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

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

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

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

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

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

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

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

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

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

PREMATURE TERMINATIONS OF PREGNANCY

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Other causes of premature births are the toxemias of pregnancy, chronic nephritis, diabetes, pneumonia, typhoid fever, organic heart disease, continuous overwork during the latter part of pregnancy, and such poisoning as lead and illuminating gas, while of alcoholism, Dr. Ballantyne says, “prematurity of birth is an undoubted result.”

Another important cause of premature births, of comparatively recent recognition, is previous operation upon the cervix, particularly high amputations; while placenta prævia and malformations of the fetus, or monsters, are also reckoned with as causative factors. Hydramnios sometimes brings on a premature labor by so distending the uterus as to stimulate contractions.

Labor is sometimes induced prematurely when this procedure may be expected to relieve an abnormality or complication which threatens the life of the mother or baby, or both. Some of the indications for this course are: seriously overtaxed heart or kidneys; a marked disproportion between the size of the child’s head and the mother’s pelvis, or a fetus that has been dead for two weeks or more. However, the reasons for it and the methods employed in inducing labor will be discussed more at length in the chapter on obstetric operations.

A therapeutic induction of premature labor, like a therapeutic abortion, is not of itself usually considered any more serious for the mother than a normal delivery, since it can be performed with care and cleanliness, qualities not usually associated with the work of practitioners who are willing to do criminal operations.

Treatment. The nursing care of the patient after a premature labor is the same as that given after a normal delivery. Much invalidism would be avoided if all women could be convinced of the importance of staying in bed just as long, and having just as good care after a premature as after a full-term labor. The difficulty of so convincing her is perhaps due to the fact that the small, premature child is expelled more quickly and less painfully than a baby at term and there is comparatively little blood lost in the course of its birth.

ANTE-PARTUM HEMORRHAGE

Ante-partum hemorrhage, which is a hemorrhage occurring before delivery, is another serious complication of pregnancy. During the early months, hemorrhages are usually due to abortion, menstruation or lesions of the cervix and are not severe as a rule. But during the last three months hemorrhages are almost invariably due to placenta prævia or premature separation of a normally implanted placenta, and are often profuse.

Placenta Prævia is one of the most serious conditions met with in obstetrics, the maternal mortality being about 40 per cent. and the baby death rate about 66 per cent. The frequency with which it occurs is variously estimated as from one in 250 cases to one in every 1000.

In order to understand what is happening to the patient in this condition, we must go back to the question of the implantation of the ovum. We learned that, as a rule, after the ovum entered the uterus it attached itself to a point in the uterine lining high up on the anterior or posterior wall. Unhappily, the position of this point of attachment is a mere matter of chance, and the ovum sometimes, but not often, is implanted so far down toward the cervix that as the placenta develops at that site it partially or completely overlaps the internal os. It is the extent to which the placenta grows over the cervical opening that determines whether it is of the central, partial or marginal variety.

A centrally implanted placenta prævia (Fig. 44) is one which entirely covers the os; a partial placenta prævia (Fig. 45), as the name suggests, only partially covers the opening, while if it is implanted so high up that only its margin overlaps the os, it is designated as marginal placenta prævia. (Fig. 46.)

Another classification groups all placenta prævia as complete or incomplete, the latter comprising the partial and marginal varieties, as well as the lateral which is so attached that it does not quite reach the edge of the internal os. However, as these terms do not differ widely and are clearly descriptive, the differences are of no great moment to the nurse, as the treatment is practically the same and the nurse’s duties quite the same for all varieties.

Cause. Not much is definitely known about the cause of placenta prævia, but it is evident that multiparity is a factor, since the condition is found about six times as frequently among women who have borne children, as it is among those who are pregnant for the first time. A diseased uterine lining is probably the fundamental cause, and this may explain why the trouble is found more frequently among the poorer classes, since such women as a class have less skilled medical attention than those in better circumstance.

One theory is that an old endometritis results in a very unfertile soil for the implantation of the ovum and as a result the ovum migrates to other parts of the uterine cavity in its search for a more favorable site, and comes to lodge near the lower segment.

