In general, the nursing care during the puerperium is much the same as that which is given to a surgical patient, with special attention to the breasts and perineum and a sustained effort to prevent complications and restore the mother to a normal state of health in due time.

As the nurse doubtless realizes by this time, the principal complications to guard against during the puerperium are hemorrhage from the still raw area, where the placenta was attached to the inner surface of the uterus; infection of the birth canal; breast abscesses; displacement of the uterus and subinvolution, or failure of the uterus to return to its normal size and condition in the usual length of time.

In addition to guarding against these definite complications, the nurse must help to save her patient from the less tangible, but perhaps equally injurious effects of fatigue of mind and body. As many young mothers are in a more or less unstable, excitable condition after the baby’s birth, the beneficial effect of promoting a tranquil and contented state of mind can scarcely be overestimated.

The doctor may be ever so tactful and cheering and sustaining, but his contacts with the patient are short and infrequent as compared with the nurse’s constant companionship. She can, therefore, by her attitude, manner and conduct practically create or destroy the atmosphere that is necessary to her patient’s welfare.

In order to give the best and most helpful service the nurse must try from the very beginning to understand her patient as an individual and adapt herself to the patient’s temperament. Some women are rested and soothed by being talked with, read to, diverted and amused in one way or another, during most of the time, and will grow nervous and depressed if left to their own devices. Others, who have greater resources within themselves are happier and better off when left to themselves a good deal, and given an opportunity to think things over. Some women are much subdued as the consciousness of their motherhood grows upon them, and they feel a kind of awe and wonder about this baby that they begin to realize is their own. It is a big experience, this one of motherhood, full of promise and responsibilities, and the young mother herself very often wants to think it out. She will enjoy talking when she wants to talk, but may be irritated and exhausted by a nurse who tries to entertain her all of the time.

For this reason, the most conscientious and painstaking nurse imaginable may destroy her usefulness, by adopting the wrong attitude toward her patient during this period of enforced intimacy. Some women want, and even need to be indulged and petted; but, on the other hand, a certain type of reserved and dignified woman is affronted by such attention or by the easy air of familiarity that another courts; one patient is exhausted by the unvarying punctuality and precision of a conscientious, but unadaptable nurse, while that very punctuality and precision is satisfying and restful to another.

It is not a simple matter to sound the depths of a patient’s personality, for they are all complex and each one is peculiar to herself. That fact must not be overlooked for each patient is an entirely new and different problem and not like any other that the nurse has had before. But the nurse who is sincere and sympathetic and who earnestly tries to put herself in her patient’s place and see things from her standpoint, will, by virtue of that very attitude, accomplish much toward sensing the patient’s temperament and establishing harmonious relations. Moreover, the patient, herself, will all unconsciously make something of an adjustment to the nurse when she feels the nurse’s sincerity and her eagerness to be of service.

One factor in shaping the young mother’s state of mind, which the nurse must take into account is that the entire scheme and purpose of her patient’s life have been changed. She has been plunged very suddenly into a wholly new condition and her reaction to this change will depend upon her temperament, disposition and habits of adjustment.

She has spent nine months looking forward to an event that has been consummated; she has spent nine months in a state of more or less apprehension and suspense that have been abruptly ended, and we know that it is quite natural for any one to experience a letting down, or something akin to collapse, when long-continued uncertainty is ended, even though it ends happily.

And as recovery progresses the patient becomes aware, perhaps only vaguely, of another change which is not always a welcome one. For nine months she has been the centre of interest in her immediate circle; she has been the object of unremitting concern and solicitude, and much as she and her family may have tried to keep her life normal, she and her needs have constantly been given the first consideration. The very mystery of the child developing within her has created an attitude of respect, almost of reverence, which was never her portion before. In every way she has been shielded, protected and cared for, and all eyes, including her own, have steadily looked forward to the event for which this care has been preparing her—her ordeal of childbirth and the coming of her baby.

And now her ordeal is over. Her baby is here. Every one may be said to be breathing easily at last and they are no longer apprehensive and absorbingly interested in her. As a result the young mother will soon become simply one of the family and the community, and will cease to be the centre of reverential interest and solicitude.

It is scarcely human to welcome such a change in one’s state, and though in all probability very few mothers are conscious of resenting it, very many actually do. And for this reason very many unwittingly cling to a rôle of semi-invalidism. It is entirely unconscious on their part and it is also very human and natural.

To aid in the process of bracing up such a young woman to resume her former life and to meet the demands which it imposes; or to protect another patient of the eager, buoyant type from exposing herself too early to the onslaughts made by everyday life, is far from being a simple task, and to meet it no one rule can be laid down. There are all of the variations and degrees between the timid or self-indulgent woman, who must be encouraged and spurred on, and the too active, ambitious patient, who must be steadied and held back for a time.

