Obstetrical Nursing / A Text-Book on the Nursing Care of the Expectant Mother, the Woman in Labor, the Young Mother and Her Baby

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.

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.

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.)

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.

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.

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.

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.

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.

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:

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.

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.

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.)

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.

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.

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.

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.

The expulsion of the placenta ends the third stage and completes the process of labor.

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.)

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.

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.

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.

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.