make babyhood such a precarious period may be grouped
very largely under the general headings of unfavorable ante-natal
conditions, nutritional disturbances and infections. The care and
supervision of the expectant mother will remove many of the unfavorable
ante-natal causes. Nutritional disturbances and infections must be dealt
with after birth.

Faulty nutrition may result in rickets, scurvy, malnutrition, marasmus,
acute inanition or the less serious colic, constipation or diarrhea. The
most frequent results of infection among young babies are the
respiratory diseases in winter, such as bronchitis and pneumonia, and
the intestinal disorders in summer, commonly referred to as “summer
complaint.” Since undernourished babies are very susceptible to
infection, the two conditions are frequently coincident.

With the baby’s frailty and imperfect development in mind, as well as
the needs of his growing body and the evils that beset his way, we can
understand the reasons for the painstaking, protecting care which he is
given during the early weeks of his life.

The essential features of this care are as follows:

  1. Proper feeding.

  2. Fresh air.

  3. Regularity in his daily routine.

  4. Cleanliness of food, clothing and surroundings.

  5. Maintenance of an equable body temperature.

  6. Conservation of his forces.

These requirements seem so rational that one might expect them to be met
as a matter of course; but the annual sickness and death rate among
babies are a constant reminder that they are not.

The nurse should begin by arranging a daily schedule for the baby’s
feedings, fresh air, bath, sleep and exercise, and follow it with
unfailing regularity. The hours for the nursings, which vary with
different doctors, will constitute the greater part of the daily
schedule, and for a baby on four hour feedings, for example, some such
program as the following may be arranged:

               6 a.m. Feeding.
               8 a.m. Orange juice (when ordered).
               9 a.m. Bath.
              10 a.m. Feeding.
      10.30 to 2 p.m. Out of doors.
               2 p.m. Feeding.
       2.30 to 4 p.m. Out of doors.
               4 p.m. Orange juice (when ordered).
       4 to 5.30 p.m. In-door airing and exercise (when ordered).
            5.30 p.m. Preparation for the night.
               6 p.m. Feeding.
              10 p.m. Feeding.
               2 a.m. Feeding (when ordered).

The importance of punctuality in the daily routine cannot be stressed
too often and it is one aspect of the baby’s care for which the nurse is
absolutely responsible. No matter how well the baby is nursed, in other
respects, nor how skillfully the doctor directs his care, the baby
cannot be expected to progress satisfactorily if his life is irregular.

=The Bath.= The first office which the nurse usually performs for the
new-born baby, and which she repeats daily, is to bathe and dress him.
The bath may be given in a tub, under a spray or in the nurse’s lap,
according to the wishes of different doctors, while sponge baths are
sometimes given with soap and water and sometimes with oil.

The first bath, particularly, is likely to be an olive oil sponge, given
immediately after birth, before the baby is taken from the mother’s
bedside, and many doctors have the sterile cord dressing and abdominal
binder applied at this time. This oil bath is given, not alone for the
purpose of removing the vernix caseosa, but also, to lessen the
radiation of body heat, which the baby can ill afford to lose. When such
a practice is followed it only remains for the nurse to dress the baby
and place him in his crib to sleep undisturbed for several hours.

Some doctors have the baby sponged every morning with albolene or olive
oil, instead of with soap and water, until the cord separates, when tub
bathing is adopted. When the daily bath is given with oil, the baby’s
thighs and buttocks are wiped clean with an oil sponge each time that
the diaper is changed. Other doctors have the baby’s first bath given in
a tub, with soap and water, while still others who fear that the cord
may be infected by immersing the baby, have him sponged with soap and
water, after the vernix caseosa has been softened with oil.

Sponge bathing is commonly employed for all babies until the cord
separates and for frail delicate babies or those suffering from skin
trouble. The sponge bath may be given in the nurse’s lap or on a table
covered with a pad, either method being satisfactory if the baby is kept
warm and comfortable. But one inclines to the idea of having the baby
bathed in the nurse’s lap for he seems happier there; more comfortable
and less frightened and we cannot be sure that these factors are
unimportant.

The best time for the daily bath, during the first three or four months,
is about an hour before the second feeding in the morning. After this
age the full bath is sometimes given before the six o’clock feeding, in
the evening, for a bath at this hour is soothing and restful and often
helps toward giving the baby a good night.

Preparation for the bath should made with its possible effects, both
good and bad, in mind, for the baby may be helped or harmed according to
the skill with which he is bathed. He must not be chilled during his
bath, and fatigue and irritation must be avoided by giving it quickly
and with the least possible handling and turning. These ends may be
served by conveniently arranging all of the articles which will be
needed, on a low table at the right hand side of the nurse’s chair,
before the baby is undressed.

There should be a pitcher of hot and one of cold water; a bath
thermometer; two soft wash-cloths; soft towels; bath blankets; Castile,
or some other mild soap; boracic acid solution; sterile cotton pledgets;
large and small safety pins, or large ones and a needle and thread if
the band is to be sewed on; unscented talcum powder; sterile albolene or
olive oil; soft hair brush and a complete outfit of clothing. The little
garments should be arranged in the order in which they will be put on,
the petticoat slipped inside the dress, and all hung before the fire or
heater, to warm.

The temperature of the room should be about 72° F. and if it is possible
to bathe the baby before an open fire or a heater, so much the better.
In any case he must be protected from drafts. A sheet hung over the
backs of two straight chairs will serve very well as a screen if no
other is available.

The tub or basin should be about three-quarters full of water at 100° F.
for the new baby; about 95° after the third month and gradually lowered
to 85° F. or 90° F. for the baby a year old. The temperature of the
water should not be guessed at, but tested with a thermometer, though in
an emergency the nurse may safely use water that feels comfortably warm
to her elbow.

It is a good plan to lay a folded towel in the bottom of the tub, before
beginning, as babies are often frightened by coming in contact with the
hard surface.

[Illustration:

  FIG. 153.—Nursery at Manhattan Maternity Hospital. Note beam scales,
    low table with articles for bath, and method of protecting babies’
    heads from drafts.
]

The nurse should wear a waterproof apron, covered with one of flannel
over which is laid a soft towel until the bath is finished, when it is
slipped out, leaving the dry flannel apron to wrap about the baby. She
should wash her hands thoroughly with hot water and soap; sit squarely,
with her knees together, in a chair without arms; take the baby in her
lap and undress him under a blanket.

In order that the bath may be given deftly and quickly, it is a good
plan to give the different parts in the same order every day, for
practice makes perfect.

It is usually a routine to weigh the baby every morning, during the
first two or three weeks and once or twice a week afterwards. Premature
babies and those who are very frail are weighed at longer intervals
because of the inadvisability of disturbing them so often. The baby is
undressed for his bath, wrapped in a blanket, and laid in the scoop or
basket of a beam scale (Fig. 153) and a note made of the entire weight,
for if he is placed in the scales without protection he is likely to be
chilled and frightened. The weight of the blanket is ascertained
separately and deducted from the total thus giving the baby’s exact
weight.

The eyes should be bathed first, with pledgets of sterile cotton dipped
in warm boracic acid solution, each pledget being used but once. To
prevent the solution from running from one eye into the other, the
baby’s head is turned slightly to one side and the lower eye wiped
gently from the nose outward. The lids may then be separated by placing
one thumb below the brow and lifting it slightly, and the eye flushed
with a gentle stream by squeezing a freshly soaked pledget just above
it. The head is turned to the other side and the eye on that side bathed
in like manner.

The mouth is swabbed out _very gently_ with boric-soaked cotton wrapped
about the tip of the little finger, care being taken not to abrade the
delicate mucous lining. The nostrils are cleaned with little spirals of
cotton dipped in liquid petrolatum or olive oil.

The face is then washed with warm water, no soap, and patted dry. The
scalp, neck and ears are washed with soap and water and thoroughly dried
by patting and wiping gently in the creases. The body should then be
well soaped, with the nurse’s hand, only one part being exposed at a
time, to avoid chilling. To place the baby in the tub the nurse may slip
her left hand under his head in such a way that his head will rest upon
her wrist, her fingers support his shoulders and her thumb curve over
and hold the upper part of his arm. She may then grasp his ankles with
her right hand and lower the little body into the water, feet first. If
his arm and shoulder are firmly held and supported by the left hand it
is an easy matter to steady the entire body and keep the baby’s head out
of the water while giving the bath with the right hand. (Fig. 154.) The
new baby is not usually kept in the tub for more than two or three
minutes, but when he is three or four months old he may stay in for five
minutes and still longer as he grows older.

[Illustration:

  FIG. 154.—Method of supporting baby’s head above water while giving
    tub bath.
]

Hot water should not be poured into the bath after the baby has been
placed in it but cold water is often added, for a three or four months
old baby, or the warm bath followed by a quick sponge with cold water.
The little body is quickly patted dry and rubbed briskly with the palm
of the nurse’s hand; the legs and arms stroked toward the body; the back
from the neck downward and the chest and abdomen with a circular motion.
Babies who react well to cold baths are benefited by them but such
“toughening” methods have to be tempered to the resistance of the
individual baby and are employed only under the supervision of the
doctor.

[Illustration:

  FIG. 155.—Preparation for circumcision. (From photograph taken at The
    Cleveland Maternity Hospital, with description, by courtesy of Miss
    MacDonald.)
]

  _On Table at Left_:

    Basin of sterile water.
    3 sterile towels.
    12 small sponges.
    6 cotton pledgets.
    1 inch gauze bandage.
    Tube of 00 plain catgut with small needle.
    Needle holder.
    2 small hemostats.
    Curved Kelly clamp.
    Sharp pointed curved scissors.
    Blunt dissector.
    Mouth tooth forceps.

_Stand at Right_:

    Large basin of sterile water.

_For Baby_:

  Brandy, 1 dram.                  } In sterile medicine glass with
  Sterile water, 6 drams.          }   dropper.
  Sugar, ½ dram.                   } Used for anesthetic.

One nurse holds the baby by his knees with his hands under her arms.
The second nurse begins the anesthetic, three minutes before doctor
begins to operate, by dropping brandy and water on small piece of
sterile cotton in gauze in baby’s mouth.

    The genitals should be bathed and dried with care; inspected daily
    and any abnormality reported to the doctor. It is not uncommon for
    girl babies to have a slight bloody discharge from the vagina. This
    is unimportant and soon disappears, but a purulent discharge is
    likely to be an evidence of gonorrheal vaginitis. It is routine in
    many hospitals to retract the foreskin of male babies every morning
    at the time of the bath by rubbing it back with gauze or cotton,
    taking pains that it is again pulled forward into the original
    position after the part underneath has been bathed with boracic acid
    solution. If retraction is impossible after several successive daily
    attempts, the baby is not infrequently circumcised. (Figs. 155,
    156.)

[Illustration:

  FIG. 156.—Baby in Fig. 155 draped with sterile sheet.
]

    When the entire body, including creases and folds, has been patted
    quite dry, it may be dusted with an unscented talcum powder, but
    this powdering must not be resorted to as an aid in drying the skin.
    In order to prevent chafing, the buttocks and thighs should be wiped
    clean with oil or bathed with warm water, no soap, patted dry and
    powdered or oiled each time that the diaper is changed.

[Illustration:

  FIG. 157.—Cord stump dressed with dry sterile gauze. (From photograph
    taken at Johns Hopkins Hospital.)
]

    If the first bath is a tub bath the cord is dressed after the baby
    is dried and powdered. The form and method of cord dressings vary
    somewhat with different doctors but in practically all instances the
    dressings are sterile, to prevent infection, and porous in order
    that air may gain access to the cord and promote the drying,
    separating process. The dressing itself may consist of dry, sterile
    gauze or gauze wet with alcohol, applied to the cord in the manner
    of a finger bandage (Fig. 157); or it may consist of squares of
    sterile gauze or muslin with holes in the centres to fit around the
    cord, and dusted with some such powder as boric acid, bismuth or
    salicylic acid and starch. These squares are folded about the cord
    stump which is laid over on the abdomen, being directed upward to
    prevent its being wet with urine. A gauze sponge is placed over the
    dressing and the binder applied with firm, even pressure, but not
    tightly, and sewed on or held in place with safety pins. (Fig. 158.)
    The cord dressing is not removed until the cord separates, unless it
    is wet or soiled, but as a rule the band is removed every morning at
    the time of the bath, or whenever it is soiled.

[Illustration:

  FIG. 158.—Flannel band applied over cord dressing.
]

    After the band has been applied the warmed shirt, diaper, petticoat
    and dress are put on, with the fewest possible motions, and the
    baby’s hair brushed upward from the neck and back from his forehead.
    He should be wrapped in a small blanket, fed and laid quietly in his
    crib to sleep. If his hands and feet are cold a hot-water bottle at
    125° F. with a flannel cover, may be placed beside him.

    When the baby is made ready for the night he may have either a
    sponge bath or simply have his face and hands sponged with warm
    water, according to the wishes of the doctor. The clothing which the
    baby has worn during the day should be replaced by an entirely fresh
    outfit. The day and night clothing may be worn more than once, if
    clean and if aired between times, but it is better not to have the
    baby wear the same clothes day and night.

    =Clothes.= The baby’s clothes may play an important part in
    promoting his well-being, and to accomplish this they must be warm,
    light-weight, soft and porous. They should be simple; fit smoothly
    and be loose enough and short enough to permit the baby to move
    unhampered. In order that his body may be kept at an even
    temperature their weight must always be adjusted to the needs of the
    moment. The general tendency is to dress the baby too warmly, as a
    result of which he perspires; is listless, pale, fretful; sleeps
    badly; is susceptible to colds and other infections and has poor
    recuperative powers. His digestion is likely to be deranged and he
    may have prickly heat. On the other hand, if the baby is not dressed
    warmly enough his hands and feet will be cold and his lips blue; he
    will cry from discomfort and the general result may be lowered
    vitality and disturbed digestion. If the baby’s clothes are not
    comfortable, if they pull and drag or have tight bands, he will be
    fretful and restless, with disturbed sleep and digestion in
    consequence.

    The little wardrobe will be entirely adequate, under ordinary
    conditions, if it consists of shirts, bands, diapers, flannel
    petticoats, dresses, flannel wrappers and sacques with a cap and
    cloak for extra warmth during in- or out-door airing. (Fig. 159.)

    The =shirts= should have long sleeves and high necks; they should
    open all the way down the front and come well down over the hips.
    During the cold months they should be of silk, silk and wool or
    cotton and wool, as all wool shirts are usually too warm, and during
    the summer months they should be of all cotton and very thin. Size
    No. 2 is the best size to start with as the smaller size is soon
    outgrown.

[Illustration:

  FIG. 159.—An outfit of practical baby clothes:

  A. Thin cotton dress, open down the back.
  B. Flannel night-gown with set-in-sleeves.
  C. “Gertrude” petticoat, open down the back.
  D. Shirt, opened all the way down the front.
  E. Flannel night-gown with kimono sleeves.
  F. Knitted band with shoulder straps.
  G. Flannel square with tapes run through casings to form hood of one
    corner.
  H. Bag, with hood, suitable for premature baby or for outdoor
    sleeping.
]

    The first =bands= usually consist of strips of all wool or cotton
    and wool flannel about six inches wide and eighteen or twenty inches
    long, torn across the width of the material and not hemmed. This
    straight binder is worn until the cord dressing is discontinued,
    when it is replaced by a knitted band with shoulder straps. If the
    cord dressing is held in place by a gauze binder, the knitted band
    with straps is used from the beginning. Whether the binder be
    flannel or gauze, it must be applied firmly and with even pressure,
    but not tight. It is a mistake to think that a tight band
    strengthens the baby’s abdominal muscles for it has the opposite
    tendency. A tight band may give pain or discomfort and even cause
    colic or vomiting.

[Illustration:

  FIG. 160.—Appearance of properly adjusted diaper which has been folded
    diagonally.
]

[Illustration:

  FIG. 161.—Appearance of properly adjusted diaper which has been folded
    longitudinally.
]

    The knitted band is usually worn for three or four months,
    particularly in cold weather, to provide a little extra warmth over
    the abdomen. Thin, delicate babies sometimes need this band for a
    year or more.

    The =diapers= should be of soft, absorbent material, of a loose
    weave, such as cheese cloth, bird’s-eye, stockinette, thin Turkish
    towelling or outing flannel; should be 18 or 20 inches square and
    hemmed. There are two methods of putting on the diaper. One is to
    fold the square diagonally and bring the diagonal fold around the
    baby’s waist. One of the lower corners is drawn up between the
    thighs, the two corners from the sides brought over this and the
    fourth corner brought up over these and all pinned securely with a
    safety pin. (Fig. 160.) Small safety pins hold the margins together
    above the knees. The other method is to fold the diaper straight
    through the centre, forming a rectangle, twice as long as it is
    wide; lay the baby on it lengthwise, draw it up between his thighs
    and pin it on each side at the waist line and above the knees. (Fig.
    161.)

    In either case the diaper must be put on smoothly and care taken to
    avoid forming a thick pad between the thighs as this will tend to
    curve the bones of the legs. Squares of soft, absorbent material,
    which may be burned, placed inside the diapers, will greatly
    facilitate the laundry work. In some hospitals a very soft absorbent
    paper is used for this purpose, sometimes being covered with gauze.

    The baby’s diaper should be changed whenever it is wet or soiled,
    for in addition to making him restless and fretful for the time
    being, the skin about the thighs and buttocks will grow red and
    chafed if he is allowed to wear wet diapers. Wet diapers should not
    be dried and used again but washed with a mild soap, boiled and
    whenever possible, dried in the open-air and sunshine.

    All of this makes it apparent that the regular use of waterproof
    protectors cannot be justified since the chief reason for putting
    them on a baby is to avoid the necessity of changing his diaper as
    soon as it is wet. Under special circumstances such as a drive, a
    short journey or visit the diaper may be protected by water-proof
    drawers. Their habitual use saves work for the nurse but makes the
    baby uncomfortable and unhappy.

    The =petticoat= should be of light-weight, cotton and wool flannel,
    cut after the familiar Gertrude pattern and hang straight from the
    shoulders. It may fasten in the back or on the shoulders, with small
    buttons or with tapes. Tapes are often objected to on the ground
    that the baby tangles them up with his fingers, which annoys him,
    and often puts them in his mouth. This petticoat is worn practically
    all the time, except during very warm weather.

    The =slips or dresses= are most satisfactory if cut after the same
    pattern as the petticoat, with the addition of sleeves which may be
    set in, or of the kimono style. The dresses serve chiefly to keep
    the petticoats clean and make the baby look dainty, and are
    accordingly made of soft cotton material such as nainsook, cambric
    or lawn. In summer, it is true, the petticoat is often discarded and
    the thin slip put on over the shirt and diaper.

    The =night gowns= are made like the dresses but are of soft flannel
    or stockinette, in cold weather, and tape is often run through the
    hems in order that they may be drawn up, bag-fashion, to keep the
    baby’s feet warm. During very warm weather the baby sleeps in a thin
    cotton slip.

    In addition to these garments there are many times when a soft
    little sacque or wrapper is used to keep the baby warm, and one or
    two flannel squares (one yard), to wrap around him when he is
    carried about the house are practically indispensable.

    The petticoats, dresses and night gowns are cut about twenty-seven
    inches long and many doctors feel that they offer sufficient
    protection for the feet of the average baby to make stockings
    unnecessary until he is from four to six months old. The skirts may
    then be shortened to ankle length and stockings added to the little
    wardrobe. Some doctors think it wiser to put knitted socks or part
    wool stockings on the new baby particularly if he is born during
    cold weather.

    When the baby begins to creep, he should wear soft soled shoes, part
    wool stockings in cold weather and thin cotton or silk ones during
    the summer, and firm but flexible soled shoes as soon as he tries to
    stand alone or to walk.