Symptoms. The symptom of placenta prævia is hemorrhage, occurring during the latter part of pregnancy or at the onset of labor. The cause of the hemorrhage is the separation of that part of the placenta covering the internal os, when the latter dilates, thus presenting an exposed, bleeding surface. The hemorrhage is usually so profuse that unless it is controlled, both mother and child may bleed to death.

Treatment. Unhappily there is no preventive treatment for placenta prævia, beyond that which is included in treatment for endometritis, and good care during the preceding puerperium.

Since the great danger in this complication is from hemorrhage the doctor’s principal effort is directed toward its control. Infection and shock are also feared but the first step is to stop the bleeding. A common method is to stimulate the uterus to contract; that necessitates the removal of its contents, or the induction of labor.

The separation of the placenta leaves open, bleeding vessels in the uterine wall and placenta, which can only be closed by pressure, until the uterus contracts on its own vessels. The doctor sometimes makes pressure with tampons of gauze, by rupturing the membranes and bringing down the presenting part of the child to press against the bleeding surface, or by introducing a rubber bag into the cervix and pumping it full of sterile water. (Fig. 47.) By means of its weight and downward traction, this bag presses against the bleeding areas and thus checks the hemorrhage. It also tends to dilate the cervix, after which the baby is sometimes born spontaneously and sometimes delivered artificially.

Premature Separation of a Normally Implanted Placenta. A placenta prævia, as has been explained, is abnormally situated. But it sometimes happens that a placenta that is normally placed will separate prematurely, with hemorrhage as the inevitable result. Such a hemorrhage is termed “accidental” to distinguish it from the unavoidable bleeding caused by a placenta prævia. If the blood escapes from the vagina, the hemorrhage is called “frank,” but if it is retained within the uterine cavity it is called a “concealed” hemorrhage.

Causes. Endometritis is probably an underlying cause, though very little is definitely known on the subject. Previous pregnancies are believed to be a factor, as this accident occurs less often among women who are pregnant for the first time than among those who have borne children, and also as the frequency of the hemorrhages apparently increases with the number of previous pregnancies. Nephritis is believed to be a possible cause, as well as anemia, general ill-health, toxemia, physical shocks, and frequently recurring pregnancies.

Symptoms. In a frank hemorrhage, the chief symptom is an escape of blood from the vagina, occasionally accompanied by pain. A frank accidental hemorrhage occurs once in about every two hundred cases, according to Dr. Edgar’s estimate, but, although more frequent than placenta prævia, it is much less serious.

A concealed accidental hemorrhage, on the other hand, is an extremely grave complication for both mother and child, for according to observations made by Dr. Goodell, the death rate is 51 per cent. among mothers and 94 per cent. among babies.^[4] The symptoms are acute anemia, abdominal pain, a general state of shock, and usually an increased enlargement of the uterus. The blood may be retained between the uterine wall and the placenta or membranes, or its escape from the vagina may be prevented by the child’s presenting part fitting tightly into the outlet and acting as a plug.

Treatment. The treatment of a frank hemorrhage depends upon its severity. If the bleeding is only moderate, labor is ordinarily allowed to proceed normally and unassisted. If the bleeding is profuse, however, the patient is usually delivered promptly.

The treatment for a concealed hemorrhage consists of emptying the uterus speedily in order that the muscles may contract and stop the bleeding by closing the uterine vessels; and of treating the accompanying shock which may be almost, if not quite, as serious as the hemorrhage itself.

It is very disappointing to have to realize that there is very little that a nurse may do, before the arrival of the doctor, for a patient who is having an ante-partum hemorrhage. As has been explained, it is often necessary to pack the cervix or introduce a bag, for the purpose of stopping the bleeding by pressure, and of stimulating the uterine contractions which will expel the child and empty the uterus. These measures are surgical operations and quite evidently the nurse cannot attempt to perform them. She can, however, put the patient to bed and have her lie flat, without a pillow, and, partly for the mental effect upon the patient, apply ice-bags or compresses to her abdomen. As nervousness and excitement only tend to increase the bleeding, the nurse has an excellent opportunity to try to soothe and quiet a frightened woman, and convince her that she can help herself, in this emergency, by quieting her mind and body.

