The supra-pubic region and abdomen are scrubbed across, back and forth, working up from the symphysis; the strokes on the thighs are up and down; in the groin, down toward the rectum, and away from the vagina, never toward it, and fluids poured upon the vulval region must never run into the vagina from over surrounding skin. A sponge or scrub ball must be discarded after approaching the rectum, or stroking away from the vagina in any direction. Some obstetricians instruct the nurse to place a firm, sterile cotton pad or scrub ball between the labia, against the vaginal opening while scrubbing and flushing the adjacent areas, to preclude the possibility of introducing fluids. But with a painstaking nurse this is scarcely necessary.

After the surrounding areas have been prepared, the labia are separated and the inner surfaces scrubbed, first across, then from above downward, and flushed by pouring the solution directly between the folds. After the patient has been given this preparation, a dry sterile towel or pad is placed over the vulva; the douche pan is removed, the back and hips are dried, after which the patient is so draped with a clean sheet that only the perineal region is exposed, and a sterile towel is slipped under the buttocks. (Fig. 75.)

To summarize the preparation for vaginal examination or delivery:

1.

Trim nails and scrub hands with soap and hot water.

2.

Shave vulva.

3.

Scrub and soak hands.

4.

Scrub vulva, inner surface of thighs and lower abdomen with green soap and sterile water, alcohol, 70%, and lastly bichloride 1–1000 or lysol 1% or 2%, using sterile sponges and taking care not to contaminate vulva from surrounding fields.

5.

Cover vulva with sterile towel or pad.

This may be taken as a description of a fairly typical method of preparing a patient for vaginal examination or for delivery, which is widely employed and with satisfactory results. But it is by no means the only satisfactory procedure, for many other and different methods of preparation also are followed by excellent results, as measured by the patient’s temperature during the puerperium.

The details of preparation vary so greatly, even among different doctors in the same hospital, that the nurse will simply have to bear in mind the general principles of asepsis and antisepsis, and adjust herself to the practices of the individual doctor. And she must remember that in spite of the best planning, there will be emergencies and precipitate labors, when the preparation will necessarily be modified, and sometimes so curtailed that even the bath and enema are omitted.

But in all cases the nurse can, and must, bear in mind that on one point there is virtually no difference of opinion among obstetricians of to-day; and that is the imperative necessity of having everything sterile that is brought to the perineal region or used in any way in connection with the delivery, or as nearly sterile as is possible under the circumstances.

By many doctors this is considered the most important factor, as to surgical cleanliness, in the entire preparation. In their opinion the local preparation of the patient may, with safety, be restricted to clipping the pubic hairs (instead of shaving), and scrubbing the vulva with only soap and water. But these doctors believe at the same time that the patient is dangerously susceptible to infection which may be conveyed to her from without, and accordingly they do not permit vaginal examinations to be made during labor, and make the most exacting demands concerning the maintenance of perfect surgical technique, by all who assist with the delivery.

In this connection, much depends upon the actual sterilization of the rubber gloves, either by boiling or by steam under pressure; and the method of putting on the gloves, in order that once having been sterilized, they may be kept so. It is useless to attempt to sterilize gloves by boiling, if they are thrown loosely into a kettle of water. There will practically always be enough air in the fingers to keep at least a part of the gloves out of the water, and consequently unaffected by its heat. They should be put into a covered wire basket that will be entirely submerged, or they may be wrapped in a towel, the weight of which will carry them below the surface of the water (Fig. 76), and insure their being completely covered while boiling, which should continue for ten to fifteen minutes. The doctor will usually want boiled gloves placed in a large basin of bichlorid solution, 1–1,000, or lysol 2 per cent., from which he may remove them after scrubbing his hands. If dry gloves are used, there should be in readiness a sterile towel and powder with which to dry and powder the hands before putting on the gloves. (Fig. 77.)

Whether boiled or steamed, the cuffs of the gloves should first be turned up toward the hand, to make it possible to put them on without touching the glove fingers with ungloved hands. (Fig. 78.) For no matter how long and carefully the hands are scrubbed and soaked, they cannot be made absolutely sterile, and therefore, in relation to the gloves which are sterile, the bare hands must always be regarded as unclean. Too much thought and attention cannot be given to the sterilization and handling of the gloves, for the patient’s very life may depend upon their aseptic condition.