    During the first month or two, the baby scarcely needs special
    clothing for out-door wear, as he may be warmly wrapped in one of
    the flannel squares by being placed on it diagonally, the upper
    corner folded about his head to form a hood and held under his chin
    with a safety pin. The corners on the sides are folded about his
    shoulders, the lower one brought up over his feet and limbs and the
    additional blankets tucked in over all. But as he grows older and
    moves about in his carriage, he will need a cap and cloak or wrap
    with hood attached. In cold weather the cap should be knitted or
    wool lined and the cloak of soft woolen material or wool lined. In
    moderate weather the cap may be of one thickness of cotton or silk,
    or very light flannel, while on very warm days he will need no head
    covering.

    To sum up: The baby’s clothes should be simple in design, hang from
    the shoulders, fit smoothly but loosely and have no constricting
    bands; they should be soft, light and porous, their warmth always
    adjusted to the immediate temperature so that the baby will be
    protected from being either chilled or overheated. And his clothing
    must always be clean and dry.

    =Fresh Air.= An abundance of fresh air is one of the baby’s greatest
    needs as it increases his resistance and recuperative powers,
    improves his appetite and aids digestion. In general, the more the
    baby is in the open air and the more fresh air he has while in the
    house, the better.

    The two factors which must be considered in supplying the baby with
    fresh air are the condition and vigor of the baby himself and the
    immediate temperature and state of the weather. His age and the
    season of the year can be only partial guides because of the
    difference between individual babies of the same age and the
    variations in temperature, winds and moisture during any one season.

    The air of the room which the baby occupies should be changing
    constantly in order that it may always be fresh, but the temperature
    should be equable and the baby protected from drafts. As the
    tendency here, as with the baby’s clothes, is toward overheating,
    the nurse will do well to remember that the new baby who lies
    covered up in his crib, may usually be kept in a colder room than is
    advisable for an older one who is creeping or walking about.

    During cold weather the baby’s bed should not be directly in front
    of an open window and he should be protected from direct currents of
    cold air by a sheet hung over the head and side of his crib. (See
    Fig. 153.)

    Two or three times daily, while the baby is out of the room, the
    windows should be opened wide to air the room thoroughly, one of
    these airings being just before the baby is put to bed for the
    night.

    The usual instructions concerning the temperature of the nursery are
    to keep it from 68° F. to 70° F. during the day and about 65° F. at
    night, during the first three months and lower it gradually to 64°
    F. during the day and about 55° F. at night as the baby grows older.
    It is customary to begin to open the nursery window at night when
    the baby is three or four months old, if he is well and the
    temperature is above freezing.

    In planning to take the baby out-of-doors it is wiser, as a rule, to
    begin with the indoor airing when he is about a month old, except,
    of course, during the moderate or mild months of the year, when he
    is taken out at once. If the weather is cold, the baby may be
    protected with extra wraps and carried in the nurse’s arms, into a
    room in which the windows are open and kept there for fifteen or
    twenty minutes. This indoor airing is increased by being gradually
    lengthened to two or three hours and by having the windows opened
    wider and wider. By the time he is two or three months old he is
    taken out of doors on clear, bright days, the best time being
    between ten and three o’clock, when the sun is high. If he is
    carried in the nurse’s arms at first the warmth of her body serves
    as a protection and helps to accustom him to the out-of-door life,
    when he spends a good deal of his time out of doors in his carriage.

    On windy, stormy days or when there is melting snow on the ground
    the baby may be given his airing on a protected porch or in a room
    with the windows open. He is not usually taken out if the
    temperature is below freezing until the third or fourth month. After
    this time the average baby is taken out when the temperature is not
    lower than 20° F.

    When the baby is dressed in his extra wraps he must be taken out of
    doors or the windows opened immediately, for otherwise he will
    become overheated and be in danger of chilling when taken into the
    colder air.

    Warm hands and feet, a good color and the baby’s tendency to sleep
    most of the time while out-of-doors are evidences of his being
    adequately clothed for his airing, while the reverse is true if he
    is not warm enough.

    A robust baby who has been gradually accustomed to being
    out-of-doors during the day will usually be much benefited by
    sleeping out at night. But he must be protected from winds and his
    clothing so arranged that he cannot be chilled. Knitted or flannel
    sleeping garments or sleeping bags (See Fig. 159) are valuable and
    in addition, the blankets which cover the baby should be securely
    pinned to the mattress with safety pins and tucked well under it at
    the sides and foot. The baby should wear a warm cap and the bed
    should be warmed before he is put into it. Or better still, he may
    be dressed for the night, put to bed in a warm room and the crib
    then moved out on the sleeping-porch.

[Illustration:

  FIG. 162.—Sutton poncho which keeps the baby warm by covering all but
    his head. The insert shows slit for his head. The regular bedding is
    temporarily turned back in this picture. (From photograph taken at
    Bellevue Hospital.)
]

    An excellent device for protecting the baby’s arms and chest and
    keeping him generally well covered is the poncho (Fig. 162) devised
    by Dr. Lucy Porter Sutton of Bellevue Hospital. The poncho is a
    rectangle made of flannel, outing flannel or an old blanket and cut
    large enough to tuck well under the head and sides of the mattress
    and extend below the baby’s feet. The baby’s head slips through an
    opening, which is almost a right-angled slit, near the centre of the
    poncho and about 20 inches from the top. The slit is firmly bound
    and provided with tapes to tie it together after the baby is put in.
    The poncho should be put on loosely enough to permit the baby to
    move about at will beneath it. After it is adjusted the bed is made
    up as usual with additional blankets.

    Under all conditions the baby’s airings must be increased gradually,
    both as to lowering the temperature and lengthening the time, and
    always adjusted to the vigor and reaction of the individual baby. He
    must be warm, but not too warm; he must be protected from wind and
    dust, and his eyes shielded from glare and from flickering light
    such as may be caused by a tree in a light breeze.

    =Exercise.= Although the baby should not be handled unnecessarily
    nor tossed about and played with by friends and relatives, it is
    important that his muscular development be promoted by regular and
    carefully planned exercise. It is usually considered best for the
    baby to lie quiet and undisturbed in his crib most of the time
    during the first three or four weeks. Dr. Griffith begins the baby’s
    exercise about that time by having the nurse take him in her arms on
    a pillow and carry him about for a few moments, several times daily.
    After a week or two of this form of exercise, the nurse carries the
    baby without a pillow but supports his head and back.

    The position of the baby’s body is changed by being carried about in
    this way, while the movement of the nurse as she walks about causes
    a certain amount of motion of the baby’s muscles, constituting a
    gentle exercise.

    This exercise, in the form of picking up and carrying about is
    regarded by many pediatricians as of great importance. There is a
    possibility that lack of this form of “mothering” is one reason why
    babies in hospital practice sometimes fail to progress as they
    should. Certainly lying too long in one position is harmful. The
    nurse should carry the baby first on one arm and then on the other
    in order that both sides of his body may be equally exercised. By
    the third or fourth month he sits up in her arms as she carries him
    about, and he may be placed on the outside of his crib coverings for
    a little while every day, to kick and struggle at will. His skirts
    should be rolled up under his shoulders, or removed entirely, to
    leave his legs quite free, care being taken that the room is warm
    and that he has on stockings.

[Illustration:

  FIG. 163.—A comfortable position for the baby being trained to use
    chamber.
]

    By about the sixth month he will usually begin to make an effort to
    creep, if turned over on his stomach and helped a little, and he may
    be propped up in the sitting position, in his crib, for a few
    moments every day. As he gives evidence of having enough energy to
    creep farther than the size of his crib permits, he may be put into
    a creeping-pen, or upon the floor under certain conditions. It must
    be remembered that the floor is likely to be cold, drafty and dusty.
    The nurse must assure herself, therefore, that the floor is warm;
    must cut off all drafts and spread a clean sheet or quilt on the
    floor before the baby is put down to creep. When the sheet is taken
    up, it is folded with the upper surface inside in order that when it
    is again put down the baby will play on the clean side and not on
    the side that has been next the floor.

    A creeping-pen or cariole or some such provision is often more
    satisfactory than the floor, consisting as it does of a railed-in
    platform raised about six or eight inches from the floor.

    The suggestions for exercise, like those for the baby’s airing, must
    be very general since it must always be adjusted to the powers of
    the individual baby and under the doctor’s supervision.


                           TRAINING THE BABY

    =Bowels.= It is possible to train even a very young baby to have
    regular daily bowel movements; this training should be started when
    the baby is about a month old. At the same hour each day he may be
    laid on a padded table, or taken in the nurse’s lap, a small basin
    being placed against or under the buttocks, and a soap stick
    introduced an inch or two into the rectum and moved gently in and
    out. This slight irritation will usually result in the baby’s
    emptying his bowels almost immediately. Or he may be held on a small
    chamber on the nurse’s lap, in a comfortable reclining position
    (Fig. 163) or with his back supported against her chest, and the
    desire to empty the bowels stimulated by using the soap stick.

    It is of greatest importance that the position and method which are
    adopted, be employed at exactly the same time each day. If this is
    done, and the baby is being properly fed, it will usually be found
    that, before he is many months old, his bowels will move freely and
    regularly without the stimulation of the soap stick and only when he
    is resting on the small basin or chamber. This establishment of a
    regular bowel movement not only simplifies the laundry work but is
    of great moment to the baby’s health.

    =Thumb-Sucking.= It is scarcely necessary to remind a nurse that the
    baby must not be allowed to suck on an empty bottle or a pacifier
    nor be permitted to suck his thumb. The habits are very dirty and
    help to spread infections. The baby may swallow air while practicing
    them, with colic as a result, and he may so deform the shape of his
    upper jaw that, later in life, the upper and lower teeth will not
    meet as they should when he masticates; his front teeth may protrude
    in a disfiguring manner; and by narrowing and elongating the roof of
    his mouth the structure of the air passages is altered, with
    respiratory troubles and adenoids as a frequent consequence.
    Thumb-sucking may be prevented by the simple procedure of putting
    stiff cuffs on the baby’s elbows (Fig. 164) which make it impossible
    for him to reach his mouth with his thumb. These cuffs may be made
    by covering pieces of cardboard with muslin and attaching tapes with
    which to tie them on the baby’s arms. His hands may be put into
    celluloid or aluminum mitts, or little bags made of stiff, heavy
    material, which in turn are tied to his wrists, or his sleeves may
    be drawn down over his hands and sewed or pinned with safety pins.
    It should be borne in mind that a baby sometimes sucks his thumb
    because he is hungry or thirsty and gives up the practice when his
    food is increased or when he is regularly given water to drink.

[Illustration:

  FIG. 164.—Stiff cuffs to prevent thumb sucking. (From photograph taken
    at Johns Hopkins Hospital.)
]

    =Ear Pulling= is not uncommon among young babies and if allowed to
    continue a long, misshapen ear may result. This may be prevented by
    using a thin, close fitting cap which ties under the chin, or by
    using the same kind of elbow splints as for thumb-sucking.

[Illustration:

  FIG. 165.—Cap, to prevent ruminating. (Devised by Miss Hammer.)
]

    =Crying.= It is very easy to allow the baby to develop the crying
    habit, but very difficult to break it up. A baby who is properly
    fed, kept dry and warm but not too warm, and whose clothes are
    comfortable will usually cry very little if wisely handled. But a
    baby may cry because he is hungry, thirsty, wet, cold, over-heated,
    sick or in pain or simply because he wants to be taken up and
    entertained and has learned that the way to realize his wish is to
    cry. By closely observing the baby’s habits and his condition the
    nurse will usually be able to ascertain the cause of the crying.
    Very often a drink of fairly warm, sterile water will quiet him,
    particularly at night. But both the nurse and the mother should
    refrain from taking the crying baby up and carrying him or holding
    him when it is discovered that this attention stops his crying.
    Persistent crying should always be reported to the doctor, as it may
    have serious significance.

    =Ruminating.= Some babies have the habit, called “ruminating,” of
    bringing up food; chewing it; moving it about and finally rolling it
    out of their mouths. Although this habit has not been recognized
    until comparatively recently, it is now believed to be of fairly
    common occurrence and often mistaken for vomiting. It is seen as a
    rule in precocious babies who take more interest in their
    surroundings than the average, more placid infant, beginning very
    early to fix their attention upon light, sounds and moving objects.
    The ruminator begins by bringing up a small amount of his last
    nourishment, then a little more and a little more until finally he
    has brought up nearly or quite all of it, apparently deriving a
    certain amount of pleasure and satisfaction from the procedure.
    Quite obviously, a continuation of this practice results in
    undernourishment, sometimes even starvation, since the baby actually
    retains very little if any of his food. As liquids come up more
    easily than fluids, the first step toward breaking up this habit is
    usually to give the baby more solid and concentrated food than he
    has been taking and to carry him about, talk to him and entertain
    him for about an hour after feedings, for if his attention is
    otherwise engaged, he is not likely to ruminate. Another efficacious
    measure is the use of a cap (See Fig. 165) so constructed and tied
    under his chin that the baby’s jaws are held tightly together and he
    is unable to make the movements which are necessary to rumination.
    (Fig. 166.)

[Illustration:

  FIG. 166.—Ruminating cap applied. (From photograph taken at Johns
    Hopkins Hospital.)
]


                            FEEDING THE BABY

    Proper feeding is probably the most decisive single factor in the
    routine care of the baby.

    In order that the food be satisfactory it must be not only suitable
    in composition for the individual baby, but it must be clean, fresh
    and at the right temperature; given in suitable amounts and at
    suitable and regular intervals; it must be given properly—not too
    fast nor too slowly and it must be given under favorable conditions.

    Moreover, the baby himself must be kept in a general condition which
    will favor the digestion and assimilation of the food that is given
    to him. Fresh air, suitable clothing, an even body temperature,
    gentle handling, proper bathing, regular sleep, freedom from
    excitement, fatigue and irritation, all promote the baby’s ability
    to use his food to advantage. Reverse influences all work against
    it.

    The character, amount and intervals of the baby’s feeding are
    definitely ordered by the doctor, but the many factors which
    influence the baby’s nutrition are so largely a matter of nursing
    that the nurse has grave responsibilities in connection with his
    nourishment.

    After other conditions have been made favorable, the factors which
    determine the character of the baby’s food are the kind and amount
    of food materials which are needed by his growing body and the
    powers of his digestive organs. If he is given less food than he
    needs at each stage of his progress he will not be properly
    nourished; but if he is given food materials in quantities,
    proportions or character which are beyond the power of his immature
    alimentary tract to digest, he not only will not be properly
    nourished but probably will be made ill.

    There are three methods of nourishing the baby: breast feeding,
    artificial feeding and a combination of the two, termed mixed or
    supplementary feeding.

    =Breast Feeding.= From all standpoints, maternal nursing under
    normal conditions is the most satisfactory method of infant feeding.
    If the breast milk is suitable it meets all of the baby’s
    requirements and the proportion and character of its constituents
    are exactly suited to his digestive powers.

[Illustration:

  FIG. 167.—Proper method of carrying baby to support head and back.
    (From photograph taken at Johns Hopkins Hospital.)
]

    In order that the nursing be entirely satisfactory, the condition of
    both mother and baby must be favorable to its success. The
    preparation and care of the mother have been described: her general
    condition and state of nutrition; the care and condition of her
    nipples, flat or retracted nipples being brought out if possible,
    and if not, the nursing facilitated by the use of a shield. If the
    baby’s diaper is wet or soiled, it should be changed before he is
    put to the breast, partly to make him comfortable and partly to
    avoid disturbing him after his feeding. His mouth is gently swabbed
    with boric soaked cotton, if this is ordered, he is wrapped in a
    little blanket and carried to his mother dry and warm and
    comfortable. (Fig. 167.) Although nursing is an instinct, the baby
    sometimes has to learn or to acquire the habit which is one reason
    for putting him to the breast during those first two or three days
    when he obtains little or no actual food. (See Chapter XVI.) As he
    expresses the milk by a squeezing and suction made possible only
    when the nipple is well back in his mouth, he must take into his
    mouth practically the entire pigmented area which surrounds the
    nipple. To do this he lies in the curve of his mother’s arm as she
    turns slightly to one side, and holds her breast away from his
    nostrils in order that he may breathe freely.

    Sometimes even when other conditions are favorable, the baby is
    unable to nurse because of some physical disability. He may be too
    feeble; have a cleft palate or find suckling painful because of an
    abrasion of the mucous membrane which occurred when his mouth was
    bathed just after birth. The manner in which the baby nurses,
    therefore, may be significant and should be carefully noted and
    described to the doctor.

    There is a difference of opinion among doctors concerning the
    interval between feedings which is most satisfactory. Some have the
    baby nurse every four hours and others every three hours during the
    early months of life. It is believed by some doctors that although a
    baby who is fed on a four-hour schedule may regain his birth weight
    more slowly than the baby who is fed every three hours, he suffers
    less from digestive disturbances and ultimately makes an entirely
    satisfactory gain in weight. Another point in favor of the four-hour
    interval is the longer period of freedom which this gives to the
    mother and this may influence her willingness to nurse her baby. But
    other doctors, both pediatricians and obstetricians, feel that the
    four-hour interval is too long for most babies.

    Whether the baby shall nurse from one or both breasts at each
    feeding is another moot question. Some doctors believe that the
    results are better if both breasts are partially emptied at each
    nursing, while others feel that the function of the breasts is more
    satisfactorily promoted by completely emptying one breast at a time,
    at alternate nursings. Although the baby should pause every four or
    five minutes to prevent his nursing too rapidly, which is a common
    cause of colic, neither he nor his mother should be allowed to sleep
    during the nursing periods. When he has finished, he should be taken
    up very gently and placed in his crib and left to sleep. If he is
    nursing satisfactorily, he will be sleepy and contented after
    nursing and will sleep for two or three hours afterwards; he will
    seem generally good humored and comfortable while awake; he will
    have good color; gain weight steadily and have two or three normal
    bowel movements daily. The normal stool in breast fed babies is
    bright yellow, smooth and with no evidences of undigested food.

    If he is not being adequately nourished, he will present exactly the
    opposite picture, in some or all of these respects. He will be
    unwilling to stop nursing after the normal length of time and will
    give evidence of not being satisfied when taken from his mother. He
    may be listless and fretful and sleep badly. He will not gain weight
    as he should, and he may vomit or have colic after nursing.

    To ascertain whether or not such a baby is getting enough milk it is
    customary to weigh him, without undressing him, before and after
    each nursing. Each fluid ounce of food will increase his weight one
    ounce. If the baby is not getting a normal amount of milk at each
    nursing he is often given enough modified milk after each meal to
    supply the deficit, but at the same time an effort is made to
    increase the supply of breast milk by improving the mother’s
    personal hygiene.

    The amount which the baby needs at each feeding varies, not only
    according to his weight and age, but also according to his vigor and
    activity, and must always be figured for the individual baby. A very
    general estimate of the amount taken by the average well baby at
    each feeding, is about as follows:

               First week                1½ to 2½ ounces
               Second and third week     2  to 4  ounces
               Fourth to ninth week      3  to 4½ ounces
               Tenth week to fifth month 3½ to 5  ounces
               Fifth to seventh month    4½ to 6½ ounces
               Seventh to twelfth month  6½ to 9  ounces

    =Artificial Feeding.= There is no entirely adequate substitute for
    satisfactory maternal nursing, and any other food that is given to
    the young baby is at best a makeshift. Considering the baby’s
    delicacy, therefore, and his urgent needs, no pains should be spared
    to make any artificial food which is given to him as satisfactory as
    possible. In preparing and giving artificial food it must be borne
    in mind that normal breast milk:

     1. Is exactly right in quantity, quality and proportion.

     2. Is fresh, clean and sweet.

     3. Is free from bacteria.

     4. Tends to protect the baby from infection.

     5. Definitely protects him from certain nutritional diseases.

    Cows’ milk, suitably modified, is apparently the best available
    substitute for mother’s milk, but it must first meet certain
    requirements and then be handled with scrupulous cleanliness and
    care, if it is to be at all satisfactory.