Pending the doctor’s arrival, the nurse should have a large receptacle of water, boiling, to sterilize the instruments and bags that he may want to use; clean towels and sheets, a nail brush, hot water, soap, and a basin of an antiseptic solution for his hands.

TOXEMIAS OF PREGNANCY

There is probably no group of complications which prove to be more baffling to the obstetrician than the toxemias of pregnancy. Certainly they are challenging the best efforts of many earnest investigators, for it is known that the toxemias cause some of the gravest conditions that arise during pregnancy, and they are suspected of being the underlying cause of still others which are as yet unaccounted for.

Comparatively little is known of the origin of the toxemias, except that they are due to pregnancy. But happily, a good deal is known about preventing them, and also about relieving them, particularly in the early stages; accordingly many mothers and babies are saved who otherwise would perish.

The entire subject of the prevention and treatment of these disorders will be somewhat simplified for the nurse if she will recall the general question of the adaptations of the mother’s physiology during pregnancy. She will then remember that there were certain alterations of function which were necessary to keep the maternal organism normal, while it bore the strain of supplying nourishment to the fetus from its own blood stream, and received in turn the broken-down products of fetal activity. If these adaptations are insufficient to meet the demands made upon the maternal organism, a serious toxic condition may result.

To put the matter briefly, there is in the toxemias of pregnancy a disturbance of the mother’s metabolism, involving the liver and kidneys, and a resulting retention within her body of something which should be excreted. The retention of this material, which may be of fetal or maternal origin, or both, may give rise to symptoms which range anywhere from slight headache or nausea to coma, convulsions and death.

Beyond these general facts, there seems to be deep obscurity concerning the cause of this group of complications, of which pernicious vomiting, pre-eclamptic toxemia and eclampsia are the most widely and generally recognized.

While nephritic toxemia and acute yellow atrophy of the liver cannot be designated, quite accurately, as toxemias due to pregnancy, they are usually included in this group. This may be because they are toxemias which have many features in common with those of pregnancy, as to symptoms and treatment, and because of the frequency with which they appear coincidently with pregnancy, although not always due primarily to that state.

From the nurse’s standpoint, it will perhaps be as well to regard all of the toxemias of pregnancy as manifestations of the same general disturbance, which vary according to the stage of pregnancy at which they appear, and which differ from each other chiefly in severity, or degree, rather than in kind.

In all cases the patients need to have their toxicity lessened by dilution, and this is accomplished by giving fluids, copiously, and by increasing elimination by promoting the activity of the skin, kidneys and bowels. And since the nervous system is irritated by the toxins, sometimes slightly and sometimes profoundly, the patient must be protected from outside irritation and stimulation. This means quiet; a soft light, or even darkness in the room; gentle handling; and with mildly toxic, conscious patients, a pleasant, reassuring and encouraging manner. With those who are unconscious, each touch must be the lightest and gentlest possible.

These are the main features of the nursing care: forcing fluids and keeping the patient warm and quiet. They offer the nurse wide scope in adjustment and adaptation to each patient, according to her immediate condition and to the methods of the physician in charge. There is a difference of opinion among doctors as to details of treatment, but the fundamentals of the care are the same. In taking up, in turn, these manifestations of disturbed metabolism during pregnancy, we find that vomiting is the first to appear.

Pernicious Vomiting of Pregnancy usually occurs during the first three months. We learned in the preceding chapter that a milder form of the malady, known as “morning sickness,” is present in about half of all pregnancies. This mild type ordinarily consists of a feeling of nausea, possibly accompanied by vomiting, immediately upon raising the head in the morning, and a capricious appetite. It appears at about the fourth or sixth week and subsides in the course of a few weeks, sometimes after no more care than the nursing which was described, leaving the patient none the worse as a result of the attack.

With some women, however, the distress does not disappear in this prompt and satisfactory manner, in which case it is described as “pernicious vomiting.” The nausea in the morning may then persist for hours; it may occur later in the day, or even at night; it may come on during a meal and consist of a single attack of vomiting, after which food is taken and retained; or it may be so persistent that the patient will be unable to retain anything taken by mouth at any time of the day or night. Such a condition, is, of course, serious, and may terminate fatally. The patient may become exhausted from lack of food or because of the toxic condition which is responsible for the vomiting, or both.