After the doctor has seen the patient, the nurse will make observations and communicate with him in accordance with instructions which she must make sure to obtain from him at that time. Many doctors wish to be with a primipara continuously from the time the cervix is completely dilated, and with multiparæ after it is half dilated. But that, of course, is a matter which each doctor decides for himself. The nurse’s responsibility is to learn his wishes.

Watchfulness, then, is of extreme importance; watching for symptoms of complications or change in the patient’s condition, and watching the progress of labor in order to keep the doctor fully informed about his patient’s condition. Nurses are very frequently taught to make rectal examinations for the sake of increasing the value of their assistance in this respect.

Although unexpected symptoms do not, as a rule, develop suddenly during the first stage, the nurse must be none the less vigilant for them. The doctor should be notified if the pains suddenly grow either more or less frequent, or more or less severe; if there is any bulging of the perineum; if the membranes rupture; if there is any bleeding or a prolapsed cord; if there is extreme restlessness or any evidence of unusual distress; a rising temperature or pulse; a temperature of 100° F. or a pulse of more than 100 or less than 60; a fetal heart rate of more than 150 or less than 116, or any marked change of any kind in the patient’s condition.

During the latter part of the first stage, and during the second stage, the patient has an almost continuous desire to empty her bowels, because of pressure made upon the rectum by the descending head. This is another point which the nurse explain to her patient, in assuring her that frequent attempts to use the bed-pan will give no relief.

The end of the first stage is reached when the cervix is fully dilated, at which time the pains occur about every two minutes, are stronger and more severe, and the patient begins to feel like bearing down. The membranes frequently rupture at this point and the vaginal discharge is blood tinged. The patient should remain in bed and not be left alone from this time on.

To sum up the nurse’s duties during the first stage of labor, when the patient is almost entirely in the nurse’s care:

1.

She must be a sympathetic, encouraging friend to the patient.

2.

She must help the patient to preserve her strength by giving her light nourishment about every four hours; by advising her not to bear down; not to exhaust herself by walking about too much but to lie down when tired.

3.

She must watch the progress of labor and watch for symptoms of complications.

4.

She must employ strictest aseptic and antiseptic methods.

5.

She must prepare for the birth of the baby.

SECOND STAGE

The second stage is shorter, harder and more perilous than the first. The uterine contractions are stronger; more frequent and more expulsive, and the baby steadily curves and rotates its way down through the birth canal.

With the onset of the second stage the nurse should complete the preparations for the baby’s birth, bearing in mind that with a primipara the baby probably will not come for an hour and a half or two hours, but may come in half an hour or less if the patient is a multipara. Everything which is to be used should be conveniently placed, but the packages are not necessarily opened at this time.

In addition to the sterile dressings, basins, gloves, instruments and various other articles which have been enumerated, the nurse must remember that there should be for the baby a box or basket lined with a blanket and containing one, or preferably two, hot-water bottles at 125° F.; in hospitals, an adhesive strip for the baby’s name or a name necklace; a binder of flannel or sterile gauze, according to the custom of the doctor; sterile olive oil or albolene for the first oiling and one or two tubs, in case the baby needs to be resuscitated.

There will be needed, also, a covered basin for the placenta; chloroform and an inhaler; Wassermann tubes, for those doctors who make this test as a routine; hypodermic syringe and needles, with pituitrin, ergotole and drugs for stimulation which the doctor may specify. (Figs. 79, 80.)

In the meantime, the force and frequency of the pains should be noted, and some doctors require a record of both the fetal and maternal pulse rate every half hour, and notification if the baby’s is over 150 or below 116, or the mother’s over 100 or below 60. Extreme restlessness, distress, vaginal bleeding, prolapsed cord, a temperature of 100° F., or any marked change must be communicated to the doctor immediately, if it occurs before he has started for his patient.

The patient may complain of intense pain in her back and cramps in her legs during the second stage. Pressure made by the nurse’s hand, or a small pillow slipped under the small of the back will frequently relieve the backache, while cramps in the legs may be relieved by straightening, and slightly elevating the leg, and rubbing it while in that position. As these pains are usually due to pressure they have no serious significance and subside as soon as the child is born.