    The requirements are that the milk shall be:

     1. Whole milk. It must not be altered by the removal of cream nor
          the addition of such preservatives as salicylic acid,
          formaldehyde or boracic acid.

     2. Its composition must not vary greatly from day to day.

     3. It must be clean and free from disease germs; other organisms
          should not be present in excessive numbers.

     4. It must be fresh: less than 24 hours old when it is delivered.

    All of this means that the milk must come from a herd of healthy,
    tuberculin-tested cows. The milk from a single cow may vary markedly
    from day to day but that from several cows is nearly constant. The
    stables and the cows must be kept clean, the udders carefully washed
    before each milking; the milkers themselves must wear freshly washed
    clothing, scrub their hands thoroughly and milk into sterile
    receptacles; the milk must be immediately covered and cooled to a
    temperature of 45° F. or 50° F. and kept there.

    Milk produced under such conditions is usually described as
    “certified milk” and is often prescribed as infant food without
    being pasteurized or sterilized. But if there is any doubt about the
    source of the milk and the method of its handling, it should be
    strained into a clean receptacle through filter paper or a thick
    layer of absorbent cotton and subsequently boiled or pasteurized.

    When the nurse is in a position to offer advice about the baby’s
    milk she must explain the importance of always obtaining the
    freshest, cleanest and purest milk possible, no matter what it
    costs.

    Whether certified or not the milk must always be placed in the
    refrigerator or some other place at a temperature of 50° F. as soon
    as it is received and _it must be kept cool and clean_. Mother’s
    milk, which is being imitated, is clean and sweet and free from
    disease germs.

    Keeping the milk cool means keeping it at a temperature of 50° F.
    Keeping it clean implies cleanliness of the milk itself, the
    utensils, the nurse’s hands and the destruction, by sterilization or
    pasteurization, of disease germs. Those which are likely to be
    present in infected milk are streptococci, tubercle bacilli, colon
    bacilli, germs of typhoid, diphtheria and scarlet fever.

    The amounts and proportions of the constituents of the substitute
    feeding will be specified by the doctor, as well as the intervals
    between feedings and the amount to be given each time. But the
    doctor’s careful adjustment of the milk formula to the baby’s
    immediate needs and digestive powers will be set at naught unless
    the nurse is absolutely _accurate_ in preparing and giving the milk.

    The nurse’s invariable responsibility, therefore, is to keep the
    milk _cool_ and _clean_ and prepare and give it _accurately_.

    The nurse will appreciate the necessity and principles of modifying
    cows’ milk for the human infant if she will consider for a moment,
    the differences between mother’s milk and cows’ milk, as indicated
    by the following table, and the reasons for these differences:

                         _Mother’s Milk._  _Cows’ Milk._
              Fats       3.5    to   4. %    3.5 to  4.  %
              Sugar      6.5    to   7.5%    4.5 to  4.75%
              Proteins   1.     to   1.5%    3.5 to  4.  %
              Salts                   .2%     .7 to   .75%
              Water      87     to  88. %           87.  %

    It will be remembered that the tissues and bony skeleton are built
    by the proteins and salts (lime and phosphorus). Accordingly Nature
    supplies these in greater abundance to the calf, who grows so fast
    as to double his birth weight in about 47 days, than to the baby who
    scarcely doubles his within 180 days. The calf begins life with a
    physical need for the abundance of proteins and salts which are
    present in cows’ milk, and with digestive organs that can cope with
    them, but the baby needs less, can digest less and therefore must be
    given less. There are, of course, other and finer differences
    between the two milks and an attempt is sometimes made to meet
    these. For example, mother’s milk is slightly alkaline and cows’
    milk slightly acid and the curd of cows’ milk is larger, tougher and
    harder to digest than that formed by mother’s milk. Accordingly some
    doctors add lime water to cows’ milk to make it alkaline, and render
    the curd softer, finer and more digestible by boiling it.

    It is often not possible to give a bottle-fed baby the full 4% of
    fat which mother’s milk contains, and some doctors make the protein
    of the artificial mixture very much larger in amount than is found
    in human milk. The nurse will see that this is a matter which can be
    decided only by the physician.

    =Articles Needed in Preparing the Baby’s Food.= A complete equipment
    for preparing and giving the baby’s milk should be assembled, kept
    in a clean place, separate from utensils in general use, and never
    put to any other service. A satisfactory outfit for this purpose
    comprises the following articles:

      One dozen graduated nursing bottles.
      One dozen nipples.
      Clean, new corks or a package of sterile, non-absorbent cotton
         for stoppers.
      Bottle brush.
      Covered kettle, capacity one gallon, for boiling bottles and
         possibly pasteurizing milk.
      Pasteurizer or wire bottle rack.
      Small kettle, about one quart size.
      Graduated pint or quart measuring glass.
      Pitcher, two quart size.
      Long-handled spoon for mixing.
      Funnel.
      Measuring spoons—table and tea sizes.
      Double boiler.
      Thermometer which will register at least 212° F.
      Cream dipper (if ordered).
      Two small covered jars for sterile and used nipples.
      Sugar (lactose, maltose or cane sugar according to orders).
      Lime water, if ordered.

    Utensils of enamel or aluminum ware are probably the most
    satisfactory ones to use as they are easily kept clean, while
    bottles with wide mouths and curved bottoms and inner surfaces can
    be thoroughly washed more easily than those with small necks and
    sharp corners. Nipples that can be turned inside out to be washed
    should be selected as it is almost impossible to clean thoroughly
    those with tubes or narrow necks. New bottles will be rendered less
    breakable if placed in cold water, which is gradually heated,
    allowed to boil for half an hour and cooled before the bottles are
    removed.

[Illustration:

  FIG. 168.—Preparing the baby’s milk. (From photograph taken at Johns
    Hopkins Hospital.)
]

    The bottles should be rinsed with cold water after each feeding and
    then carefully washed and scrubbed with the bottle brush in hot
    soapsuds or borax water, containing two tablespoonsful to the pint.
    They may be kept full of water while not in use or rinsed with hot
    water and stood upside down until they are all boiled on the
    following morning, preparatory to being filled with the freshly
    prepared milk. The baby’s bottles should never be washed in
    dishwater nor dried on a towel. The nipples should be rinsed in cold
    water, turned inside out and scrubbed with a brush, in hot soapsuds
    or borax water; rinsed and placed in a jar ready to be boiled with
    the bottles.

    =Preparation of Milk.= The full quantity of milk which the baby will
    take in the course of twenty-four hours is prepared at one time and
    the prescribed amount for each feeding poured into as many separate
    bottles as there will be feedings. (Fig. 168.)

    The nurse should first boil for five minutes all of the articles
    that will come in contact with the milk, including the full number
    of bottles and nipples and the jars in which the nipples are kept;
    remove them with the long-handled spoon without touching the edges
    or inner surfaces and place them on a clean table, dropping the
    nipples into one of the sterile jars.

    She should wash the mouth of the milk bottle before removing the cap
    and pour the amount which the formula calls for into the sterile
    pitcher. To this is added the sterile water in which the sugar has
    been dissolved in the glass graduate, and the potato or barley
    water, the lime water or soda solution as ordered. This mixture is
    thoroughly stirred and the amount for one feeding at a time measured
    in the graduate and poured into the specified number of bottles
    which are then stoppered.

    If certified milk is used for the milk mixture it is often given to
    the baby without being pasteurized, in which case the bottles are
    placed in the refrigerator as soon as they are filled and stoppered.
    Very frequently, however, the milk is sterilized or pasteurized. The
    nurse will feel surer of keeping the mouths of the bottles clean if
    she covers them with squares of gauze or muslin before they are
    sterilized, holding the caps in place with tapes or rubber bands.
    Pasteurization as applied to infant feeding consists of heating the
    milk to 140–165° F. and keeping it at that temperature 20 to 30
    minutes.

    There are many excellent pasteurizers for home use on the market, or
    entirely satisfactory results may be obtained by using a wire bottle
    rack (See Fig. 168) and the large kettle already provided. One
    method is to place the rack containing the bottles in the kettle
    which is filled with cold water to a level a little above the top of
    the milk in the bottles, and allow the water to come to the boiling
    point. The kettle is removed from the fire, covered tightly and the
    bottles allowed to stand in the hot water for twenty minutes. Cold
    water is then run into the kettle to cool the milk gradually and
    avoid breaking the bottles, after which they are placed in the
    refrigerator, well or spring-house and kept at a temperature of 50°
    F. until they are taken out one at a time for feedings. If a wire
    rack is not available the bottles may be stood on a saucer or a
    thick pad of folded newspapers in the bottom of the kettle.

    Pasteurization does not destroy all germs that may be in the milk,
    but it kills the more important ones and apparently impairs the
    nutritive and protective properties of the milk less than boiling.
    However, pasteurized milk must be kept cold and must be used within
    twenty-four hours, for the nurse will recall that aging of milk is
    quite as undesirable as souring.

    Scalding is another method of destroying germs in milk. The milk is
    placed in an open vessel and the temperature raised to about 180°
    F., or until bubbles appear around the edge and the milk steams in
    the centre, after which it is cooled and kept at a temperature of
    50° F.

    Many doctors prefer to have the baby’s milk boiled, since boiling
    insures absolute sterilization and also renders the curd more
    digestible. Other changes are produced by boiling, however, which
    make it important to add an anti-scorbutic and cod-liver oil to the
    baby’s diet at an early date.

    Milk may be boiled directly over the flame for a time varying from
    three to forty-five minutes, or it may be placed in a double boiler,
    the water in the lower receptacle being cold, and allowed to remain
    until the water has boiled from six to forty-five minutes. All of
    these points are definitely specified by the doctor.

    When milk is boiled or scalded the other ingredients are added
    beforehand, as a rule, after which it is measured and poured into
    the bottles. Or the milk mixture may be poured into the bottles as
    for pasteurization and the bottles kept in the actively boiling
    water for any desired length of time.

    =Giving the Baby His Bottle.= At feeding time, the bottle should be
    taken from the refrigerator, the stopper removed and a nipple taken
    up by the margin and put on the bottle without touching the
    mouthpiece. The milk is brought to a temperature of about 100° F. by
    standing the bottle in a deep cup or kettle of warm water and
    placing it on the fire. The temperature of the milk may be tested by
    dropping a few drops on the inner side of the wrist or forearm where
    it should feel warm but not hot. This dropping will also indicate if
    the hole in the nipple is of the proper size to allow the milk to
    drop rapidly in clean drops but not to pour. If the hole is too
    small, the drops will be small and infrequent and the baby will be
    obliged to work too hard to obtain it; while if the hole is too
    large the baby will feed too rapidly and may have colic as a result.

[Illustration:

  FIG. 169.—Proper position in which to hold baby and bottle during
    feeding.
]

    The baby’s diaper should be changed if it is soiled or wet before he
    is given the bottle and he should be held comfortably in a reclining
    position on the nurse’s arm while she holds the bottle with her free
    hand. (Fig. 169.) The bottle should be inclined sufficiently to keep
    the neck full of milk; otherwise the baby may draw in air as he
    nurses. He should be kept awake while feeding but he should be
    allowed to pause every three or four minutes in order not to take
    his milk too rapidly. Not less than ten nor more than twenty minutes
    is devoted to a feeding, as a rule, and if the baby refuses a part
    of his milk, it should be thrown away; never warmed over for another
    time.

[Illustration:

  FIG. 170.—Holding the baby upright and gently patting his back to
    bring up air immediately after feeding.
]

    After being fed, the baby should be held upright against the nurse’s
    shoulder for a moment or two (Fig. 170), and ever so gently patted
    on the back to help bring up any air which he may have swallowed. He
    should on no account be rocked or played with after taking the
    bottle, but should be placed gently in his crib, warm and dry and
    left alone to sleep. Turning him or moving him about even to the
    extent of changing his diaper at this time may cause vomiting.

    The evidences of satisfactory and unsatisfactory feeding in the
    bottle-fed baby are about the same as in the baby who is fed at the
    breast, except that the gain in weight on artificial food may be a
    little slower and less steady than on maternal nursing; the stools
    have a characteristic sour odor; are a little lighter in color and
    may contain white lumps of undigested fat; are usually dryer than in
    breast-feeding and may be formed in even a very young baby.

    It is fairly generally agreed that all babies, whether breast-fed or
    on the bottle, require a certain amount of cool boiled water to
    drink between feedings. A small amount is given at first and
    gradually increased according to the doctor’s instructions, and it
    may be given from a bottle, a medicine dropper or poured slowly from
    the tip of a teaspoon.

    =Ingredients of the Baby’s Food.= In referring to the ingredients of
    the baby’s food we cannot use the terms “sugar” or “milk” as though
    they indicated definite and unvarying materials.

    There are three kinds of sugar which are commonly used in modified
    milk: cane or granulated sugar; lactose or milk sugar and maltose.
    _Cane sugar_, the one most widely used, is the least expensive of
    the three and it apparently is satisfactory for most babies.
    _Lactose_ is fairly expensive and while it causes diarrhea in some
    babies, others digest it more easily than cane sugar. Lactose is
    lighter than cane sugar, three spoonfuls being equal in weight to
    two of cane sugar. The _maltose_-dextrine preparations are easily
    digested and somewhat laxative. Some babies gain more rapidly when
    maltose constitutes part of the sugar in their food than when only
    lactose is used.

    The question of milk is somewhat complicated and though the doctor
    will specify what percentage of fat shall be in the milk which is
    used in each case, the nurse must know how to obtain it from the
    milk at her disposal. If the formula is made up with “whole milk,”
    which contains 4 per cent. fat, the bottle in which it was delivered
    should be turned upside down and shaken vigorously in order that the
    cream which has risen to the top may be redistributed evenly
    throughout the fluid.

    If the doctor employs what is termed “percentage feeding,” he may
    use whole milk, skimmed milk, or top milk. What he is endeavoring to
    do is to prepare a food which contains definite known percentages of
    the different ingredients, fat, carbohydrates and protein. Where a
    mixture is desired which contains more fat than it does protein, the
    milk to be employed is obtained by discarding a certain amount from
    the bottom of the jar of milk, the remainder being then called “top
    milk.” When he wishes the fat to be lower than the protein
    percentage, he discards some of the top milk in the jar, using the
    rest, which is then a partially skimmed milk. The upper 2 ounces in
    a quart bottle of milk contains 24 per cent. fat; the upper 8 ounces
    is 12 per cent. fat; the upper 16 ounces is 8 per cent. fat and the
    upper 24 ounces is 5 per cent. fat. If the formula calls for 6
    ounces of the upper 8 ounces of milk, therefore, the nurse will see
    that it is very important that she remove the full 8 ounces and use
    6 ounces of the milk which she has removed and not simply take the
    upper 6 ounces, as this would contain a higher percentage of fat
    than is ordered. (Figs. 171, 172, Dr. Griffith’s tables of fat
    percentages.)

    Top milk may be removed by tipping the bottle gradually and slowly
    pouring the designated amount into a measuring glass, or it may be
    removed by pushing a cream dipper, especially made for this purpose
    and holding one ounce, down into the bottle until the cream flows
    in. Another method is to syphon off the lower milk through a bent
    glass tube, leaving in the bottle the desired amount of top milk.

    Many doctors feed the baby according to his caloric needs and
    prepare the formula from whole milk, sugar and water, determining
    the amounts of each according to the age and weight of the baby.

    Under any condition it is so necessary that the amount and
    composition of each baby’s food be adjusted to his needs, that it is
    not considered possible to make out any formulae or feeding
    schedules which would be safe or satisfactory for general use.

        Ready Method for Selecting Amounts to be Employed in Making
       Various 20–Oz. Milk-Mixtures, and the Caloric Values Resulting

      [Illustration:

        READY METHOD FOR SELECTING AMOUNTS TO BE EMPLOYED IN MAKING
       VARIOUS 20–OZ. MILK-MIXTURES, AND THE CALORIC VALUES RESULTING

 ┌────────────────┬─────┬─────┬─────┬─────┬─────┬─────┬─────┬─────┐
 │  Percentages   │Lower│Lower│Lower│Whole│Upper│Upper│Upper│Upper│
 │   desired of   │8 oz.│ 16  │ 28  │Milk │ 24  │ 20  │ 16  │ 10  │
 │                │     │ oz. │ oz. │     │ oz. │ oz. │ oz. │ oz. │
 │                │     │     │     │     │     │     │     │     │
 ├───┬─────┬──────┼─────┼─────┼─────┼─────┼─────┼─────┼─────┼─────┤
 │Fat│Sugar│Prot’n│     │     │     │     │     │     │     │     │
 ├───┼─────┼──────┼─────┼─────┼─────┼─────┼─────┼─────┼─────┼─────┤
 │0.5│5    │1     │     │     │ 5   │     │     │     │     │     │
 ├───┼─────┼──────┼─────┼─────┼─────┼─────┼─────┼─────┼─────┼─────┤
 │0.5│6    │2     │     │10   │     │     │     │     │     │     │
 ├───┼─────┼──────┼─────┼─────┼─────┼─────┼─────┼─────┼─────┼─────┤
 │1  │6    │1     │     │     │     │5    │     │     │     │     │
 ├───┼─────┼──────┼─────┼─────┼─────┼─────┼─────┼─────┼─────┼─────┤
 │1  │6    │1.5   │2.5  │     │     │5    │     │     │     │     │
 ├───┼─────┼──────┼─────┼─────┼─────┼─────┼─────┼─────┼─────┼─────┤
 │1  │6    │2     │     │     │10   │     │     │     │     │     │
 ├───┼─────┼──────┼─────┼─────┼─────┼─────┼─────┼─────┼─────┼─────┤
 │1.5│6    │1     │     │     │     │     │     │5    │     │     │
 ├───┼─────┼──────┼─────┼─────┼─────┼─────┼─────┼─────┼─────┼─────┤
 │1.5│6    │1.5   │     │     │     │7.5  │     │     │     │     │
 ├───┼─────┼──────┼─────┼─────┼─────┼─────┼─────┼─────┼─────┼─────┤
 │2  │6    │1.5   │2.5  │     │     │     │     │     │5    │     │
 ├───┼─────┼──────┼─────┼─────┼─────┼─────┼─────┼─────┼─────┼─────┤
 │2  │6    │2     │     │     │     │10   │     │     │     │     │
 ├───┼─────┼──────┼─────┼─────┼─────┼─────┼─────┼─────┼─────┼─────┤
 │2.5│6    │1.5   │2.5  │     │     │     │     │     │     │5    │
 ├───┼─────┼──────┼─────┼─────┼─────┼─────┼─────┼─────┼─────┼─────┤
 │2.5│6    │2     │     │     │     │     │10   │     │     │     │
 ├───┼─────┼──────┼─────┼─────┼─────┼─────┼─────┼─────┼─────┼─────┤
 │2.5│6    │2.5   │     │     │     │12.5 │     │     │     │     │
 ├───┼─────┼──────┼─────┼─────┼─────┼─────┼─────┼─────┼─────┼─────┤
 │3  │6    │1     │     │     │     │     │     │     │     │     │
 ├───┼─────┼──────┼─────┼─────┼─────┼─────┼─────┼─────┼─────┼─────┤
 │3  │6    │1.5   │2.5  │     │     │     │     │     │     │     │
 ├───┼─────┼──────┼─────┼─────┼─────┼─────┼─────┼─────┼─────┼─────┤
 │3  │6    │2     │     │     │     │     │     │10   │     │     │
 ├───┼─────┼──────┼─────┼─────┼─────┼─────┼─────┼─────┼─────┼─────┤
 │3  │6    │3     │     │     │     │15   │     │     │     │     │
 ├───┼─────┼──────┼─────┼─────┼─────┼─────┼─────┼─────┼─────┼─────┤
 │4  │4    │4     │     │     │     │20   │     │     │     │     │
 └───┴─────┴──────┴─────┴─────┴─────┴─────┴─────┴─────┴─────┴─────┘