There seem to be three possible classifications of pernicious vomiting: (1) One of reflex origin, (2) one of neurotic origin, and (3) one due to a toxemia, resulting from disturbed metabolism. Not all physicians accept the possibility of all of these factors, however, for while some recognize both toxemia and neuroses as causes, they question the possibility of a reflex cause. Others believe that all nausea of pregnancy, from the mildest to the most severe form, is of toxic origin, while still others contend that even the severest pernicious vomiting is always neurotic. However, as toxicity under any conditions is very likely to give rise to nervous symptoms, and as a nervous, unstable woman may be made very ill by a slight degree of toxicity, it may be that both factors sometimes enter into the causation of this disorder.

Reflex vomiting. Those who subscribe to the theory of reflex vomiting believe that it may result from the irritation caused by a retroverted uterus, or occasionally by an ovarian cyst, an erosion on the cervix or by adhesions.

The treatment for reflex vomiting, quite obviously, consists of correcting the disturbing condition, whatever it may be, after which the nausea usually subsides in a short time. The nurse should take care that her patient resumes a regular diet very gradually, even after the cause of the nausea has been removed, for the stomach has become irritable and the vomiting habit, both mental and physical, though easily established, is usually broken up with considerable difficulty. Breakfast in bed; concentrated liquid foods or easily digested solids, particularly carbohydrates; aerated waters; cold fruit juices and cracked ice are easy to retain and tend to allay nausea.

Neurotic vomiting. Severe vomiting which is due to some kind of mental stress or suffering, and commonly called “neurotic vomiting,” is not always so easily relieved. In the opinion of many psychiatrists the vomiting frequently constitutes a protection, or possibly a protest, which the patient has developed subconsciously, because of some reason for fearing, or not wanting, to become a mother.

It is difficult to outline the nursing care of such patients with any degree of precision, as no two can be cared for in quite the same way. While in some cases the patient is a selfish, overindulged woman who objects to motherhood because of its inconveniences, in others, she is tortured by fear of inability to go through her pregnancy successfully, though sincerely wanting to; or she may be bewildered and overwhelmed by the prospect of the dangers of childbirth and responsibilities of motherhood, a truly pathetic figure whose distress may often be greatly relieved by the nurse who has enough insight to grasp the situation. As I have discussed this subject more at length in the chapter on mental hygiene, I shall say only a word here, as a reminder that the nurse will need all of the tact, resourcefulness, sympathy and understanding which she is capable of offering, if she is to give real help to some of her patients who suffer from neurotic vomiting.

In addition to the mental nursing, which will be necessary, the patient also needs physical care, for though her trouble may be of emotional origin, she is, nevertheless, physically ill. As a rule, the best results are obtained by putting the patient to bed and separating her from her family as completely as possible. A daily routine should be adopted and rigidly observed, and the patient repeatedly assured that the course being followed will end in recovery.

It is usually considered advisable not to offer food by mouth, in the beginning, but instead to give nourishment, as well as large amounts of saline and sugar solutions by enemata, during the first few days. One routine is to give 500 cubic centimetres very slowly, every six hours at first, gradually decreasing the treatments to one a day as the patient improves. The rectum is irrigated with a simple enema, once daily, immediately preceding one of the injections, consisting of an ounce of dextrose or glucose and one dram of salt to a pint of water.

Small amounts of liquid nourishment are finally given by mouth, and given frequently, the quantity being increased gradually as the patient improves. Very light and easily digestible solid foods, chiefly carbohydrates, are added by degrees, and in the end, five or six small meals, rather than three full ones, are given in the course of the day.

In some cases the patient is induced to drink, daily, two or three quarts of sugar solution (an ounce of lactose to a pint of water), and to nibble at will on olives, walnuts, crisp crackers, or some such articles of food, which are kept within reach on her bedside table. These are usually retained, excepting in very severe cases, to the patient’s great encouragement.

The duration and severity of the attacks vary widely. Some patients are very ill and for a long time, even requiring an abortion before showing signs of improvement, while others recover in a few days if wisely managed. If a patient once suffers from neurotic vomiting, she is very likely to have it in subsequent pregnancies, particularly if the circumstances of her life remain unaltered.

