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

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.”