 ┌────────────────┬─────┬─────┬─────┬───────┬────────┐
 │  Percentages   │Upper│Water│Sugar│Caloric│Calories│
 │   desired of   │8 oz.│ oz. │ oz. │ Value │per oz. │
 │                │     │     │     │  of   │        │
 │                │     │     │     │Mixture│        │
 ├───┬─────┬──────┼─────┼─────┼─────┼───────┼────────┤
 │Fat│Sugar│Prot’n│     │     │     │       │        │
 ├───┼─────┼──────┼─────┼─────┼─────┼───────┼────────┤
 │0.5│5    │1     │     │15   │0.8  │175    │ 8.75   │
 ├───┼─────┼──────┼─────┼─────┼─────┼───────┼────────┤
 │0.5│6    │2     │     │10   │0.8  │225    │11.25   │
 ├───┼─────┼──────┼─────┼─────┼─────┼───────┼────────┤
 │1  │6    │1     │     │15   │1    │225    │11.25   │
 ├───┼─────┼──────┼─────┼─────┼─────┼───────┼────────┤
 │1  │6    │1.5   │     │12.5 │0.9  │237.5  │11.88   │
 ├───┼─────┼──────┼─────┼─────┼─────┼───────┼────────┤
 │1  │6    │2     │     │10   │0.8  │250    │12.5    │
 ├───┼─────┼──────┼─────┼─────┼─────┼───────┼────────┤
 │1.5│6    │1     │     │15   │1    │250    │12.5    │
 ├───┼─────┼──────┼─────┼─────┼─────┼───────┼────────┤
 │1.5│6    │1.5   │     │12.5 │0.9  │262.5  │13.13   │
 ├───┼─────┼──────┼─────┼─────┼─────┼───────┼────────┤
 │2  │6    │1.5   │     │12.5 │0.9  │287.5  │14.38   │
 ├───┼─────┼──────┼─────┼─────┼─────┼───────┼────────┤
 │2  │6    │2     │     │10   │0.8  │300    │15      │
 ├───┼─────┼──────┼─────┼─────┼─────┼───────┼────────┤
 │2.5│6    │1.5   │     │12.5 │0.9  │312.5  │15.63   │
 ├───┼─────┼──────┼─────┼─────┼─────┼───────┼────────┤
 │2.5│6    │2     │     │10   │0.8  │325    │16.25   │
 ├───┼─────┼──────┼─────┼─────┼─────┼───────┼────────┤
 │2.5│6    │2.5   │     │7.5  │0.7  │337.5  │16.88   │
 ├───┼─────┼──────┼─────┼─────┼─────┼───────┼────────┤
 │3  │6    │1     │5    │15   │1    │325    │16.25   │
 ├───┼─────┼──────┼─────┼─────┼─────┼───────┼────────┤
 │3  │6    │1.5   │5    │12.5 │0.9  │337.5  │16.88   │
 ├───┼─────┼──────┼─────┼─────┼─────┼───────┼────────┤
 │3  │6    │2     │     │10   │0.8  │350    │17.5    │
 ├───┼─────┼──────┼─────┼─────┼─────┼───────┼────────┤
 │3  │6    │3     │     │5    │0.4  │375    │18.75   │
 ├───┼─────┼──────┼─────┼─────┼─────┼───────┼────────┤
 │4  │4    │4     │     │0    │     │400    │20      │
 └───┴─────┴──────┴─────┴─────┴─────┴───────┴────────┘

        FIG. 171. Table of fat percentages, by permission, from “The
        Diseases of Infants and Children,” by J. P. Crozer Griffith,
                                    M.D.

      ]

                  *       *       *       *       *

      [Illustration:

         ─────────────────────────────────────────────────────
           TABLE GIVING APPROXIMATE PERCENTAGE-STRENGTHS OF
                       DIFFERENT LAYERS OF MILK

                                 Per cent. Per cent.   Ratio
                                    Fat     Protein
                                           and Sugar
         Upper  2 oz.                   24         4    6 to 1
         Upper 4 oz.                    20         4    5 to 1
         Upper 6 oz.                    16         4    4 to 1
         Upper 8 oz.                    12         4    3 to 1
         Upper 10 oz.                   10         4  2.5 to 1
         Upper 16 oz.                    8         4    2 to 1
         Upper 20 oz.                    6         4  1.5 to 1
         Upper 24 oz.                    5         4 1.25 to 1
         Upper 32 oz. whole milk         4         4    1 to 1
         Lower 30 oz.                    3         4  .75 to 1
         Lower 28 oz.                    2         4  .50 to 1
         Lower 16 oz.                    1         4  .25 to 1
         Lower 8 oz.                   0.5         4   .0 to 1
         ─────────────────────────────────────────────────────

                  *       *       *       *       *

         TO FIND THE AMOUNT OF ANY LAYER OF MILK TO BE USED TO GIVE
                            PERCENTAGES DESIRED

  Equation:

      Total amount of food × Percentage of fat desired   Amount of
      ———————————————————————————————————————————————— = this milk in
      Fat-strength of layer of milk used                 the mixture.

  (1) Select from the “Layers of Milk” Table the milk which possesses
      the desired ratio of fat to protein.

  (2) Substitute in the equation.

  (3) As the sugar-percentage has been reduced equally with that of
      the protein, add sufficient sugar to raise to the desired
      percentage.

  EXAMPLE: 20–oz. mixture desired. Percentages desired = Fat 3, Sugar
      6, Protein 1. Use upper 8 oz. (fat 12%, protein 4%, viz.: 3:1).
      Then 20 × 3/12 = 5 oz. of upper 8 oz., with 15 oz. of water in
      the 20–oz. mixture. The protein necessarily becomes 1%, and the
      sugar likewise. The mixture already containing 1% of sugar, add
      5% of 20 oz., i. e., 1 oz. of sugar to increase this to the 6%
      desired.

                  *       *       *       *       *

      TO DETERMINE THE PERCENTAGES PRESENT IN ANY MILK-MIXTURE ALREADY
                                   IN USE

         Quantity of substance used
       (milk, cream, or skimmed milk)
         × Its percentage-strength
       ————————————————————————————— = Percentage of element
           Total Quantity of Food      (F., S. or P. in the mixture.)

  EXAMPLE: The mother has mixed: Upper 8 oz.; 6 oz.—Lower 8 oz.; 3
      oz.—Milk-sugar 3 level tablespoonfuls.—Water 27 oz. Total
      quantity = 36 oz. The upper 8 oz. contains 12% fat (see Table).
      Both top and bottom milk contain 4% protein and sugar. Three
      tablespoonfuls sugar = approximately 1 oz. The fat of the lower
      8 oz. may be ignored. Then 6 × 12/36 = 2 = Fat percentage from
      the top-milk. 3 × 0/36 = 0 = Fat-percentage from the bottom
      milk. 9 × 4/36 = 1 = Protein and sugar percentages from combined
      top and bottom milk. The 1 oz. additional sugar divided by 36 =
      approximately 3% sugar added. There being already 1% sugar
      derived from the milk, the total sugar = 4%.

                  *       *       *       *       *

                FIG. 172. Reverse side of card in Fig. 171.

      ]

    Moreover, it does not ordinarily devolve upon the nurse to do more
    than prepare and give the baby’s food as ordered by the doctor, but
    situations sometimes do arise when the doctor is not within reach
    which the nurse must meet as best she can. In such an emergency she
    might be guided by the following suggestions contained in a pamphlet
    entitled, “Save the Babies,” prepared by Dr. L. Emmet Holt and Dr.
    H. K. L. Shaw and published by the American Medical Association,
    remembering that they are intended for the average, normal baby and
    are not necessarily suitable for all babies:

      “The simplest plan is to use whole milk (from a shaken bottle)
      which is to be diluted according to the child’s age and
      digestion.

      “Beginning on the third day, the average baby should be given 3
      ounces of milk daily, diluted with seven ounces of water. To
      this should be added one tablespoonful of lime water and 2 level
      teaspoonfuls of sugar. This should be given in seven feedings.

      “At one week, the average child requires 5 ounces of milk daily,
      which should be diluted with 10 ounces of water. To this should
      be added 1½ even tablespoonfuls of sugar and one ounce of lime
      water. This should be given in seven feedings.

      “The milk should be increased by ½ ounce about every 4 days.

      “The water should be increased by ½ ounce about every 8 days.

      “At three months the average child requires 16 ounces of milk
      daily, which should be diluted with 16 ounces of water. To this
      should be added 3 tablespoonfuls of sugar and 2 ounces of lime
      water. This should be given in 6 feedings.

      “The milk should be increased by ½ ounce about every 6 days.

      “The water should be reduced by ½ ounce about every 2 weeks.

      “At 6 months the average child requires 24 ounces of milk daily,
      which should be diluted with 12 ounces of water. To this should
      be added 2 ounces of lime water and 3 even tablespoonfuls of
      sugar. This should be given in 5 feedings.

      “The amount of milk should be increased by ½ ounce every week.

      “The milk should be increased only if the child is hungry and
      digesting his food well. It should not be increased unless he is
      hungry, nor if he is suffering from indigestion even though he
      seems hungry.

      “At 9 months, the average child requires 30 ounces of milk
      daily, which should be diluted with 10 ounces of water. To this
      should be added 2 even tablespoonfuls of sugar and 2 ounces of
      lime water. This should be given in 5 feedings.

      “The sugar added may be milk sugar or, if this cannot be
      obtained, cane (granulated) sugar or maltose (malt sugar).

      “At first plain water should be used to dilute the milk.

      “At three months, sometimes earlier, weak barley water may be
      used in the place of plain water; it is made with ½ level
      tablespoonful of barley flour to 16 ounces of water and cooked
      20 minutes.

      “At six months the barley flour may be increased to 1½ even
      tablespoonfuls, cooked in the 12 ounces of water.

      “At nine months, the barley flour may be increased to 3 level
      tablespoonfuls, cooked in the 8 ounces of water.

      “A very large baby may require a little more milk than that
      allowed in these formulas. A small delicate baby will require
      less than the milk allowed in the formulas.”

    These formulas may be tabulated as follows:

 ────────┬────────┬────────┬────────────┬────────────┬──────────────
   Age   │  Milk  │ Water  │Barley-Water│ Lime-Water │    Sugar
 ────────┼────────┼────────┼────────────┼────────────┼──────────────
         │        │        │            │            │
 ════════╪════════╪════════╪════════════╪════════════╪══════════════
 3–7 days│ 3  ozs.│ 7  ozs.│  16 ozs.   │      ½ ozs.│2  teaspoons
 2d week │ 5  ozs.│10  ozs.│  15 ozs.   │     1  ozs.│1½ tablespoons
 3d week │ 6  ozs.│10½ ozs.│  14 ozs.   │     1  ozs.│1½ tablespoons
 1 month │ 7  ozs.│11  ozs.│  12 ozs.   │     1  ozs.│2  tablespoons
 2 month │11  ozs.│13  ozs.│  12 ozs.   │     1½ ozs.│2½ tablespoons
 3 month │16  ozs.│        │  11 ozs.   │     2  ozs.│3  tablespoons
 4 month │19  ozs.│        │  10 ozs.   │     2  ozs.│3  tablespoons
 5 month │21½ ozs.│        │            │     2  ozs.│3  tablespoons
 6 month │24  ozs.│        │            │     2  ozs.│3  tablespoons
 7 month │26  ozs.│        │            │     2  ozs.│3  tablespoons
 8 month │28  ozs.│        │            │     2  ozs.│2½ tablespoons
 9 month │30  ozs.│        │            │     2  ozs.│2  tablespoons
 ────────┴────────┴────────┴────────────┴────────────┴──────────────

 ────────┬───────────────┬────────────────
   Age   │No. of feedings│     Hours
 ────────┼───────────────┼──────────┬─────
         │               │   Day    │Night
 ════════╪═══════════════╪══════════╪═════
 3–7 days│       7       │6–9–12–3–6│10–2
 2d week │       7       │6–9–12–3–6│10–2
 3d week │       7       │6–9–12–3–6│10–2
 1 month │       7       │6–9–12–3–6│10–2
 2 month │       7       │6–9–12–3–6│10–2
 3 month │       7       │6–9–12–3–6│10–2
 4 month │       6       │6–9–12–3–6│10
 5 month │       6       │6–9–12–3–6│10
 6 month │       5       │6–10–2–6  │10
 7 month │       5       │6–10–2–6  │10
 8 month │       5       │6–10–2–6  │10
 9 month │       5       │6–10–2–6  │10
 ────────┴───────────────┴──────────┴─────

    =Mixed Feeding.= Under some conditions the breast-fed baby is given
    also a certain amount of modified milk, and this combination of
    natural and artificial feeding is termed mixed or supplementary
    feeding.

    A deficiency in the breast milk, ascertained by weighing the baby
    before and after each nursing, may be supplied by following each
    nursing with a bottle feeding; or one or two breast-feedings, in the
    course of the day may be replaced by entire bottle feedings. In any
    case the milk mixture to be used as supplementary feeding is
    prepared with exactly the same painstaking care as is the milk for
    entire artificial feeding.

    If supplementary food is given because of an inadequate supply of
    breast milk, it is of great importance that the baby be put to the
    breast regularly, no matter how little food he obtains, for his
    suckling is the best possible means of stimulating the breasts to
    secrete more milk and of equal importance is the fact that they will
    tend to dry up if the baby nurses less than about five times in
    twenty-four hours. Moreover, even a little breast milk is valuable
    to him and he should have the benefit of all there is to be had.

    An entire bottle feeding is sometimes given to a baby who is nursing
    satisfactorily at the breast, in order to give his mother an
    opportunity to take longer outings than are possible between the
    regular nursings. And sometimes it is to the mother’s advantage, and
    therefore to the baby’s, to give him a bottle during the night and
    thus allow her to sleep undisturbed.


                         COMMERCIAL BABY FOODS

    Since the baby’s food is prescribed by the doctor, the nurse has
    little concern with the various proprietary baby foods and the
    canned and powdered milks which are so persuasively advertised to
    young mothers. It is hoped, however, that the discussions on
    nutrition in general and on baby feeding in particular, have made it
    clear to the nurse that these foods cannot be expected to be
    satisfactory if used as a sole article of diet throughout the
    bottle-feeding period.

    There are many times and circumstances, however, when the temporary
    use of a prepared infant food or canned or powdered milk is
    advantageous. In some cases of intestinal disturbance, for instance,
    or while the mother is traveling and is unable to have freshly
    prepared milk formulas supplied to her along the way; during the
    summer, while staying at a hotel or boarding house where the
    freshness, cleanliness or purity of the milk are uncertain; or
    during a sudden shortage of fresh milk, as may occur during a strike
    or severe storm when transportation is interfered with, a
    proprietary food may be a great boon.

    If the nurse is confronted with the necessity of choosing and making
    temporary use of a prepared food she may be guided by considering
    the general principles of baby feeding and the character of the
    materials at her disposal.

    =The Proprietary Foods= may be divided into two general groups: one
    kind contains milk powder and is usually added to water while the
    other consists largely of sugar and starch and is added to fresh
    milk before being given to the baby.

    =Canned Milk= is of two kinds; evaporated, which is unsweetened, and
    condensed, which is sweetened. _Evaporated milk_ is whole milk from
    which part of the water has been removed, the milk then being canned
    and sterilized. The addition of water to evaporated milk restores it
    to the composition of whole milk in many respects, but it is still
    milk that has been heated. _Condensed milk_ is evaporated milk to
    which cane sugar has been added to aid in its preservation. Since
    bacteria do not grow well in highly sweetened foods, it is not
    necessary to bring sweetened condensed milk to as high a temperature
    as the unsweetened product, to prevent subsequent bacterial
    decomposition. The high percentage of sugar in condensed milk quite
    obviously renders it unsuitable for continuous use as the sole
    article in a baby’s dietary.

    =Milk Powders or Dried Milks= are prepared by rapidly evaporating
    the water from whole milk, skimmed milk or partly skimmed milk,
    leaving the solid constituents in the form of a light, white powder.
    Milk powder readily dissolves in water, forming a “reconstructed
    milk” which closely resembles the fresh milk from which it was
    prepared. But it must not be forgotten that reconstructed milk has
    been heated. Many doctors consider whole milk powder the most
    satisfactory form of preserved milk which is available for baby
    food. Should it be used, however, the importance of keeping it
    tightly covered and in a cold place must be recognized, for the
    presence of fat renders it likely to become rancid if not kept cold.


  ARTICLES OF FOOD WHICH ARE SOMETIMES INCLUDED IN THE BABY’S DIETARY

    =Barley Water=, sometimes used to dilute whole milk, is made by
    mixing the barley flour to a smooth paste in cold water, adding
    boiling water and boiling for twenty minutes or cooking in a double
    boiler for an hour, straining and adding enough water to replace the
    amount lost in cooking. The proportions for different ages are as
    follows:

    Three months, ½ level tablespoonful barley flour to 16 oz. water
    Six months, 1½ level tablespoonful barley flour to 12 oz. water.
    Nine months, 3 level tablespoonfuls barley flour to 10 oz. water.

    =Potato Water.= One tablespoonful of thoroughly boiled potato is
    mashed into one pint of the water in which the potato was boiled and
    carefully strained.

    =Spinach.= Spinach is carefully washed, steamed for half an hour and
    mashed through a fine sieve. It is sometimes started at the sixth
    month; one teaspoonful daily, gradually increased to one or two
    tablespoonfuls daily.

    =Orange Juice.= The orange should be dipped in boiling water and
    wiped on a clean towel before being cut and squeezed, to avoid
    possible infection of juice. It is usually given to babies getting
    heated milk, sometimes as young as one month old. It is carefully
    strained and started gradually by giving one teaspoonful in water
    once or twice daily between feedings and increasing to ½ or 1 ounce
    by the sixth month and 1½ to 2 ounces by the end of the first year.

    =Infusion of Orange Peel.= This is sometimes used instead of orange
    juice, and is made by boiling one ounce of finely grated orange peel
    in two ounces of water, adding a little sugar to counteract the
    bitter taste and adding enough sterile water to bring it up to two
    ounces.

    =Tomato Juice.= Canned tomato strained through a fine sieve, is
    sometimes given to a baby a few weeks old, starting with one dram
    and gradually increasing to four to six ounces daily.

    =Whey.= One quart of whole milk heated to 98° F. or 100° F. and
    one-half ounce of liquid rennet or one junket tablet stirred into it
    and allowed to stand half an hour or until firm and solid, is poured
    into a cheese-cloth bag and allowed to drain for about an hour
    without being squeezed.

    =Protein Milk.= The curd from one quart of milk, which remains after
    the whey is drained, as directed above, is mashed through
    cheese-cloth in a fine wire sieve, with a potato-masher or bowl of a
    spoon and the curd washed through with one pint of water. A pint of
    buttermilk is added and the mixture boiled while being stirred
    constantly. This is sometimes given in diarrhea.

    =Beef Juice.= One pound of thick round steak, slightly broiled, is
    cut into small pieces and the juice expressed with a meat press or a
    lemon squeezer, the amount varying from 2 to 3 ounces. It may be
    diluted with an equal amount of warm water, or slightly warmed by
    being placed in a cup standing in hot water, and salted to taste.

    =Broths.= One pound of lean meat, all fat and gristle removed, is
    allowed to one pint of water. The meat is cut finely and put on in
    cold water, heated slowly and allowed to simmer for three or four
    hours, when water is added to replace what was lost in cooking. It
    is strained, the fat removed and slightly salted.