Toxemic vomiting is regarded by some doctors as a very grave and very rare complication of pregnancy, which is usually fatal; by others as simply a severe form of the very common “morning sickness,” which they believe is always toxic, no matter how mild; while still others, as already stated, doubt the occurrence of such a condition as toxemic vomiting of pregnancy. I mention these differences of opinion in order that the nurse may be aware of their existence and be prepared to adjust herself whole-heartedly to the different methods of treatment for which they are responsible. For no matter what else may vary, the earnestness and sincerity of the nurse’s attitude must be a veritable Gibralter of reliability.

The chief symptoms of toxemic vomiting, in addition to persistent vomiting, as described by those who recognize its occurrence, are coffee-ground vomitus; a diminished amount of urine, possibly containing albumen, acetone bodies and casts; coma and sometimes convulsions. The disease may run its course swiftly and the patient die in a week or ten days, or it may persist less acutely for weeks, in which case there is extreme emaciation and prostration. In those cases which come to autopsy there is a definite and characteristic, central necrosis of the liver lobule.

The treatment and nursing care vary widely because so little is definitely known about the cause, and because of the varieties of theories concerning it which are held by different obstetricians. Some believe that prompt emptying of the uterus is about the only course which is effective, while others feel that because of the probable toxicity of the patient it is advisable also to stimulate all of the excretory organs. Accordingly, they give free purges, colonic irrigations, hot packs and copious amounts of sugar and saline solution by mouth, rectum, intravenously and by infusion.

Corpus luteum, too, is sometimes given hypodermically two or three times weekly. Although this treatment is not in universal use or favor, some patients seem to be given absolute relief by its administration.

A fairly typical method of treating toxemic vomiting, and of which the nursing care forms a large part is somewhat as follows: When the vomiting is only moderately severe, the patient is put to bed and isolated from relatives and friends, because of her nervousness resulting from the toxemia. She is given an abundance of very cold, 5 per cent. lactose solution by mouth in water or lemonade; from four to six ounces being given every half hour if she is able to retain it. If she is unable to take, by mouth, a total of about three litres of this solution, in the course of twenty-four hours, she is sometimes given one or two litres (of a 10 per cent. solution) by rectum by means of the drip method. At least three hours are devoted to giving this amount of fluid, the rectum being first washed out with a simple enema.

It is usually considered important to persist in giving small amounts of practically any article of food that the patient fancies, in order to encourage her in the belief that she can take nourishment and also to accustom her stomach to receive and retain food. Olives and nuts are particularly valuable for this purpose and are often kept on the patient’s bedside table where she can reach them and nibble on them at will. Ice cold fruits and fruit juices are useful, while strained apple sauce, ice cold, is very valuable as a starting point from which a more generous diet may be gradually developed. All foods should be very cold except broths, which should be very hot. The dietary is gradually increased to six small meals daily from which fats and proteids are omitted.

In more severe cases, or if the patient does not improve, an injection of 300 cubic centimetres of fresh 5 per cent. solution of glucose is given under each breast daily, and sometimes a mild sweat-bath, given with blankets and lasting twenty minutes. (See page 197 for sweat-bath.)

In very severe cases when the patient is unable to retain anything taken by mouth; loses weight and strength; when possibly the urine decreases in amount and contains acetone bodies and ammonia, the situation is serious and the treatment is more drastic. All effort to give fluid by mouth is abandoned and in addition to the sub-mammary injection of glucose solution, a colonic irrigation of one and a half to two gallons of sodium bicarbonate solution (from 2% to 5%) at 110° F., is given once daily by the drip method. The daily hot pack is continued; a mustard leaf is applied to the abdomen if necessary to relieve the pain and nausea; glucose solution may be given intravenously and also a nutritive enema, three times daily, consisting of a raw egg, four ounces of peptonized milk and one-half ounce of whiskey.