But here, again, this is simply a part of the nurse’s duty; one aspect which makes nursing the gratifying service that it is.

Fortunately the majority of young mothers are happy and normal in their outlook and may be kept so by the exercise of an average amount of tact and amiability on the part of the nurse. The actual physical care of the patient during the puerperium is a fairly simple matter for the well trained nurse. She will find, however, that in hospitals, private practice and public-health work alike there will be wide differences in the treatment given by different doctors, during this period, just as there were during pregnancy and labor, and she will have to carry out the prescribed directions enthusiastically and loyally no matter how they vary from those of the doctors who helped in her training.

The details of the care will be indicated by the individual doctor, but the general, underlying principles—cleanliness, watchfulness, adaptability and sympathetic understanding will apply to the nursing of all patients. The most notable differences of opinion relate to the care of the breasts, the perineum and the use of abdominal binders, the accepted routine for the general nursing of average, normal cases being fairly uniform the country over.

NURSING CARE

As has been stated, the general nursing care of the puerperal patient is much the same as that given to any surgical patient, with such adaptations as are indicated by the condition and needs of the young mother.

Position in Bed. The question of the patient’s position in bed is probably the first one that presents itself to the nurse after that first hour when the patient must be kept flat on her back and the fundus closely watched. She should continue to lie quietly on her back for a few hours, with only a small pillow under her head, as moving about may cause hemorrhage. Some doctors permit the patient to turn from side to side at will after a few hours of quiet, while others do not allow this for two or three days particularly if the patient has perineal stitches, unless her knees are tightly bound together. Their reason for this precaution is fear that the stitches may be torn out if the thighs are separated and also that air may gain access to the uterine vessels, through the relaxed and gaping birth canal, and produce air embolism. It is a routine in some hospitals to keep the head of the patient’s bed elevated during the first week, to promote drainage, but as a rule it is in the usual position.

Quite commonly the patient is encouraged to lie first on one side and then on the other, after she begins to move about in bed unassisted, and then face downward at intervals, in order to change the position of the uterus and thus tend to prevent backward displacement.

In many hospitals, it is part of the daily routine to measure and record the height of the fundus (Fig. 116) above the symphysis, in addition to noting the character, amount and odor of the lochia, in order to judge if involution is progressing normally. A uterus that does not remain firm and does not steadily shrink in size and descend into the pelvis is not involuting properly, and the usual remedy is more rest and a longer stay in bed, with an icecap over the fundus.

Sitting Up. Except when there are perineal stitches or the temperature has been elevated at some time following delivery, the patient is ordinarily allowed to sit up in bed about the sixth or eighth day. If the lochia is normal, the uterus firm and in the proper position in the abdomen and her general condition satisfactory, she is allowed to sit up in a chair for a little while about the ninth or tenth day. Some patients are able to sit up for an hour the first time without being tired, but it is often better for them to sit up for a few moments morning and afternoon on the first day, than for a longer time at one stretch. The patient is usually allowed to sit up an hour longer on each successive day and to walk a few steps on the third or fourth day after getting up.

A patient with stitches does not usually sit up in bed until the ninth or tenth day, when the stitches are removed, sitting up in a chair for an hour, two or three days later. If she has had fever, the time at which she may sit up will of necessity depend upon her condition.

The return to normal life must be very gradual and this also must be regulated by the patient’s general condition and her recuperative powers. A pinkish or red discharge or backache should be taken as warnings against standing or walking or working. The possible consequences of ignoring these warnings and being up and about too soon, may be displacement, even prolapse of the uterus; hemorrhage, from dislodgment of clots in the uterine vessels; metritis or endometritis.

It is not a good plan, as a rule, for the patient to go up and down stairs until the baby is about four weeks old, nor wholly to resume her normal activities within six or eight weeks after delivery.

In addition to this sustained, general care, it is a customary preventive measure for the doctor to make a thorough pelvic examination from four to six weeks after delivery. A slight abnormality, if detected at this time may usually be corrected with little difficulty, but if allowed to persist may result in chronic invalidism or necessitate an operation. If the uterus is not properly involuted, for example, or the perineum is found to be flabby, more rest in bed is indicated; while a uterine displacement, which seems to be present in about a third of all cases, usually may be corrected by the adjustment of a pessary.

The time of sitting up, of getting up and of walking about varies so with the individual, therefore, that it is not possible to describe a definite routine, for some patients recover slowly and would be injured by getting up and about at a period which would be entirely safe and normal for the majority. It must be determined in each case by the condition of the uterus, the appearance and amount of the lochia and the patient’s general condition.