    =Oatmeal Water.= Two level tablespoonfuls of oatmeal in a pint of
    boiling water is cooked in a double-boiler for two hours, strained
    and enough boiling water added to replace the amount lost in
    cooking.


                               TRAVELING

[Illustration:

  FIG. 173.—The baby will travel comfortably in a basket converted into
    a bed. (Courtesy of the Maternity Centre Association.)
]

    The difficulties of traveling with a young baby may be greatly
    lessened by making certain preparations. If the baby is bottle-fed,
    the preparations will depend upon the length of the journey and
    whether or not it will be possible to have freshly prepared
    feedings, for each twenty-four hours, put on the train from
    laboratories along the way. If this is not possible and the journey
    is not to take more than twenty-four hours, the entire quantity of
    food, ice cold, may be carried in a thermos bottle. The requisite
    number of sterile nursing bottles may be taken or one bottle which
    is boiled before each feeding. Or the milk may be prepared as usual
    and the bottles packed in a portable refrigerator. Such a
    refrigerator may be bought or one may be improvised. The bottles are
    placed in a covered pail and packed solidly in crushed ice; this is
    placed in a second pail or a box with a diameter which is at least
    two inches larger than the inner pail and the space between the two
    packed firmly with sawdust. Several thicknesses of newspapers should
    be pressed down over the top and a tight cover fitted to the outer
    receptacle.

    The sterile nipples may be taken in a sterile jar and a deep cup or
    kettle will be needed in which to warm the bottle before each
    feeding. It is usually possible to obtain water on the train which
    is hot enough for this, or cans of solid alcohol, a stand and a
    metal tray may be added to the traveling outfit. If fresh formulae
    cannot be delivered to the train, daily, and the journey is to last
    more than twenty-four hours, one of the proprietary foods or a
    powdered milk will often prove to be a satisfactory solution to the
    problem of feeding.

    The baby will usually travel more comfortably and sleep better if he
    is carried in a basket. A large market basket with a handle or a
    small clothes basket will serve. It may be lined with a sheet or a
    blanket; have a small hair pillow or folded blanket in the bottom
    and be made up like a crib. (Fig. 173.) If this basket stands on the
    car seat during the day, and on the foot of the nurse’s berth at
    night, the baby will be cleaner, quieter and less exposed to drafts
    than if carried in the arms.


                           THE PREMATURE BABY

    All of the precautions and gentleness which are necessary in the
    care of the normal baby, born at term, must be greatly increased in
    caring for the baby who is born prematurely.

    As was explained in Chapter III the premature baby’s prospects of
    living increase with the length of his uterine life, and it is often
    possible to estimate this by measuring and weighing him. During the
    last five months the child’s length in centimetres divided by five
    gives the month of pregnancy, according to the following table by
    Dr. Williams:[15]

    At the fifth month of pregnancy 5×5, fetus is 25 cm. long
    At the sixth month of pregnancy 6×5, fetus is 30 cm. long
    At the seventh month of pregnancy 7×5, fetus is 35 cm. long
    At the eighth month of pregnancy 8×5, fetus is 40 cm. long
    At the ninth month of pregnancy 9×5, fetus is 45 cm. long
    At the tenth month of pregnancy 10×5, fetus is 50 cm. long

    But consideration of the baby’s weight is also of importance when
    attempting to forecast his chances of living. A baby weighing less
    than 2500 grams or about 5½ pounds should be regarded, and treated,
    as premature, unless it is more than 45 centimetres, or about 18
    inches long. This length would indicate greater maturity, and
    therefore greater viability than would be expected from the weight.
    A baby weighing less than 1500 grams (3 pounds and 5 ounces) can
    scarcely be expected to live.

    The premature baby is not only small, but in general is imperfectly
    developed, having slenderer powers than the full-term baby and at
    the same time much greater needs. His respiratory and digestive
    organs are less ready to function than in the full-term baby; his
    muscles and nerves are feeble; his heat-producing mechanism is
    unstable and yet there is an excessive radiation of body heat
    through the relatively large area of skin.

    Accordingly, the baby who has been deprived of those valuable last
    weeks of growth and development is small and limp; lies quietly most
    of the time and moves very feebly if at all. He is often too weak to
    nurse at the breast and may swallow with difficulty. His temperature
    is low, his respirations irregular and he is frequently cyanotic.

[Illustration:

  FIG. 174.—Quilted robe, with hood, for the premature baby.
]

    The care of this frail little body practically resolves itself into:

    1. Maintaining a normal body temperature.
    2. Promoting and maintaining normal respirations.
    3. Supplying adequate and suitable nourishment.
    4. Conserving his strength.
    5. Preventing infection.

[Illustration:

  FIG. 175.—Premature baby in basket lined with quilted pad; wearing
    quilted robe and being fed from a Boston feeder. The blanket is
    turned back showing hot-water bag. (From photograph taken at Johns
    Hopkins Hospital.)
]

    To maintain a normal body temperature it is necessary to give
    special thought to the baby’s clothing, bed and room. He should be
    oiled with warm olive oil and entirely wrapped in cotton batting or
    flannel or enveloped in a quilted garment, with hood attached, made
    of cheese-cloth or flannel and cotton batting. (Fig. 174.) Diapers
    are often omitted in caring for very feeble babies, a pad of cotton
    being slipped under the buttocks instead as this may be changed with
    less disturbance to the baby than a diaper.

[Illustration:

  FIG. 176.—Model of improvised bed for premature baby: closely woven
    clothes basket with padded bottom and four, flannel-covered bottles
    of hot water attached to the sides. Thermometer and feeder are shown
    in basket. (By courtesy of Dr. Alan Brown, Hospital for Sick
    Children, Toronto.)
]

    His bed consists of a box or basket, with the bottom well padded
    with several inches of cotton, a small pillow or a soft blanket
    folded to the proper size, covered with rubber or oiled muslin and a
    cotton sheet. The sides of the basket should be lined with heavy
    quilted material (Fig. 175), to shut out drafts and help to preserve
    an even temperature of the air immediately around the baby. A
    flannel covered hot-water bag at 110° F. may be placed beside the
    baby, or two, three or four glass bottles, each holding about a
    pint, containing water at 100° F. and securely stoppered, may be
    hung in the corners of the basket. (Fig. 176.) A thermometer should
    hang in the basket also, and the temperature kept between 80° F. and
    90° F. It is easier to keep the temperature even if the bottles are
    filled in rotation instead of all at the same time.

    The amount of heat needed around the baby is decided by taking his
    temperature (by rectum) at regular intervals; supplying more heat if
    the temperature is low and less if it is at or above normal. Some
    doctors have the temperature taken every four hours; others twice
    daily. As the baby grows able to maintain a temperature of 98° F. to
    100° F., unassisted, the surrounding heat is gradually reduced and
    finally removed, and flannel clothing replaces the quilted robe.

    In many hospitals there are special rooms for premature babies,
    which are divided by glass partitions into cubicles so that each
    baby is in a three-sided enclosure. The rooms are usually darkened
    to save the baby from the needless irritation of light, and are
    supplied with constantly changing fresh, moist, filtered air, the
    temperature being kept at from 80° F. to 90° F.

    In a patient’s home or in a hospital where there is no special room
    for premature babies, a cubicle may be improvised by placing the
    basket in which the baby lies, in the corner of a room and placing a
    screen parallel with one of the walls. Such a room should be
    darkened, well ventilated and have in it a large open vessel of
    water.

    Since the premature baby’s lungs are not fully expanded,
    respirations are likely to be shallow and irregular, thus failing to
    supply the amount of oxygen which he sorely needs. As crying
    inevitably involves deep breathing, it is a common practice to make
    the premature baby cry at regular intervals during the day in order
    to promote the respiratory function. Dr. Griffith further recommends
    plunging the baby into a mustard bath at 100° F. or 105° F. if
    necessary to make him cry vigorously. It is also important to turn
    the premature baby from side to side, several times a day to prevent
    fluid from collecting in the lowermost part of the lung, a condition
    favorable to the development of pneumonia.

    In feeding premature babies, breast milk is ordinarily the most
    desirable food. If the baby is too feeble to nurse, as frequently
    occurs, the milk may be expressed from the breast of his mother or a
    wet nurse, by stripping or pumping, into a sterile receptacle, and
    if not used immediately it should be covered and placed in the
    refrigerator. Breast milk is sometimes used whole and sometimes
    diluted with water, and is given by gavage if the baby is very
    feeble; from a medicine dropper or a special feeder. Such a feeder
    consists of a glass tube with a small nipple on one end and a rubber
    bulb on the other, by means of which the milk may be gently
    expressed into the baby’s mouth, thus minimizing his effort to
    obtain it. (See Fig. 175.)

    The amount and intervals for feeding the premature baby have to be
    adjusted to the individual with even greater care than for a normal
    baby, for he needs more fuel and building material, because of his
    imperfect development and yet because of that same imperfect
    development his digestive powers are feebler than those of the
    full-term baby. During the first day or two, he is sometimes given
    nothing but water or sugar solution, the milk being started
    gradually when the baby is from thirty-six to forty-eight hours old.
    He may be given a very small quantity every two hours, or he may be
    fed at three- or four-hour intervals, depending entirely upon his
    condition and progress. It is usually considered very important for
    the premature baby to have sterile water or sugar solution to drink
    between feedings, and this is given in the same manner as his milk.

    Unlike the normal baby he is not taken from his bed to be fed,
    unless he nurses at the breast.

    The premature baby is weighed as often as is safe for him, since the
    suitability of his food is largely indicated by changes in his
    weight. But sometimes very young and feeble babies are weighed only
    once or twice a week because of the inadvisability of disturbing
    them more frequently.

    Avoidance of fatigue and the conservation of the premature baby’s
    limited strength and energy are accomplished through reducing his
    muscular activity to the minimum, by very little and very gentle
    handling; and by minimizing his loss of energy in the form of heat
    by keeping the little body warm and quiet.

    In this connection the daily bath is of considerable importance. It
    almost always consists of sponging the baby with warm olive oil as
    he lies in his bed, and with the least possible exposure and
    turning. It is given every day or every second or third day
    according to his condition. The eyes are wiped with boric pledgets
    and the nostrils with spirals of cotton dipped in oil. The buttocks
    are wiped with an oil sponge each time the diaper is changed.

    The premature baby is very susceptible to infection and strongly
    predisposed to pneumonia. Infection in general is guarded against by
    having everything that comes in contact with the baby scrupulously
    clean; protecting him from drafts, chilling and dust; allowing no
    one with a suspicion of a cold to come near him and by the nurse’s
    wearing a clean gown and protecting her nose and mouth with a gauze
    mask while attending him.


                   CARE OF THE BABY DURING THE SUMMER

    The dangers of infancy are greatly increased in summer, more babies
    dying during the hot months than any other time during the year. The
    cause of these deaths is variously termed summer complaint, summer
    diarrhea, acute gastro-enteritis and cholera infantum, and is due to
    infected or decomposing food or both.

    Clearly this malady is practically preventable through care.

    Although such care as has been described in the preceding pages
    largely constitutes the prevention of the much-to-be-dreaded summer
    diarrhea, there are a few extra precautions and safeguards with
    which the nurse must surround her little patient during the warm
    weather.

    She must bear in mind the character of the illness to be avoided:
    indigestion associated with infection.

    It becomes almost a matter of life or death, then, to give the baby
    clean, suitable food and avoid deranging his digestion.

    Babies suffer from the heat more than adults do and are often
    excessively irritated and exhausted on warm days. And this
    overheating, exhaustion and restlessness are of themselves enough to
    affect his digestion.

    Accordingly the scourge of summer diarrhea is prevented by giving
    the baby proper food and keeping him clean, cool and quiet.

    The baby should have maternal nursing if possible, for breast-fed
    babies fall victim to summer diarrhea much less frequently than
    bottle-fed babies. He should be fed with absolute regularity, and as
    a rule, no matter what the nature of his food, it is reduced
    one-quarter to one-third in amount during very warm weather and he
    is given an increased amount of cool boiled water to drink. His
    weight may increase very slightly, or even stand still for a short
    time, as a result of his decreased food, but this is not usually
    deplored, if he keeps well, for the important thing is to avoid
    digestive disturbances while the weather is warm.

    Cleanliness, as at other times, applies to the baby’s food, clothing
    and surroundings. Many doctors think it safer to have all milk
    boiled during the summer, and of course require flawless technique
    in its preparation and administration. The baby’s soiled napkins
    should be placed immediately in a covered receptacle containing
    water, and not left for even a moment where they can be reached by
    flies. They should be washed, boiled and dried in the open air and
    sunshine as promptly as possible.

    The baby should be protected from flies and mosquitoes by screens in
    the windows and netting over his crib and carriage, both because
    they make him restless and irritable and because flies particularly
    are carriers of filth and disease—the kind of disease that kills so
    many babies during the summer. Accordingly the nurse must always
    regard flies with a deadly fear.

    The baby should be kept away from dusty places and from cats and
    dogs. And since babies will put their fingers in their mouths it is
    a wise precaution to wash their hands several times a day.

    The baby should be in the country, in the mountains or at the
    seashore if possible during the warmest part of the summer at least,
    but if he is in town there is much that the nurse can do to keep him
    cool and comfortable. His clothing at this time must be adjusted to
    his condition and the temperature of the moment just as it is in
    cold weather. A thin shirt, band, diaper and cotton slip will
    usually be enough for out-of-door wear, while in the house he may
    often dispense with the slip and sometimes with everything but his
    diaper.

    During excessively hot days, the baby should have two or three cool
    sponge baths, in addition to the soap and water bath, one of the
    sponges being given before he is put to bed for the night. He should
    sleep on a firm mattress, preferably curled hair but never feathers,
    and in the coolest, best ventilated room available. During the day
    it is usually best to take him out-of-doors early in the morning and
    late in the afternoon, but to keep him indoors during the warmest
    part of the day, when it is likely to be cooler indoors than out,
    particularly if the blinds are closed. Quite naturally the nurse
    will have to take into consideration the size, arrangement and
    location of the baby’s home in her effort to keep him in cool,
    quiet, shady places and out-of-doors as much as possible.

    He must not be played with, held on hot laps nor subjected to the
    entertainment and attention which misguided but well-meaning mothers
    and friends are so eager to lavish on a hot, fretful baby.

    Very often during warm weather a fine rash known as “prickly heat”
    appears on the back of the baby’s neck and spreads over his head,
    neck, chest and shoulders. This rash is due to too warm clothing or
    to the hot weather or to both. Less clothing and frequent baths will
    often give relief, but if the baby is very uncomfortable, he may be
    greatly soothed by being immersed in cool baths containing soda,
    bran or starch in the following proportions:

    =Soda bath.= Two tablespoonfuls of baking soda to one gallon of
    water.

    =Bran bath.= A cheese-cloth bag about six inches square, partly
    filled with bran, is soaked and squeezed in the bath water until it
    is milky.

    =Starch bath.= About eight ounces of cooked laundry starch to one
    gallon of water.

    No soap should be used while the baby has prickly heat and after the
    bath he should be patted thoroughly dry and powdered with some such
    soothing powder as the following:

    Powdered starch one ounce
    Oxide of zinc one ounce
    Boracic acid powder 60 grains

    As we look back over these pages of somewhat detailed description of
    the case of the baby, it is borne in upon us that the nursing of
    this unfailingly delightful and interesting little patient has
    special adjustments and adaptations for different seasons and
    circumstances; but that on the whole the care of all babies the year
    around resolves itself into the observation of a few general
    principles, namely: proper feeding; fresh air; regularity in his
    daily routine; cleanliness of food, clothing and surroundings;
    maintenance of an equable body temperature and conservation of his
    forces.

    If the nurse fixes these principles firmly in her mind and acts upon
    them, she will do a great deal to give her baby patient a fair start
    on his life’s journey.



                             CHAPTER XXIII
          COMMON DISORDERS AND ABNORMALITIES OF EARLY INFANCY


    The common ills of early infancy are due largely either to errors in
    feeding or to infection or both. Of the nutritional disturbances,
    rickets and scurvy were discussed in the chapter on nutrition, but
    the obstetrical nurse will sometimes see also, malnutrition,
    marasmus, inanition, diarrheal diseases, acidosis, colic,
    constipation and vomiting.

    All of these disorders are practically preventable through suitable
    feeding, good care and hygienic surroundings. The nurse’s part in
    this prevention consists in giving the painstaking care which was
    described in the preceding chapter.

    The terms _malnutrition_, _marasmus_, and _inanition_ designate
    different forms and degrees of starvation, and are characterized by
    loss of weight, prostration, feeble powers of assimilation, general
    weakness and arrested growth. The temperature is likely to be low,
    but in acute inanition, a rapid loss in weight may be accompanied by
    a sudden rise in temperature. (Charts 6, 7, and 8.)

    These so-called “wasting diseases” are frequently seen in children
    who have congenital nervous instability and those born of
    tuberculous, syphilitic or otherwise delicate parents. The treatment
    is suitable food; fresh air and sunshine; an abundance of fluid by
    mouth, rectum, subcutaneously or intraperitoneally; clean
    surroundings and good nursing care.


                         THE DIARRHEAL DISEASES

    These are among the most frequent and most serious illnesses of
    early infancy. They may result from mechanical causes, such as a
    mass of undigested food, which produces increased intestinal
    secretion and peristalsis; from the action of bacteria, or their
    toxins, together with the inability of an enfeebled digestive tract
    to meet the needs of a rapidly growing body; or from such reflex
    causes as sudden chilling of the body, excitement, fatigue or the
    prostration resulting from excessively hot weather.

    =Acute gastro-enteritis=, the diarrheal disease which is so common
    and so fatal during the hot months of July and August, is often
    referred to as “summer complaint” or “summer diarrhea.” It is so
    largely avoidable through good nursing that the methods of its
    prevention were described in connection with the care of the baby
    during the Summer, resolving itself, as it does, into feeding the
    baby properly and keeping him clean and cool and quiet.

    =Symptoms.= While there are different forms of summer diarrhea, the
    general symptoms are much the same and may develop gradually after
    some evidence of indigestion, or suddenly with a rise of temperature
    to 101° F. or 102° F., or even as high as 106° F., accompanied by
    pain and vomiting. The baby is usually restless, fretful and thirsty
    and his skin is hot and dry. He gives evidence of pain by shrill
    crying, drawing up his legs and flexing them on his abdomen.
    Diarrhea is the conspicuous symptom and there may be anywhere from
    four to twenty movements in the course of 24 hours. The stools are
    largely fecal matter at first but they finally become fluid and
    contain mucus. They may be expelled with a good deal of force and a
    quantity of gas come with them. The baby grows very weak, thin and
    hollow-eyed, if the diarrhea persists and unless promptly treated
    the end may be fatal.

    =Treatment and Nursing Care.= The first step is to stop all food and
    to give water freely. When water is not retained by mouth it is
    frequently given by rectum, into the tissues or intraperitoneally.
    The pain may be relieved by applying hot stupes.

    Feeding is resumed very gradually and cautiously for one attack of
    summer complaint predisposes to another and every precaution is
    taken to prevent a recurrence. Thin barley water or broth is usually
    given first, followed by whey, protein milk, buttermilk or diluted
    skim-milk in small amounts and at comparatively long intervals.

[Illustration:

  CHART 6.—Weight chart showing normal loss and gain during the first
    fourteen days of life.
]

[Illustration:

  CHART 7.—Chart showing loss of weight in inanition fever.
]

[Illustration:

  CHART 8.—Temperature chart showing sudden elevation of temperature,
    coincident with the marked loss of weight, in inanition fever.
]

    The baby should be lightly clad; should be kept quiet and in a cool,
    shady place out-of-doors as much as possible. During the warmest
    part of the day, however, he will often be much better off and more
    comfortable in the house, in a room with the shutters closed. But
    while keeping the baby cool, the nurse must bear in mind the harm
    that will be done by chilling him or exposing him to a cold draft or
    wind. Several tub baths, daily, are often given, at a temperature of
    100° F., rather than cool sponge baths because of the baby’s
    feebleness and inability to react to cool bathing. Packs are also
    employed, both for high temperature and restlessness and may be cool
    (80° F.), tepid (100° F.) or hot (105° F. to 108° F.) according to
    the doctor’s orders; intestinal irrigations; lavage and gavage.