The method employed at the Toronto General Hospital in treating patients suffering from toxemic vomiting is outlined as follows by Dr. J. G. Gallie: “The patient is given as much as she is able to drink. A nutrient enema is given three or four times daily, consisting of six ounces of a 10 per cent. solution of glucose in saline. Bromide and chloral may have to be added to the last nutrient in the evening. A simple enema is given each morning. Nutrients are discontinued when the urine becomes free of acetone bodies. In more severe cases, where fluid cannot be taken by mouth, it may be supplied interstitially or intravenously, a 5 per cent. solution of glucose being used. When vomiting ceases, and solid food can be taken, the feeding is begun very carefully with small quantities of carbohydrates. Lactose is added where possible to any fluid taken. Frequent small meals are then instituted—six between 7 a.m. and 10.30 p.m., thus reducing to the smallest space of time the period of starvation during the twenty-four hours. Protein may be added to the diet when nausea is under control, but fat should be left out for some time.”

Such a course of treatment, quite evidently, is designed to relieve a toxic condition, in which increased elimination is important, and to quiet an irritable nervous system.

As the patient with toxemic vomiting is often very uncomfortable because of a bad taste and dryness of her mouth, some kind of a mouth wash which she finds refreshing should be used frequently. And since a degree of toxicity which is capable of producing such a condition as is described above will almost inevitably produce nervous symptoms, as well, the nurse’s attitude toward her patient must always be one of sympathy, encouragement and optimism.

When the patient’s condition is so desperate that pregnancy is terminated, with the hope of saving her life, ether or nitrous oxide gas, or both, is used as an anesthetic rather than chloroform, which of itself tends to produce a liver necrosis.

Pre-eclamptic Toxemia is the most common of all the toxemias of pregnancy, occurring several times in every hundred pregnancies. It develops more frequently among women who are pregnant for the first time than among those who have borne children, and one attack usually confers an immunity against a recurrence.

As pre-eclamptic toxemia usually responds to treatment, but if neglected, frequently ends in the much more serious disease of eclampsia, the imperative need of supervision and care during pregnancy are once more borne in upon us.

Symptoms. Pre-eclamptic toxemia seldom appears before the second half of pregnancy, usually not until after the sixth or seventh month, and the symptoms vary widely in severity. They may range from headache and nausea, so slight as to cause the patient little or no inconvenience, to coma and death.

The patient may be entirely normal for six or seven months and then notice that her rings and shoes are a little tight, because of the slight swelling of her hands and feet. Puffiness of the eyelids may appear, and other parts of the body may also be slightly swollen. Headache, dizziness, lassitude, drowsiness, depression, apprehension, nausea and vomiting are all symptoms, as also are high blood pressure and a diminished amount of urine, containing albumen. The patient frequently complains of visual disturbance, which may be only a slight blurring, but in severe cases may amount to total blindness.

Other symptoms, when the condition is grave, are epigastric pain; rapid pulse; extreme nervousness and excitement, which may amount almost to insanity; or drowsiness, which grows deeper and deeper until the patient sinks into a coma. Under such conditions, she may die without recovering consciousness, but more frequently, eclampsia ensues. The child may perish as a result of the toxemia and a dead, premature baby be born.

Prevention is of course, the most important aspect of the treatment and is accomplished by means of the pre-natal care and supervision which were described in the last chapter. In this connection must be mentioned again the danger, during pregnancy, of overeating. It is more and more frequently observed that toxemic seizures follow in the wake of a single, large, heavy meal, such as one is so likely to take at Thanksgiving or Christmas time. This is particularly true of patients who have had nausea or who have even slightly disabled kidneys, which, though able to meet the ordinary demands made by pregnancy, are inadequate to cope with the sudden strain imposed by a large meal. In such a case, toxic materials which should be excreted are retained within the body, and the familiar symptoms of toxemia are the result.

Much the same condition is produced by the patient’s getting wet or chilled. The excretory function of the skin is interfered with, under such circumstances, and the kidneys are unable to do enough extra work to make up for the skin’s failure, and again toxic material is retained, instead of being excreted.

Treatment and Nursing Care. As might be expected, the details of treatment and nursing care of a pre-eclamptic patient vary with different doctors and with the severity of the attack. But the essentials of treatment, the country over, may be summed up as rest and elimination, coupled with close watching for unfavorable symptoms.

The surest way to have the patient really rest is to put her to bed, even in mild cases, and recovery is so hastened, thereby, that she is well paid for the temporary inconvenience.

