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
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.)
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.)
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.
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.
Fig. 63.
Fig. 64.
Fig. 65.
Fig. 66.
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.
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.
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.
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.
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.
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.
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.
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.