[Illustration:

  FIG. 177.—Putting the baby in a wet pack.
]

    To give a =pack=, the nurse will cover the bed with a rubber and
    sheet and bring to the bedside a basin containing a sheet wrung from
    water of the specified temperature; a basin containing ice and
    compresses for the baby’s head, and a flannel covered hot-water
    bottle at 120° F., for his feet. The baby is laid on the upper half
    of the folded wet sheet, and an upper corner wrapped about each arm
    (Fig. 177), and the sides folded around his legs. The lower half is
    brought up between his feet to cover his entire body and tuck around
    his shoulders. The hot-water bottle is placed at his feet and an ice
    compress on his head. (Fig. 178.) If the sheets are wrung from warm
    or hot water, the baby is covered with a blanket after he is put
    into the pack.

[Illustration:

  FIG. 178.—Baby in pack with hot-water bag at feet and cold compress on
    head. (Figs. 177 and 178 from photographs taken at Johns Hopkins
    Hospital.)
]

[Illustration:

  FIG. 179.—Diagrams showing successive steps in putting baby in pack
    shown in Figs. 177 and 178.
]

    =Intestinal irrigations=, of normal salt solution are often given to
    babies suffering from intestinal disorders, sometimes once or twice
    daily to wash out the lower bowel, or a cool irrigation may be given
    to reduce temperature, the amounts varying from ½ to 2 gallons of
    solution. The baby should be placed on a pillow and rest on a
    bed-pan, being protected from chilling as for, an enema (See Fig.
    186), and provision made for a two-way flow of the fluid. A small
    catheter attached by means of a connecting glass nozzle to the
    tubing on the irrigation bag may be passed into a slightly larger
    catheter, which is inserted into the rectum about six inches, the
    fluid flowing in through the small inner tube and out through the
    larger one which encases it. Or a small catheter for the outflow may
    be inserted in the rectum alongside the one through which the
    solution is introduced. Normal salt solution, glucose or bicarbonate
    of sodium solution are sometimes given by the drip method at the
    rate of 20 to 40 drops per minute. In this case a glass tube is
    introduced at some point in the rubber tubing in order that the rate
    of flow may be watched and regulated by means of a clamp or a
    stop-cock. The catheter is inserted in the rectum about six inches
    and held in place by strips of adhesive plaster.

[Illustration:

  FIG. 180.—Baby wrapped in blanket, before being given gavage or eye
    irrigation, to keep him warm and hold his arms and legs to his
    sides. (From photograph taken at Johns Hopkins Hospital.)
]

[Illustration:

  FIG. 181.—Gavage. (From photograph taken at Johns Hopkins Hospital.)
]

    =Lavage= and =Gavage=. Sometimes when the baby vomits persistently
    the stomach is washed out and a small amount of water or nourishment
    given before the tube is withdrawn. A tray containing the following
    articles should be carried to the bedside:

      A glass funnel attached to a rubber tubing which connects with a
      small rubber catheter by means of a glass nozzle.

      Basin to receive stomach contents.

      Small rubber, towel and curved basin to place under baby’s chin.

      Glass graduate containing warm water for washing out stomach.

      Food or solution which is to remain in stomach, standing in cup
      of warm water.

      Glycerin to lubricate tube.

      Mouth gag, if necessary, or roll of bandage to hold jaws apart.

    The baby should be wrapped tightly (Fig. 180) to prevent
    interference by his struggling and turned slightly to the left side.
    (Fig. 181.) The catheter is lubricated with glycerin or water and
    passed back over the tongue and quickly downward until an air bubble
    is heard as it enters the stomach. The length of tubing which is to
    be inserted may be anticipated by marking a point on the tube which
    is the same distance from the end as the baby’s mouth is from its
    umbilicus. The possibility and the serious consequences of
    introducing the tube into the trachea instead of into the esophagus
    must be borne in mind. Although the baby will often choke and
    struggle when the tube is properly introduced, he will not cough
    violently and stop breathing as he will if it enters the air
    passage. Further information is obtained by inverting the funnel in
    a basin of water after the tube is inserted; if it is in the stomach
    there will be no result, but if it is in the trachea air will be
    expelled and bubbles will rise through the water. To wash out the
    stomach, the funnel is filled with warm water and slightly raised so
    that the water will run in slowly, after which the funnel is turned
    upside down into a basin which is lower than the baby’s body, and
    the stomach contents allowed to run out. This is repeated four or
    five times, or until the solution returns clear, and the food which
    is to remain in the stomach is poured in slowly. Before the tube is
    quite empty it is pinched off with the fingers and quickly
    withdrawn.

    =Acidosis.= The diarrheal diseases are sometimes complicated by
    acidosis, a condition in which the relative amounts of acid in the
    blood are so increased that the normal alkalinity is markedly
    diminished. This condition may result from an excessive intake of
    acids; an overproduction of acids in the course of normal
    metabolism; a decrease in the reserve of normal alkali in the body
    or a failure in the mechanism by means of which excessive acids are
    usually neutralized or eliminated. Acidosis is a serious
    complication and often fatal.

[Illustration:

  FIG. 182.—Method of obtaining a fresh specimen of urine in a test
    tube.
]

    The treatment is directed toward preventing the production of more
    acids within the body; restoring the alkali reserve and promoting
    elimination of the excessive acids and their salts. Solutions of
    glucose, bicarbonate of sodium and salt are used and are given by
    mouth, rectum, intravenously and intraperitoneally. Subcutaneous
    injections are not wholly satisfactory, because of the small amounts
    which may be given in this way. From 150 to 400 cubic centimetres
    are given into the peritoneal cavity and as the solution absorbs
    readily these injections are sometimes repeated every eight or
    twelve hours, an infusion bottle and short infusion needle being
    used. From 75 to 300 cubic centimetres of glucose solution (5 per
    cent. or 10 per cent.) is given intravenously, while as much as 1000
    cubic centimetres is sometimes given per rectum in the course of 24
    hours by the drip method. Soda solution (4 per cent.) is often given
    by mouth, if the baby is able to retain it, or intravenously, as
    frequently as the condition of the urine indicates is necessary.
    From 75 to 100 cubic centimetres is given at one time to young
    babies.

[Illustration:

  FIG. 183.—Obtaining a 24–hour specimen of urine through curved glass
    tube attached to rubber tubing which empties into bottle tied to
    side of bed. (From photographs taken at Johns Hopkins Hospital.)
]

[Illustration:

  FIG. 184.—Muslin band with cuffs and tape used to keep the baby from
    kicking while a specimen of urine is being obtained. The tapes are
    tied tightly to the sides of the crib and the cuffs fastened around
    the baby’s ankles with safety pins. See Figs. 182 and 183.
]

    In preparing the soda solution it must be remembered that boiling
    drives off carbonic acid and forms sodium carbonate and that its
    reconversion into sodium bicarbonate is a complicated procedure.
    Howland and Marriott[16] say in this connection: “Oscar Schloss has
    found that sodium bicarbonate in bulk is always sterile. It is
    probably therefore sufficient to add the bicarbonate with proper
    precautions to sterile water.”

    Since the results of urine tests frequently indicate the treatment
    in acidosis, it is of very great importance that the nurse be able
    to obtain specimens from young babies. (Figs. 182, 183, 184 and 185
    for methods of obtaining fresh and 24–hour specimens from babies.)

    =Colic=, =Constipation=, =Convulsions= and =Vomiting= so frequently
    seen in young babies are symptoms rather than diseases.

    =Colic= usually consists of paroxysms of pain in the stomach or
    intestines, due to distension or to spasmodic, muscular
    contractions. The indirect cause may be unsuitable food or food
    given too rapidly; chilling of the surface of the body, excitement
    or fatigue. The distension may be due to air swallowed by the baby
    while nursing or gas formed by carbohydrate fermentation. Excess of
    protein may form an irritating mass in the intestines and cause a
    cramp.

[Illustration:

  FIG. 185.—Belt used to hold tube in place while obtaining specimen of
    urine as indicated in Figs. 182 and 183. The tube is passed through
    the hole in the tab and adjusted over penis or between labia; the
    belt fastened around the waist and straps passed between the thighs
    and fastened to belt.
]

    While colic frequently accompanies malnutrition and constipation, it
    is often seen in otherwise well and happy babies, and usually before
    the fifth month. The attacks are usually sudden and may occur
    several times a day after feeding, or only in the late afternoon or
    at night. The baby cries shrilly; his face is drawn and may be
    flushed, from crying, or cyanotic; his fists are clenched and
    pressed to his body and his feet and hands are cold. His abdomen is
    hard and distended and during a pain the baby flexes his thighs upon
    it and afterward extends them with a jerk. This painful seizure may
    last only a few moments or it may persist for hours, leaving the
    baby exhausted.

    The chief preventive measures are found in the precautions and
    attention to detail which have been described, and which should be
    included in the care of all babies. In a bottle-fed baby it is often
    found that recurrence of attacks of colic may be averted by a slight
    change in the milk formula; by giving more water to drink; by
    lengthening the intervals between feedings; by giving the milk more
    slowly or by omitting the 2 a.m. feeding, thus giving the baby more
    digestive rest.

    With breast-fed babies, prevention is often accomplished by having
    the mother nurse her baby more slowly, lengthening the intervals and
    by improving her own hygiene; particularly by increasing her
    recreation and out-of-door exercise and relieving constipation.
    Women who lead sedentary lives and eat rich food very often have
    colicky babies as do those who are nervous, irritable and inclined
    to worry. (See chapter on the nursing mother.)

    When attacks of colic occur, the pain usually may be relieved by
    giving half of a soda-mint tablet in a little warm water and an
    enema of about eight ounces of soap-suds or salt solution at 110°
    F., given through a small catheter inserted about six inches. The
    baby will experience almost immediate relief through the expulsion
    of gas and feces and he may be made still more comfortable by
    placing a hot-water bag at his cold feet; rubbing his abdomen with
    vaselin and applying hot stupes. Sometimes the first feeding which
    falls due after an attack is omitted and a little warm water or
    barley water is given instead, in order that the digestive tract may
    rest.

    =Constipation= is very common among young infants and may be
    manifest by the stools being too small, too dry or too infrequent.
    The commonest causes are:

    1. =Faulty diet=—possibly too much protein or too little fat or
       sugar.
    2. =Intestinal atony=, due to undernourishment, rickets or anemia.
    3. =Anal fissure= which makes the baby unwilling to empty his bowels
       because of pain.
    4. =Absence of habit= of emptying the bowels regularly.

    The prevention of this very troublesome condition lies largely in
    suitable food; constant fresh air; regularity in the daily routine
    and training the baby to empty his bowels at the same time every
    day.

    When constipation is due to insufficient fat in the food, cod-liver
    oil is sometimes given, 15 to 30 drops three or four times a day; or
    a teaspoonful of olive oil two or three times a day. Maltose, malt
    soup, malted milk, milk of magnesia, liquid petrolatum,
    oatmeal-water and orange juice are all found among the remedies for
    constipation; while soap sticks, suppositories and enemata of oil or
    soap-suds sometimes have to be resorted to.

[Illustration:

  FIG. 186.—Giving an enema. The baby lies comfortably on a pillow which
    reaches to the bed pan, the latter being covered with a diaper where
    the baby rests upon it. He is well protected to prevent chilling.
]

    In giving an enema to relieve constipation, the baby should be
    protected from chilling, laid on a pillow and the pan so placed that
    he will be comfortable and not inclined to move, and from 100 to 300
    cubic centimetres of soap-suds, at 105° F., given with a small
    hard-rubber nozzle. (Fig. 186.) When warm olive oil is given at
    night (1 to 2 ounces through a catheter introduced about 6 inches),
    it is very often retained and the feces so softened that the baby
    empties his bowels freely the next morning with little or no
    assistance.

    Abdominal massage will often help to increase the intestinal tone
    and make peristalsis more vigorous. The abdomen should be rubbed
    with a circular stroke, beginning in the right groin and following
    the course of the colon up to the margin of the ribs, across to the
    left side and down to the groin. This is often given for about ten
    minutes every day, preferably at night but never just after a
    feeding.

    Constipation is sometimes entirely cured by a suitable dietary; an
    abundance of drinking water; an out-of-door life; massage, and above
    all, the unremitting effort to establish a regular habit. The latter
    is the nurse’s responsibility and she should exercise the greatest
    patience in trying to accomplish the desired end.

    =Convulsions= are a symptom of several disorders of early infancy,
    which may occur unexpectedly and which the nurse may suddenly be
    called upon to relieve in the absence of the doctor. Convulsions may
    be due to brain lesions; to spasmophilia or a special tendency to
    convulsive disorders; gastro-intestinal disorders; toxemia or
    syphilis. They may be the initial symptom of an acute infectious
    disease or may occur on slight provocation in a frail,
    undernourished baby or one suffering from rickets or tetany. For
    this reason one sometimes sees convulsions in a baby who is teething
    or has colic or indigestion.

    As convulsions are a symptom of some abnormal condition, the doctor
    will often prescribe a sustained treatment designed to remove or
    relieve the cause. But when an attack occurs unexpectedly, and the
    doctor cannot come at once, the nurse may often terminate the
    seizure by employing measures that will quiet and relax the
    struggling baby. The room should be quiet and darkened and the baby
    handled with utmost gentleness because of the extreme irritability
    of his nervous system. As a rule, the most satisfactory course is to
    immerse the baby in water at 100° F., and keep him there for five or
    ten minutes, supporting his head and shoulders meantime. Someone
    else should place cold compresses on his head and change them
    frequently. When removed from the bath, the baby should be wrapped
    in a blanket, kept very quiet and the cold applications to his head
    continued.

    When it is known that the convulsions are due to indigestion the
    stomach is often washed out and a high colonic irrigation given
    before the baby is quieted by the bath. In tetanoid convulsions the
    baby may take a long deep inspiration and fail to expire.
    Respirations should be stimulated, in such a case, by spanking him
    sharply or by dashing cold water on his face and chest. When the
    attacks are recurrent the nurse may be instructed to terminate them
    by giving the baby a few whiffs of chloroform, which, with an
    inhaler is kept in readiness for instant use.

    Mustard baths and packs are sometimes given when the need for
    counter irritation is indicated. For a bath, one ounce, or six level
    tablespoonfuls of dry mustard is added to one gallon of water at
    105° F. and the baby kept in it for about ten minutes, or until the
    skin is well reddened. He is then wrapped in a warm blanket and
    surrounded by hot-water bottles, with cold compresses applied to his
    head. The mustard pack is given in the manner of other packs, with a
    sheet wrung from mustard water which is possibly a little warmer and
    stronger than that for the bath, care being taken that the sheet is
    not cooled before it is wrapped about the baby. He is usually left
    in the pack for about ten minutes or until his skin is reddened, and
    then wrapped in warm blankets, with cold compresses to his head.

    It is often helpful to the doctor if the nurse is able to describe
    the onset of the convulsions and tell him where the twitching began,
    how it progressed and whether or not it was preceded by a cry.

    =Vomiting= during early infancy is a symptom of any one of several
    conditions, the nature of which sometimes may be revealed by the
    character of the attacks. The commonest causes and varieties of
    vomiting are as follows:

      1. =Too rapid feeding= or =too large amounts of food= given at
      one time. The vomiting amounts to little more than regurgitation
      and is often induced by moving or handling the baby immediately
      after feeding him.

      2. =Acute gastric indigestion.= Sour stomach contents may be
      vomited immediately after feeding, or not until several hours
      later and may be followed by mucus and bile. The baby is usually
      pale, particularly about the mouth; he may perspire about the
      forehead and give evidence of pain, being relieved by the
      vomiting.

      3. =Stenosis of the pylorus.= The vomiting from this cause is
      projectile in character and may occur immediately after food is
      taken into the stomach, or, some time later without apparent
      cause, a larger amount of fluid may be expelled than was given
      at the preceding feeding. The vomiting may begin a few days
      after birth or several weeks afterwards in a baby who has been
      well previously.

      4. =Intestinal obstruction= due to congenital obstruction, which
      causes persistent vomiting from birth; or due to intussusception
      of the intestines, when vomitus consists first of stomach
      contents which later becomes bile stained and sometimes contains
      fecal matter, blood and mucus. It is attended by prostration,
      and after fecal matter is passed at the beginning, there is
      frequent evacuation of blood and mucus.

      5. =Chronic= or =habit vomiting=, sometimes occurring in early
      infancy, may be difficult to control because of being incited by
      such slight causes as laughing, crying or being moved.

    In addition to being caused by the above mentioned conditions,
    vomiting in young babies may usher in an acute infectious disease,
    as a chill does in an adult, or it may accompany such diseases as
    peritonitis, meningitis, brain tumors and toxic conditions such as
    uremia.


                               INFECTIONS

    The infectious diseases which the obstetrical nurse is most likely
    to see in her baby patient are ophthalmia neonatorum; syphilis;
    impetigo; pemphigus and vaginitis.

    =Ophthalmia Neonatorum=, inflammation of the eyes of the new-born or
    “babies’ sore eyes,” is one of the common diseases of infancy and
    certainly one of the most dreaded because of the tragedy of lifelong
    blindness which may follow in its wake. In the early days of
    organized work for the prevention of blindness the term “ophthalmia
    neonatorum” implied a gonorrheal infection, but it is now known that
    inflamed eyes and subsequent blindness may result from infection of
    innocent origin. Accordingly, in those states where it is required
    that the disease be reported, ophthalmia neonatorum is defined as
    inflammation of the eyes of new-born babies, irrespective of the
    cause. The disease is frequently due to the gonococcus, the baby’s
    eyes being infected from the mother during passage through the birth
    canal or infected later by her hands or clothing. Or the
    inflammation may be caused by the streptococcus, pneumococcus or the
    colon, diphtheria, or influenza bacilli while very frequently the
    infection is mixed.

    It is estimated that about 20 out of every 1000 new-born babies have
    sore eyes, and though many of the infections are mild, between 5 and
    8 of these 20 cases are capable of becoming serious and causing
    blindness if not speedily and skillfully treated. The number of
    cases which are neglected is suggested by the fact that about 10 per
    cent. of all blindness, the world over, is due to infant ophthalmia
    and that about 20 per cent. of the inmates of schools for the blind
    in this country are sightless from this cause. This does not take
    into account the unnumbered army of those who are partially blind,
    or blind in one eye, and thus seriously handicapped, as a result of
    this disease.

    =Symptoms.= The first symptoms are redness and swelling of the lids,
    usually accompanied by a discharge of pus from the beginning, and
    they ordinarily appear during the first few days of life, but
    sometimes develop as late as the second or third week. The disease
    may run a very rapid course and cause blindness in 48 hours from the
    time the first symptoms appear, or it may persist for weeks.
    Ulceration of the cornea is the dreaded consequence of the
    inflammation as ulcers are followed by scars. When the scar is
    small, or to one side of the pupil, there may be little or no
    impairment of vision, but if it is large and centrally located it
    forms an opaque screen and causes blindness by shutting out the
    light, although the interior of the eye behind the scar is sound and
    uninjured. Sometimes the ulcer causes a perforation of the cornea
    through which the lens and vitreous humor are discharged.

    Attempts have been made to remove the scar following a centrally
    located ulcer and replace it with a clear cornea from some such
    animal as a guinea pig, but the operation apparently has not been
    perfected. When it is, many blind persons may have their sight
    restored to them.