Since it is widely believed that the metabolic disturbance, in toxemia, is related to the nitrogenous part of the diet, the course usually followed in this particular is a reduction of the nitrogen intake. This is accomplished by putting the patient on a very low protein diet or a milk diet, consisting of two quarts of milk daily. This amount of milk provides adequate nourishment, for the time being, and also supplies a large part of the fluid which is needed to promote elimination. In addition to this, however, the patient is given one, or better still, two quarts of water every day, and free saline purges.

Very frequently this treatment is all that is necessary. The blood pressure falls in a few days, the albumen in the urine gradually disappears, the patient completely recovers and in due time has a normal labor.

But in more severe and less amenable cases it is necessary to increase the eliminative treatment and give copious colonic irrigations; sweat baths, in the form of hot packs or hot air baths, and even venesection and saline infusions, in order to relieve the symptoms. Sometimes, even these are not enough and the high blood pressure and albumen, which are probably the most significant symptoms, will continue. If so, and the patient grows worse, or if she simply fails to respond to the treatment, the usual practice is to induce labor. A daily output of five grams of albumen to a litre of urine, and a blood pressure of 200 millimetres are usually regarded as insistent indications that pregnancy should be terminated. Otherwise, eclampsia, always so dreaded, is practically sure to follow and endanger the life of both mother and child.

It may be mentioned here that the normal blood pressure, during the latter part of pregnancy, is about 120 millimetres. A gradual increase to 130, or even 140 millimetres, may not be serious, but a sudden rise or a pressure of 150 millimetres should be regarded with alarm, even though all other symptoms be absent. The reason for this is that eclampsia may, and sometimes does, occur with little or no warning except the high, or suddenly increasing blood pressure.

Eclampsia. Pre-eclamptic toxemia, as the name suggests, is a condition that frequently precedes eclampsia, and the importance of the prevention, early recognition and prompt treatment of this forerunner is due to the seriousness of eclampsia which threatens to ensue. This disease, which may be defined as a toxemia occurring before, during or after labor, is one of the gravest complications which arise in obstetrics. It is usually associated with both tonic and clonic convulsions, unconsciousness and coma.

Patients who have a tendency to kidney trouble and to digestive disturbances, such as so-called “biliousness,” are evidently likely to have eclampsia; and in eclampsia there is a peripheral necrosis of the liver which occurs in no other condition. These facts suggest that possibly when metabolism is proceeding normally, the liver converts certain material, whose retention within the body is inimical to health, into a form which the kidneys can excrete without great effort; that if the liver fails in this function, the kidneys are unable to stand the increased strain put upon them, as is evidenced by casts and albumen which appear in the urine, and the retained material gives rise to toxemia. It is possible that disturbed functions of other glandular organs, such as the thyroid, may play a part in causing eclampsia, but this, too, is only conjecture.

The frequency with which the disease occurs has been variously estimated at from one in 500 to one in 100 cases, apparently being more common in first pregnancies than subsequent ones, but more serious when occurring among women who have had children before. One attack is believed to confer an immunity, or, as Dr. Chipman puts it, “the woman with eclampsia vaccinates herself.” The average death rate from eclampsia is from 20 to 35 per cent. of the mothers and about 50 per cent. of the babies, except where the desired care can be given, either at home or in a hospital, when the mortality is greatly reduced. These figures vary, somewhat, according to the time of the onset, as the disease is usually more fatal if the convulsions occur before or during labor, than afterward.

Some authorities feel, however, that eclampsia is quite as fatal after, as before, labor.

Symptoms. The symptoms, as a rule, are those of pre-eclamptic toxemia which have persisted and grown more severe, accompanied by convulsions and coma. The blood pressure may be from 150 to 250 millimetres and the urine, in addition to showing many and varied casts, contains albumen, which varies in amount from a few grams per litre to more than a hundred in severe cases. In those cases which prove fatal and come to autopsy, there is always found a characteristic, peripheral necrosis of the liver, and since it is found in no other disease it definitely establishes the diagnosis. It is true that this is of no help to the poor woman who died, but it is of help to those investigators who are so earnestly studying the disease with the hope of finding its cause and cure.

Although there are frequently pre-eclamptic symptoms which have grown worse, with or without treatment, it sometimes happens that the patient has no warning discomfort and the first sign of the disease is a convulsion; or a patient who has been treated for pre-eclamptic toxemia may apparently recover, even to the extent of having the albumen disappear from her urine, and suddenly have a convulsion.