    =Prevention.= It may be stated almost without qualification that
    ophthalmia neonatorum is a preventable and curable disease, and
    accordingly that blindness from this cause is inexcusable.
    Prevention lies first, in wiping the baby’s eyes immediately after
    birth and instilling a drop or two of a silver salt, such as nitrate
    of silver, argyrol or protargol, or bathing them with boracic acid
    solution; and second, in close watching for early symptoms and
    giving speedy treatment when they appear. This is urgent because
    there is no way of determining in the beginning whether the
    infection is mild or virulent. Nitrate of silver solution, 1 per
    cent., is the prophylactic most commonly employed and its use is now
    routine in most hospitals and in the practices of many physicians in
    this country. The solution is sometimes dropped between the baby’s
    lids, immediately after the birth of the head, and before the birth
    of the entire body, and sometimes immediately after delivery is
    completed. Many doctors follow the silver drops with normal salt
    solution to prevent the slight silver catarrh which so frequently
    occurs otherwise, and which may be confused with early symptoms of
    ophthalmia. Still others prefer simply to bathe the eyes with
    boracic acid solution (unless they know that the mother has
    gonorrhea) and to watch them closely for the slightest redness,
    swelling or discharge and give prompt treatment if these appear.

    The Credé method, made famous by the Viennese obstetrician who
    introduced it in 1881, was to drop from a glass rod, a single drop
    of nitrate of silver, 2 per cent., into each eye immediately after
    birth. The routine use of this prophylaxis reduced the occurrence of
    ophthalmia in Credé’s clinics from 10 per cent. to .1 per cent.
    among the new-born babies.

    Since it is now believed that close vigilance and subsequent care
    are equally as important as the prophylactic drops, the Credé
    treatment has been variously modified and other and weaker silver
    solutions are frequently used, and with satisfactory results. The
    dropping of a germicide into the baby’s eyes kills the organisms
    which may be present at the time, but it does not protect against
    subsequent infection. For this reason the nurse cannot be charged
    too earnestly to watch the baby’s eyes closely for the first
    evidence of infection, and report it to the doctor immediately, day
    or night, for the late infections are as destructive of sight as
    those which occur before or during birth.

[Illustration:

  FIG. 187.—Irrigating the eye with a blunt nozzle, the irrigation bag
    hanging low in order that the stream may be gentle. (From a
    photograph taken at Johns Hopkins Hospital.)
]

    =Treatment and Nursing Care.= The treatment and nursing care in
    ophthalmia frequently require the greatest skill. There may be
    merely an application of silver and sponging with boracic acid
    solution or a gentle irrigation with a blunt nozzle (Fig. 187), or
    the preservation of the baby’s sight may necessitate dressings and
    treatment which will require elaborate preparation (Fig. 188), and
    may also require some form of treatment every quarter- or half-hour,
    day and night and occupy the entire time of two or three special
    nurses. The nurse’s duties in caring for the eyes will be explicitly
    defined by the doctor, but in general she must remember that she is
    nursing a baby suffering from an acutely infectious disease, who
    should be strictly isolated, and that as a rule she should wear a
    gown, rubber gloves and protective goggles while caring for him. All
    of her attentions to the inflamed eyes must be given with the
    _greatest gentleness_ in order to avoid abrasion of the conjunctiva
    or injury of the cornea. Moreover, the baby with suppurative
    conjunctivitis is a sick baby often fighting for his life as well as
    his sight, and every effort must be made to preserve his strength
    and increase his resistance. Fresh air and careful feeding are
    imperative. Breast-fed babies have a distinct advantage over
    bottle-fed babies and for this reason the mother should always
    accompany the nursing baby if he is taken from his home to a
    hospital to be treated for ophthalmia neonatorum, unless there is a
    wet nurse available at the hospital.

[Illustration:

  FIG. 188.—Method of holding baby for eye examination or treatment.
    (Photograph and appended notes by courtesy of Dr. W. Gordon M.
    Beyers, Royal Victoria Hospital, Montreal.)

  “The child’s body is swathed in a sheet or blanket in such a way that
    the arms are lightly, but securely, fixed against the sides. The
    nurse can easily support the body with one hand, and with the other
    draw down the lower lid (as shown in the photograph), or otherwise
    assist the physician. The doctor sits opposite the nurse, with a
    rubber sheet across his knees, and upon this a sterile towel. He
    holds the baby’s head gently, but firmly, between his knees, thus
    freeing both his hands for necessary manipulations. In the picture
    the physician is represented as about to apply a solution of nitrate
    of silver with an applicator of sterile absorbent cotton.

  “Close at hand is a table on which are a bowl of boracic acid solution
    and sterile absorbent cotton for irrigating the eyes; an undine (if
    one prefers) for the same purpose; a kidney dish for collecting the
    washings; sterile applicators, and small dishes for nitrate of
    silver solution and for saline solution (to neutralise): besides
    bottles containing solutions of cocaine, atropine, and fluorescein.
    Culture tubes, sterile swabs, cover slips, forceps, and a spirit
    lamp are ready for bacteriological examinations; and in a glass are
    displayed lid retractors, which are usually indispensable to a
    thorough examination of the cornea. On the floor is a paper bag,
    which, with the contaminated swabs, applicators, etc., is burned on
    the completion of the treatment. Other articles may be added as
    required; but the important point is, that everything should be at
    hand before the examination is begun.

  “The physician and the nurse are clothed in surgical gowns; and wear
    rubber gloves, which heighten cleanliness, and safety and comfort.
    It is to be carefully noted that they both are provided with
    protective glasses; for under no circumstances should this
    precaution be omitted in treating the purulent ophthalmias.

  “The conditions here depicted will not always be possible of
    fulfillment, but they represent the ideal for which one should
    strive.”
]

    It is of interest to nurses that the effort to safeguard the eyes of
    babies through preventive treatment and early care was developed
    into a national movement by one who also was influential in starting
    the training of nurses in this country, Miss Louisa Lee Schuyler.
    The lay work for the prevention of blindness, which is now
    country-wide, was started by the New York State Committee for
    Prevention of Blindness, which was organized by Miss Schuyler in
    1908. She was its first Chairman and skillfully directed the work of
    the Committee for ten years. During the Civil War Miss Schuyler was
    a member of the Sanitary Commission and afterwards was one of the
    group which was responsible for starting at Bellevue Hospital, in
    New York City (in May, 1873), the first training school for nurses
    in this country, planned in accordance with Miss Nightingale’s
    standards for the organization and conduct of a school for nurses.
    Later, in 1911, the Bellevue School for Midwives was established as
    a result of the combined efforts of the Hospital Trustees and Miss
    Schuyler’s Committee for Prevention of Blindness, the course of
    training being outlined by a sub-committee composed of Miss Lillian
    D. Wald, Dr. J. Clifton Edgar and myself. So far as it is possible
    to learn this school was the first in this country to be conducted
    along the lines of a school for nurses, or after the manner of the
    midwife schools in England.

    =Syphilis=, which ranks high among the scourges of mankind, is seen
    with distressing frequency among young babies. It may be contracted
    during uterine life, when it is said to be “inherited,” or it may be
    “acquired” after birth by kissing a syphilitic person or coming in
    contact with contaminated articles, such as clothing, or nursing
    from a diseased breast.

    The most conspicuous symptoms are the familiar “snuffles;” the
    scaling, fissures or eruption on the soles, palms, buttocks and
    about the mouth; shrill, hoarse crying; swollen painful joints;
    partial paralysis and a general feebleness and inanition. Some or
    all of these symptoms may be present when the baby is born or they
    may develop any time within the first two or three months of life.

    Babies of syphilitic mothers are often given mercurial inunctions
    immediately after birth, even though they have no symptoms of the
    disease as it is very likely to be present in a latent form. This is
    one reason for the routine inspection of the placenta, since in it
    is sometimes found the only indication for treating the baby. An
    infant who is known to have syphilis is given mercurial inunctions
    or baths, the ointment being rubbed into the groin, axilla, back and
    abdomen in rotation on successive days, to prevent irritation of the
    skin. The nurse should protect herself with rubber gloves, wash the
    area with warm water and soap and thoroughly rub in the ointment.
    Sometimes the ointment is put on the inside of the back of the
    baby’s binder, by which means he rubs it in himself. The syphilitic
    baby should be isolated and should not be put to the breast of an
    uninfected woman, but he may nurse from a syphilitic woman without
    harm to either her or himself. Good general care, including fresh
    air and sunshine are important to the baby suffering from syphilis.

    =Thrush= or =Sprue= is a highly communicable disease of the mouth of
    new-born babies, due to one of the fungi. It is common among sickly,
    undernourished babies and those living in unhygienic surroundings,
    but it is seldom seen in healthy babies who are cared for with
    absolute cleanliness. The disease is characterized by small raised,
    white spots in the baby’s mouth, frequently on the back of the
    tongue and inner surface of the cheeks.

    Prevention lies in good care and in cleanliness of the mother’s
    nipples, or the bottles and nipples for artificially fed babies, and
    of all other articles coming in contact with the baby, particularly
    his mouth. Some doctors have the baby’s mouth bathed before each
    feeding, as a preventive measure, while others feel that a gentle
    swabbing once daily is sufficient, if the nipples are kept clean,
    since an abrasion of the mucous lining is easily caused and is
    favorable to the development of thrush.

    Treatment consists in cleanliness and in gently swabbing the spots,
    three or four times a day, with sterile cotton wet with an alkaline
    solution such as borax (10%), bicarbonate of sodium (6%) and
    sometimes with formalin (1%) or a weak solution of permanganate of
    potassium.

    =Impetigo= and =Pemphigus= are highly infectious skin diseases of
    early infancy which are seen more often in hospitals than in
    patients’ homes. The treatment of the raised blisters that appear on
    different parts of the body is entirely a medical question, but in
    caring for the patients suffering from either of these infections
    the nurse must take every precaution to avoid extending the trouble
    on the skin of the infected baby, himself, and of communicating it
    to other babies in the ward. Strict isolation is imperative; gentle
    handling and frequent changing of the underclothing to prevent
    extending the disease to uninfected areas.

    =Vaginitis.= This highly infectious malady is considered troublesome
    rather than serious, as a rule, though it may be complicated by
    ophthalmia or arthritis. Gonorrheal vaginitis is the commonest form
    seen in early infancy and may be due to infection which the baby
    acquired during its passage through the birth canal or later from
    the mother’s hands or clothing. The symptoms are a vaginal
    discharge, which may be thin and serous or thick and yellow and
    purulent and it may be scanty in amount or abundant; a reddened,
    swollen condition of the vagina and vulva and sometimes redness and
    excoriation of the inner surface of the thighs. The nurse’s chief
    responsibilities are to be constantly on the alert to detect
    evidences of the disease and report them promptly to the doctor, and
    to observe strict isolation in caring for the baby while carrying
    out the doctor’s orders for douches or suppositories.


                  COMMON ABNORMALITIES OF THE NEW-BORN

    =Icterus= or =Jaundice=, which is so frequently seen in new-born
    babies, is occasionally a symptom of some septic condition; of
    syphilis or congenital cirrhosis of the liver or obstruction of the
    bile ducts, but as a rule it is without any serious significance.
    The jaundiced appearance usually begins on the second or third day
    and may continue for two or three weeks or it may subside in three
    or four days. The depth of the color varies, being very pale in some
    cases and almost green in others. When this discoloration of the
    skin is unaccompanied by other symptoms, no treatment is given.

    =A Cephalhematoma= is a tumor of blood between the periosteum and
    the bones of the skull of the new-born baby. It is often due to some
    injury sustained during birth and is most frequently seen after
    prolonged labors. Cephalhematoma is sometimes confused with a caput
    succedaneum, but whereas the caput disappears in a few days the
    cephalhematoma may not be entirely absorbed for two or three months.
    Although certain conditions sometimes indicate the advisability of
    surgical treatment, the nurse’s care consists solely of protecting
    the tumor from injury.

    =Club foot= is one of the commonest deformities of the extremities
    of young babies, occurring once in about every 1000 births. It may
    be congenital or caused by injury or it may be due to such diseases
    as cerebral paralysis or poliomyelitis. The nurse should watch for
    any abnormality in the structure or position of the feet, for the
    earlier treatment is started, the better is the prospect of a cure.

    =Engorgement of the Breasts.= Not infrequently the breasts of
    new-born babies are engorged, in which state they are easily
    infected by being rubbed or squeezed. Since the greatest care must
    be taken to avoid bruising swollen breasts, they are sometimes
    protected by the application of a pad of sterile cotton. Hot
    compresses are sometimes applied when there is redness with the
    swelling, or a tiny ice-bag, made by tying off the fingers and thumb
    of a rubber glove, and partly filling it with finely crushed ice,
    after which the wrist is tightly tied.

    =Hare Lip.= The fissured lip, which is not infrequently seen in new
    babies, may consist merely of a small notch or it may amount to a
    deep cleft reaching up into the nostril. It is due to a non-union of
    the frontonasal plate with the lateral processes and may occur on
    one or both sides, thus forming a single or double hare lip. An
    extensive fissure will usually interfere with suckling and the nurse
    may need both ingenuity and patience in feeding such a baby, for the
    prospect of successful treatment, which is surgical, increases with
    the baby’s age and improved nutrition. The longer she can feed the
    baby successfully, therefore, the better his chance of recovery.

    =Cleft palate=, a common congenital abnormality, consists of a
    fissure of the soft, and sometimes of the bony, palate; it may be on
    one or both sides and may be continuous with a hare lip. The problem
    of feeding the baby with a cleft palate is very grave since the
    fissure may make it impossible for him to form the vacuum in the
    back of his mouth which is necessary for suckling. He is sometimes
    fed with a medicine dropper or by gavage or by means of a special
    nipple provided with a flap which fits into the roof of the mouth
    and closes the opening into the nasal passages. Even more than in
    the care of the baby with a hare lip is it important to nourish the
    baby with a cleft palate, and build him up for as long as possible
    before he is subjected to the strain and shock of the inevitable
    operation.

    =Hernia.= Umbilical and inguinal hernias are both seen in young
    babies.

    =Umbilical hernia= is the commoner type and is not uncommon in thin
    babies and those with indigestion and distension and in babies who
    cry violently. Such hernias are not regarded as serious if prompt
    measures are taken to reduce them as they usually respond very
    readily to treatment. But since neglect may have serious
    consequences, the nurse should watch for protrusions and report them
    promptly. She will often be instructed to reduce the hernia and
    apply adhesive strapping, in which case the following observations
    by Dr. Griffith will be helpful:

    “Usually it is quite sufficient to draw the skin into two folds, one
    on each side of the hernia and meeting over it; holding these in
    place by straps of adhesive plaster crossing over the navel, or by a
    broad horizontal band of adhesive plaster reaching to the lumbar
    regions. Another method is the following: A silver quarter of a
    dollar is laid upon the adhesive surface of a piece of rubber
    plaster about two inches square; over this is placed the broad strap
    referred to, with its adhesive surface next to that of the smaller
    piece. After reducing the hernia and pressing the sides of the
    abdominal walls slightly together the band is applied with the
    quarter dollar directly over the position of the navel. My own
    preference is for a simple adhesive band without the use of the
    coin. The dressing should be worn constantly, changing it from time
    to time as the old one loosens. The dressing must, of course, not be
    removed during the bath. Several months are required before the
    opening is permanently closed. Occasionally the plaster produces a
    great deal of cutaneous irritation, especially in the first few
    months of life. The employment of zinc oxid plaster tends to avoid
    this difficulty.”[17]

    =Inguinal hernia= is less common in very young babies but it should
    be watched for since it usually may be easily reduced by the use of
    a truss, if discovered and treated early, but may be serious if
    neglected.

    In general, the new baby who is ill, needs the same thoughtful,
    gentle, painstaking care that the nurse gives to the well baby, but
    these must be shaped to his immediate requirements and the doctor’s
    special instructions.



                              CHAPTER XXIV
                              A FINAL WORD


    It will be well for us now to take a retrospective view of the
    various functions of the nurse which are associated with the
    phenomena of pregnancy, labor, the puerperium and the beginning of a
    new life. As we see these in perspective, our attention is fixed by
    a few important principles which stand out from the picture as a
    whole in clear and shining relief.

    We see, for example, that no matter what else may become vague and
    unimportant, be changed or discarded, there remains the conspicuous,
    unalterable requirement that the nurse shall do clean work
    throughout this entire series of experiences. All maternity patients
    and all babies need scrupulously clean care no matter what else they
    may have or may lack.

    But also must they all be watched throughout these transitional
    stages, in order that impending disaster may be apprehended and
    warded off. And that this watchfulness be intelligent, the nurse
    must of necessity know something of the normal physiological changes
    which occur during these momentous periods in the lives of her
    patients, lest she fail to detect evidence of abnormality, should it
    appear.

    Since this invariable cleanliness and close watchfulness are needed
    by all patients, whether of high or low degree, and by those in the
    care of doctors with widely varied methods, the nurse must be able
    to make adaptations to each patient’s environment and temperament
    and to the doctor as well, if all of her patients are to be well and
    happily nursed. She must be clean, then, and watchful in her work,
    and adapt it to every conceivable condition. These features stand
    out clear and bold in the perspective. But to make these offices
    effective to their utmost, the nurse’s attitude and her care of her
    patient must be mellowed by an always deepening sympathy and
    understanding. She must endeavor, in each instance, to imagine the
    mental experience of the bewildered and timid expectant mother; of
    the terrified woman in labor and the discouraged young mother—these
    she must appreciate if she is to give of her best. And so, in the
    end, the character of the nurse’s work will be influenced, in fact
    almost determined, by her awareness of her patient’s needs, mental
    and physical, and the earnestness with which she tries to relieve
    them. More than this, the nurse whose skill is warmed by a sincere
    desire to give of her best will, by virtue of this very desire,
    learn something from each patient, and will be steadily enriched and
    broadened by her experiences. She will have more to give, and
    accordingly will derive increasing satisfaction from her service to
    each succeeding mother and baby that she takes into her care.

    One word more. The maternity nurse almost inevitably becomes deeply
    attached to her baby patient, whether he is sick or well, and she is
    eager to protect him and safeguard him as long as possible. She may
    continue to serve him, even after he has passed from her trained
    hands, if she will teach his mother how to take care of him, should
    she be inexperienced, particularly if the young mother is to have
    full charge of her baby after the nurse leaves, or is to have only
    the assistance of a partly trained nursery maid. In such a case the
    nurse may often perform her most valuable and enduring service to
    the baby by gradually teaching his mother how to prepare the milk
    with cleanliness and accuracy, if he must be bottle-fed; how to give
    his bath deftly and comfortably, and impressing upon her the
    importance of fresh air and of regularity in the baby’s daily
    routine. All of these things, and also how to do the thousand and
    one other things that seem so trivial and yet mean so much to the
    baby’s immediate health and future well being.

    The first day after the nurse leaves, and the first few after that
    are often very dark ones for the inexperienced young mother, and if
    she is alone they are likely to be filled with fear and misgivings.
    The nurse may rob these days of much of their discouragement by
    anticipating them; trying to imagine the young mother’s possible
    perplexities and then teaching her how to meet them. This teaching
    is perhaps not a part of the nurse’s professional obligation but it
    is one of the privileges, one of the gratifying by-paths of nursing
    that she may take for the sheer joy of it.

    Not infrequently the young mother is so filled with awe over
    possessing anything so wonderful as her own baby that she is afraid
    to handle the exquisite little body; is fearful of harming it; and
    because of her timidity and inexperience she fails to give him the
    care that he needs, and that she wants to give. On the other hand,
    all too many young mothers have a blind confidence that the mere act
    of having a baby vests one, in some instinctive way, with the
    requisite knowledge and skill to care for it, and in this belief
    they are supported by a legion of women friends and relatives.

    It would be difficult to imagine a single factor that works more
    destruction among babies than this one of ignorant motherhood. And
    the damage is equally great whether the ignorance arises from
    timidity or from overweening confidence.