Convulsions, which are both tonic and clonic in character, occur in about 99.5 per cent. of all eclamptic cases and are very distressing to watch. They are sometimes preceded by an aura, but often are so unheralded that they may even occur while the patient is asleep. They ordinarily begin with a twitching of the eyelids; the eyes are wide open and staring and the pupils are first contracted and then dilated. The twitching extends to the muscles about the nose and mouth, then to the neck and arms, and so on until the entire body is convulsive. The patient’s face is usually cyanotic and badly distorted, the mouth being drawn to one side; she clenches her fists, rolls her head from side to side and tosses violently about the bed. She is totally unconscious and insensible to light, and during the seizure may not breathe beyond giving one or two struggling gasps. Her head is frequently bent backward, her neck forming a continuous curve with her stiffened, arched back. Another distressing feature is the protruding tongue and the frothy saliva, which is blood stained if the patient is not prevented from biting her tongue by the introduction of some sort of a mouth gag between her teeth.

Such is the typical eclamptic convulsion.

The attacks vary greatly in their intensity and duration. There may be only a few twitches, lasting ten or fifteen seconds or violent convulsions lasting as long as two minutes, their number and severity increasing with the seriousness of the patient’s condition. In mild cases there may be but one or two convulsions, particularly if the onset is either late in labor or postpartum. But as a rule, there are several convulsions; ten, twenty or thirty, and sometimes, though rarely, as many as a hundred.

The patient always goes into a coma after a convulsion and this also varies in length and profundity, her condition during the intervals being very suggestive of the probable outcome of the disease. If the attacks recur frequently, as they usually do in extreme cases, the patient is likely to remain unconscious during the entire interval; but she will usually awaken between attacks that are far apart, and this is regarded as a hopeful sign. The respirations are labored and noisy as a rule, and the pulse full and bounding, in which case the outlook is good. The temperature is often normal, but may go as high as 104° F. or 105° F., dropping rapidly as the attacks subside. But a weak, rapid pulse together with a high temperature, and above all, a persistently high blood pressure, no matter what the other symptoms may be, are always unfavorable.

Concerning the varied results of eclampsia, the opinion seems to be growing that if it develops during late pregnancy, labor is likely to set in and a premature child be born spontaneously; in some cases, however, for reasons already given, labor is induced, while in others the mother dies undelivered. The fetus may die, after which the convulsions practically always cease and the infant is often born later in a macerated state; or the patient may recover, go to term and give birth to a normal, healthy baby.

When eclampsia occurs during labor the pains usually increase in force and frequency, thus hastening delivery, after which the convulsions usually cease. It will be noted that death or expulsion of the fetus is in almost all cases followed by immediate cessation of the symptoms and by ultimate recovery.

Treatment and Nursing Care. There is so little definite information about the cause of eclampsia that there is quite naturally some difference of opinion as to the best methods of curative treatment. Unquestionably, prevention is of first importance and this is accomplished through the watchfulness and care during the antenatal period as described.

Dr. Edgar characterizes eclampsia as a preventable disease, and though an occasional case will develop in spite of preventive treatment the general results achieved tend to bear out his definition. For example, in a series of 1200 maternity cases at Bellevue Hospital during 1920, prenatal care was given to 900 women and not one case of eclampsia occurred among them, while among the remaining 300 women who had not been seen during pregnancy, there were ten eclamptics. It is but fair to bear in mind that as some of these patients were taken into the hospital because of their having eclampsia, the proportion is abnormally high. The Henry Street Settlement reports through its maternity service that there was but one case of eclampsia among 7600 women who were given prenatal care by its nurses in 1920. These figures, contrasted with the average of one case in about every 500 pregnancies, furnish astounding evidence of what can be done through prenatal care in the prevention of this one disease alone.

As to curative treatment, the variations of opinion are after all of little consequence to the nurse, for there is almost entire unanimity concerning the general principles, and it is these that shape the nursing care. Broadly speaking, they comprise effort to dilute the toxic material in the system, promote its elimination through the various excretory channels and quiet the patient’s nervous excitability.