    “Is it not preposterous,” says Herbert Spencer, “that the fate of a
    new generation should be left to the chance of unreasoning custom,
    impulse, fancy, joined with the suggestions of ignorant nurses and
    the prejudiced counsel of grandmothers? To tens of thousands that
    are killed, add hundreds of thousands that survive with feeble
    constitutions, and millions that grow up with constitutions not so
    strong as they should be, and you have some idea of the curse
    inflicted on their offspring by parents ignorant of the laws of
    life.”

    The nurse is in the most effective position possible, to help in
    dispelling maternal ignorance, during the long days of pleasant
    intimacy which she and the young mother spend together in devotion
    to the baby. And by helping the inexperienced young mother to give
    skilful care to her baby, with all of the gentleness and tenderness
    that a mother can lavish, the nurse will not only serve the baby;
    she also will awaken for many a young woman, an interest that will
    be ever fresh and absorbing, and point the way to unexpected joys
    and delights in her motherhood.

                “Can there be any higher work than this?
                Can any woman wish for a more womanly work?”



                                 INDEX

    Abdomen, changes in, during pregnancy, 102
      enlargement of, during pregnancy, 98

    Abdominal binders, in pregnancy, 122
      in puerperium, 349

    Abdominal palpation, 226

    Abdominal pedicle, 76

    Abdominal supporters, in pregnancy, 122

    Abdominal wall, in puerperium, 321

    Abnormalities of newborn, 540

    Abortion, 165, 166
      attempted, 151
      causes of, 166
      complete, 170
      early signs of, 142
      incomplete, 170
      induced, 309, and _see_ Induced abortions
      missed, 170
      prevention of, 168
      symptoms of, 167
      therapeutics, 171
      threatened, 170
      treatment of, 170
        complete, 170
        incomplete, 170
        threatened, 170

    Abscesses, in breast, 344

    Accidental hemorrhage, 178

    Accidents of pregnancy, 164

    Accouchement forcé, 309, 313

    Acidosis, 525

    Acute yellow atrophy of liver, during pregnancy, 207

    Advice for mothers, 427

    After-birth, _see_ Placenta

    After-care, immediate, of patient, 281

    After-pains, 318

    Air, fresh, during pregnancy, 129

    Albumen in urine, tests for, 118

    Alcohol, during pregnancy, 127

    Amenorrhea, 56

    Amnion, 70
      development of, 70

    Amniotic fluid, 71

    Analgesia, nitrous oxid gas, 291

    Anatomy of pelvis and genitalia, 19

    Anesthesia, à la reine, 288
      chloroform, 287, 288
      complete, 292, 293
      ether, 289, 290
      light, 288
      nitrous oxid gas, 291
      obstetrical, 286, 288
      scopolamin and morphin, 292
      unfavorable signs in, 294

    Animal foods, allowed during pregnancy, 128

    Ante-partum hemorrhage, 174

    Areola, 43

    Artificial feeding of baby, 489

    Attitude of fetus, in utero, 217

    Auscultation of fetal heart, 231

    Axis-traction forceps, 301


    Baby, and _see_ Infant, and New-born
      basket for, while travelling, 507
      care of, by visiting nurse, 437
        during summer, 514
        immediate, 265
        while travelling, 507
      feeding, 486, and _see_ Baby’s food
        artificial, 489
        breast, 486
      giving bottle to, 495
      method of holding, for eye examination, 537
      nutrition of, 368
      preparations for, 162
      supplies for, 428
      sore eyes of, 533
      toilet tray for, 417

    Baby’s food, articles used in preparing, 492
      commercial, 503
      ingredients of, 498
      proprietary, 504

    Baby basket, for travelling, 507

    Ballottement, 100

    Barley water, preparation of, 505

    Bartholin’s glands, 40

    Bath, bran, preparation of, 517
      in puerperium, 329
      soda, preparation of, 517
      starch, preparation of, 517

    Bathing, during pregnancy, 119

    Baudelocque’s diameter, 25, 27

    Bed exercise, in puerperium, 349

    Bed, position in during puerperium, 326
      preparation of for labor, 248

    Beef juice, preparation of, 506

    Beri-beri, 376

    Binders, abdominal, during pregnancy, 122
      in puerperium, 349
      for breast, 123, 345, 347

    Birth, changes in fetal circulation at, 84, 87

    Bladder, 37
      care of in puerperium, 332

    Blastodermic vesicle, 65, 66

    Bleeding, _see_ Hemorrhage

    Bones, changes in, during pregnancy, 104

    Bottle, giving of to baby, 495

    Bowels, care of in pregnancy, 120
      care of, in puerperium, 331
      of fetus, 88

    Bradycardia, puerperal, 322

    Bran bath, preparation of, 517

    Bread, allowed during pregnancy, 128

    Breast, and _see_ Lactation, and Nursing
      abscess in, 344
      anatomy of, 41, 42
      binders, in pregnancy, 123
        in puerperium, 345, 347
      caked, 344
      care of, during pregnancy, 131
        in puerperium, 339
      changes in, in pregnancy, 96, 103
      drying up of, 366
      feeding, 486, and _see_ Nursing, Lactation
        contraindications, 357
      infusion under, 202
      stripping, 348
      supporting, in puerperium, 343
      supports for, in puerperium, 343, 345

    Breast tray, 417

    Breath, shortness of, during pregnancy, 140

    Breech extraction, 298

    Bregma, 89

    Broad ligament, 33, 38

    Broths, preparation of, 506


    Cæsarean section, 305
      conservative, 307
      extra-peritoneal, 307
      indications for, 306
      radical, 307

    Caked breasts, 344

    Cane sugar, 498

    Canned milk, 504

    Caput succedaneum, differentiated from cephalhematoma, 541

    Cardiovascular system, changes in pregnancy, 103

    Care of baby, by visiting nurses, 437
      in traveling, 507
      during summer, 514
      immediate, 265
      of mother, by visiting nurses, 437

    Carriage, in pregnancy, 105

    Catheterization, 333

    Cephalhematoma, 541

    Cereals allowed during pregnancy, 128

    Certified milk, 490

    Cervix, changes in pregnancy, 99, 102
      during labor, 234

    Champetier de Ribes’ bag, 311

    Childbirth, deaths in, 112, 405

    Chloasma, 97, 105

    Chloroform anesthesia, 287, 288

    Chorion, 68
      development of, 68
      frondosum, 70
      læve, 70
      primitive, 67
      villi, 68, 70

    Circulation, fetal, 84, 85
      changes in at birth, 84, 87

    Cleft palate, in new-born, 542

    Climacteric, 56

    Clinic assistant, duties of, 431

    Clinic equipment, 432

    Clitoris, 40

    Clothes, during pregnancy, 121

    Club foot, in new-born, 541

    Coccyx, 20

    Colic in infants, 528

    Colonic irrigations in eclampsia, 195

    Colostrum, 103

    Commercial baby foods, 503

    Complete abortion, 170

    Complicated labors, 295

    Complications of pregnancy, 164
      early signs of, 141, 143
      of puerperium, 391

    Concealed hemorrhage, 178

    Conception, 62

    Condensed milk, 504

    Confinement, to calculate date of, 93, 94

    Constipation, during pregnancy, 120
      in infants, 529

    Contracted pelvis, measurements in, 29

    Convulsions, in infants, 531

    Cord, umbilical, 76
      development of, 61
      ligation of, 272
      prolapsed, 285

    Corpus luteum, 49
      false, 49
      of menstruation, 49
      of pregnancy, 49
      verum, 49

    Corsets, during pregnancy, 121
      front-lace, 122
      maternity, 122

    Cow’s milk compared with mother’s milk, 491

    Cramps in legs, during pregnancy, 140

    Cravings, during pregnancy, 127

    Cul-de-sac of Douglas, 36, 39


    Dämmerschlaf, 292

    Date of confinement, to calculate, 93, 94

    Deaths in childbirth, 112, 405

    Decidua basalis, 66
      gravidatis, 65
      reflexa, 66
      serotina, 66
      vera, 66

    Deficiency diseases, 372, 378

    Delivery, dressings required for, 159
      patient draped for, 262
      preparation of dressings for, 155, 158
        of equipment for, 155
        of room for, 155
      requirements of mother for, 158
        of physician for, 161
      room ready for, 258, 259

    Detachment of placenta, 241

    Desserts allowed in pregnancy, 128

    Development of cord, 61
      of embryo, 61, 76, 78, 80
      of fetus, 61, 76, 78, 80
      of membranes, 61
      of ovum, 61
      of placenta, 61, 72

    Diameters of fetal head, 90, 91
      of pelvis, 25, 26, 27, 28

    Diarrhea, during pregnancy, 136

    Diarrheal diseases of infants, 518

    Diastasis of rectus muscles, 102

    Diet during pregnancy, 125, 128
      during puerperium, 329
      of nursing mother, 363

    Digestive tract, changes in during pregnancy, 104
      during puerperium, 321

    Discoloration of skin during pregnancy, 97

    Discomforts during pregnancy, 134

    Discus proligerus, 48

    Distress during pregnancy, 136

    Douches, vaginal, in puerperium, 338

    Douglas, cul-de-sac of, 36, 39

    Dressings, post-partum, 336
      required for delivery, 155, 158, 159

    Dried milk, 505

    Drugs excreted in milk, 331

    Dry labor, 235

    Dry pack, hot, in eclampsia, 197

    Ductless glands, changes in during pregnancy, 105

    Duncan’s mechanism of placental separation, 239, 242

    Dysmenorrhea, 56


    Eclampsia, 190
      colonic irrigations in, 195
      frequency of, 190
      mortality of, 191
      nursing care in, 193
      symptoms of, 191
      treatment of, 193

    Ectoderm, structures derived from, 67

    Elevated Sims’ position, 139

    Embryo, 67, 68
      development of, 61, 76, 78, 80

    Embryonic area, 66
      development, 67

    Emotional changes during pregnancy, 105

    Endometrium, 32
      pre-menstrual swelling of, 49

    Enema, to give to infant, 530

    Engagement of presenting part, 224

    Engorgement of breasts, in newborn, 541

    Entoderm, structures derived from, 67

    Episiotomy, 298

    Equipment, preparation of for delivery, 158

    Esbach’s test for albumen in urine, 118

    Ether anesthesia, 289, 290

    Evaporated milk, 504

    Examination of eye, method of holding baby for, 537
      of urine, in pregnancy, 117
      rectal, during pregnancy, 231
      vaginal, in labor, 248, 252
        in pregnancy, 230

    Excretions during pregnancy, 117

    Exercise, bed, during puerperium, 349
      for nursing mother, 364
      in pregnancy, 129

    Expectant mother, 109
      mental hygiene of, 145

    Extra-uterine pregnancy, 82


    Face presentation, positions in, 223

    Fallopian tubes, anatomy of, 33

    Fallopian tubes, changes in during pregnancy, 102
      fimbriæ of, 34

    Fat soluble A. vitamines, 371, 377

    Feeder, for premature babies, 513

    Feeding, 486
      artificial, 489
      breast, 486
      mixed, 503
      percentage, 499, 500, 501

    Feet, swelling of during pregnancy, 137
      varicose veins of during pregnancy, 138

    Fertilization, 62

    Fetal circulation, 84, 85
      changes in at birth, 84, 87

    Fetal head, 88, 90
      circumference of, 91
      diameters of, 90, 91
      fontanelles of, 89, 90
      rotation of during birth, 236
      sutures of, 89

    Fetal heart, auscultation of, 231

    Fetal heart beat, sign of pregnancy, 99

    Fetal mortality, 112

    Fetus, 68
      at term, 80, 218
      attitude of in uterus, 217
      bowels of, 88
      development of, 61, 76, 78, 80
      growth of, 84
      head of, 88, 90, and _see_ Fetal head
      kidneys of, 88
      maturation of, time required for, 68
      movements of, as sign of pregnancy, 99
      palpation of, 224
        as sign of pregnancy, 99
      physiology of, 84
      position of, 217
      presentation of, 217, 220
      presenting part of, 220

    Fimbria ovarica, 34

    Flatulence during pregnancy, 136

    Follicle, primordial, 47

    Fontanelles of fetal head, 89, 90

    Foods for baby, commercial, 503
      proprietary, 504

    Forceps, 300
      axis-traction, 301
      high, 303
      indications for, 301, 302
      low, 303
      Simpson’s, 301
      Tarnier’s, 301

    Fornix of vagina, 35

    Fossa navicularis, 40

    Fourchette, 40

    Frank hemorrhage, 178

    Fresh air during pregnancy, 129

    Front-lace corset, 122

    Fruits allowed during pregnancy, 128

    Funis, 76


    Gastro-enteritis, acute, 519
      nursing care in, 519
      symptoms of, 519
      treatment of, 519

    Gavage, 524

    Genitalia, anatomy of, 19
      external, 39
      internal, 30

    Germinal spot, 48
      vesicle, 47

    Gonorrhea complicating pregnancy, 212

    Gonorrheal vaginitis in infants, 540

    Graafian follicle, 34, 48

    Gymnastics during pregnancy, 130


    Harelip in newborn, 541

    Head, fetal, 88, 90
      circumference of, 91
      diameters of, 90, 91
      fontanelles of, 89, 90
      rotation of during birth, 236
      sutures of, 89

    Health, general, during pregnancy, 106

    Heart, fetal, auscultation of, 231
      lesions of complicating pregnancy, 209

    Heart beat, fetal, sign of pregnancy, 99

    Heart burn, during pregnancy, 135

    Heat and acetic acid test for albumen in urine, 118

    Hebotomy, 303

    Hemorrhage, accidental, 178
      ante-partum, 174
      concealed, 178
      during pregnancy, 143
      during puerperium, 391
      frank, 178
      post-partum, 286, 391
        causes of, 391
        treatment of, 392

    Hemorrhoids during pregnancy, 140

    Hernia, in newborn, 542
      inguinal, 543
      umbilical, 542

    Hot dry pack in eclampsia, 197

    Hygiene, of nursing mother, 363
      of pregnancy, 116

    Hysterotomy, vaginal, 305


    Icterus, in newborn, 540

    Ignorance, dangers of, 546

    Ilium, 19

    Impetigo, 540

    Impregnation, 62

    Inanition, 518

    Incomplete abortion, 170

    Indian binder for breasts, 347

    Induced abortion, 309
      indications, 309
      methods, 310

    Infancy, abnormalities of, 518
      disorders of, 518
      infection in, 533

    Infant, and _see_ Newborn
      colic in, 528
      constipation in, 529
      convulsions in, 531
      diarrheal diseases of, 518
      enema for, 530
      gonorrheal vaginitis in, 540
      syphilis in, 538
      vaginitis in, 540
      vomiting in, 532
      wasting diseases in, 518

    Infantile scurvy, 374

    Infection, in infancy, 533
      puerperal, 393
        nursing care in, 399
        prevention of, 399
        symptoms of, 396
        treatment of, 399

    Infusion, of orange peel, preparation of, 506
      saline, in eclampsia, 200
      under breast, 202

    Inguinal hernia, in newborn, 543

    Injection of salines, in eclampsia, 200

    Innominate bones, 19

    Instructions to patients, 427

    Intestinal irrigations, 522

    Invalidism, due to lack of obstetrical care, 112

    Involution of uterus, 317

    Irrigations, colonic, in eclampsia, 195
      intestinal, 522

    Ischium, 20

    Itching of skin, during pregnancy, 141


    Jaundice, in newborn, 540


    Kidneys, during pregnancy, 117
      of fetus, 88


    Labia majora, 39
      minora, 40

    Labor, cause of, 232
      cervix during, 234
      complicated, 295
      course of, 232
      definition of, 232
      dry, 235
      duration of, 233
      first stage of, 23
        nurses duties during, 245, 256
      mechanism of, 232
      nurses duties in, 243
        during first stage, 245, 256
        during second stage, 256
        during third stage, 278
        when doctor is delayed, 283
      onset of, 232
      pains of, 232
      premature, 172
        causes of, 172
        induced, 309, 310
        treatment, 173
      preparation for, 248
        of bed, 248
        of room, 248
      signs of, 232
      second stage of, 236
        nurses duties during, 256
      stages of, 232
      symptoms of, 232
      third stage of, 240
        nurses duties during, 278
      vaginal examination in, 252
      when to call physician, 247

    Lactation, 320, 342

    Lactose, 498

    Lacerations, perineal, 296
      repair of, 297

    Lavage, 524

    Layette, details of, 162
      recommended by Maternal Centre Association, 416

    Leg, cramps in during pregnancy, 140

    Leg, milk, 400

    Leg straps, to improvise, 296

    Leggings, for delivery or operation, 304

    Ligaments, broad, 33, 38
      ovarian, 34, 38
      round, 38
      uterine, 38

    Ligation of cord, 272

    Linea nigra, 197

    Lineæ albicantes, 102

    Liquor amnii, 71
      folliculi, 48

    Liver, acute yellow atrophy of during pregnancy, 207

    Lochia, 319
      alba, 319
      rubra, 319
      serosa, 319

    Longitudinal presentations, 221

    Loss of weight during puerperium, 319

    Lutein, 49


    Malnutrition, 369, 387, 518

    Maltose, 498

    Mania, puerperal, 400

    Marasmus, 518

    Marital relations during pregnancy, 133

    Masque de femmes enceintes, 105

    Massage during pregnancy, 130

    Mastitis, 345

    Maternal mortality, 112

    Maternity Centre Association, 410
      baby’s supplies, 428
      clinical equipment, 432
      clinical routine, 429
      doctor’s duties, 431
      duties of clinical assistants, 431
      forms and routines used by, 423
      instructions to patients, 427
      mother’s supplies, 428
      nurse’s duties, 429
      nursing visits, 424
      orders for nurses, 434
      post-natal follow up, 435
      records, 427, 431
      requirements, 432

    Maternity Centre Nurse, 413

    Maternity Centre orders for nurses, 434
      ante-partum, 434
      post-natal, 435
      post-partum, 435

    Maternity corsets, 122

    Maternity Protective Committee of the Woman’s City Club, 411

    Maternity records, 427, 431

    Maternity Service Association of Physicians and Hospital
       Superintendents, 411

    Maternity service for rural communities, 422

    Maternity nursing, visiting, in Montreal, 445

    Maternity work of Visiting Nurses Society of Philadelphia, 439
      delivery routine, 441
      equipment for bags, 439
      routine after delivery, 442
      routine in home, 440
      routine technique, 439

    Maturation of fetus, time required for, 68

    Mauriceau’s maneuver, 299

    Measurements, in contracted pelvis, 29

    Meatus urinarius, 37

    Membrana granulosa, 48

    Membrane, vitelline, 47

    Membranes, development of, 61
      examination of, 280

    Menopause, 56

    Menorrhagia, 56

    Menstrual cycle, 50

    Menstruation, 50
      cessation of, sign of pregnancy, 96
      corpus luteum of, 49
      difficulties of, 54
      during puerperium, 320
      modifications of, 56
      painful, 54
      relation to ovulation, 55
      vicarious, 56

    Mesoderm, structures derived from, 67

    Mental changes during pregnancy, 105
      hygiene during pregnancy, 145

    Micturition, frequent, as sign of pregnancy, 97

    Migration of ovum, 61

    Milk, canned, 504
      certified, 490
      condensed, 504
      cow’s compared with mother’s, 491
      dried, 505
      drugs excreted in, 331
      drying up of, 366
      evaporated, 504
      mixtures, formulas for, 500, 501, 503
      mother’s compared with cow’s, 491
      pasteurized, 494
      powders, 505
      preparation of for baby, 494
      reconstructed, 505
      top, 499
      whole, 499

    Milk leg, 400

    Miscarriage, 165
      early signs of, 142

    Missed abortion, 170

    Mixed feeding, 503

    Mons Veneris, 39

    Montgomery, tu