Quite evidently, then, much ill health and many gynecological operations may be prevented by caution, prudence and good care during the first few days and weeks after the baby’s birth, while the patient returns to a normal mode of living.

The Daily Bath. During the first week or two the patient’s skin must aid in excreting fluids from the edematous tissues throughout the body and broken down products from the involuting uterus. Therefore she should have a bath of warm water and soap every day, to remove material already on the surface and stimulate the skin to further activity, and an alcohol rub at night, if possible. It is important for the nurse to remember, while bathing her patient, that she is perspiring freely and therefore may be easily chilled if not well protected.

It is often a good plan to have the patient, without stitches, begin to bathe herself in bed, after the third or fourth day, for the sake of the exercise, and also the encouragement that it offers. When all is going well, tub-bathing is usually resumed by the third or fourth week.

Diet. Opinions as to diet vary slightly with different doctors and in different hospitals, but in general, a patient in good condition is given liquid food during the first twelve to twenty-four hours after delivery; then a soft diet for a day or two, a nourishing, light diet being resumed by the third or fourth day, or after the bowels have moved freely.

The patient will usually have little appetite, at first, and will have to be tempted by small amounts of invitingly served food. The factors which the nurse must bear in mind when arranging the patient’s dietary are the general nutrition of the mother; the desirability of minimizing her loss of weight during the puerperium; increasing her strength and, particularly, of promoting the function of her breasts, in order to produce milk of a quality and quantity adequate to nourish the baby.

The best producer of such milk is a diet consisting largely of milk, eggs, leafy vegetables and fresh fruits, taken with an appetite that is made keen by constant fresh air. The nurse will do well to convince her patient of this, in addition to bearing it in mind herself, and to place little reliance on so-called milk producing foods.

The young mother’s dietary may well be made up from the groups of foods that are suitable for the expectant mother. (See Chapter VI). At this time, as during pregnancy, she must avoid all food which may produce any form of indigestion, but for the baby’s sake, now, as well as her own. While it is not generally believed, to-day, that there are many, if any articles of diet which in themselves affect the mother’s milk unfavorably, it is generally conceded that a derangement of her digestion may, and usually does, have a deleterious effect upon her milk, and therefore upon the baby.

The old, and widespread, belief that certain substances from such highly flavored vegetables as onions, cabbage, turnips and garlic are excreted through the milk, to the baby’s detriment, is not given general credence to-day. On the other hand, it is known, however, that certain protective substances in certain foods are excreted through the milk, to the baby’s distinct advantage, and it is therefore, important that the mother’s diet should regularly contain those articles of food which contain them. These foods are milk; egg yolk; glandular organs, such as sweet-breads, kidneys and liver; the green salads, such as lettuce, romaine, endive and cress and the citrus fruits, or oranges, grapefruit and lemons.

These are called “protective foods” because they protect the body against the so-called deficiency diseases known as scurvy, beri-beri, xerophthalmia, which with rickets and pellagra are discussed in the chapter on Nutrition. It is possible for a baby who nurses at the breast of a woman whose diet is poor in protective foods, to be so insufficiently nourished, in some particular, as to be on the border line of one of these diseases, or even to develop the disease itself. This is one reason for the statement that the nursing mother must “eat for two.”

Certain drugs are excreted through the milk and may affect the baby in the same way as though they were administered directly, for example: salicylic acid, potassium iodid, lead, mercury, iron, arsenic, atropine, chloral, alcohol and opium.^[9]

In addition to her food the nursing mother should have an abundance of water to drink, and to facilitate this it is a good plan to keep a pitcher or thermos bottle of water on the bedside table, and replenish it regularly, every four hours.

In general, the young mother should have light, nourishing, easily digestible food, with little, if any meat; an abundance of cereals, creamed dishes, creamed soups, eggs, salads and the fresh fruits and vegetables which ordinarily agree with her; at least a quart of milk, daily, in addition to that which is used in preparing her meals, and an abundance of water to drink.

The Bowels. The puerperal patient is almost always constipated, and needs assistance in regaining regularity in the movements of her bowels.

The routine use of cathartics and enemata varies, but it is very common to give an enema on the second morning after delivery or castor oil or Rochelle salts, followed by an enema if necessary. After this, a mild cathartic or a low enema is given often enough to produce a daily movement when this is not accomplished by means of the diet.

Some doctors, however, prefer that the bowels shall not move for four or five days after delivery, believing that this delay reduces the danger of infection from the intestinal contents, which are swarming with organisms, particularly the colon bacillus.

In cases of third degree tears, catharsis is practically always delayed for four to six days in order that the torn edges of the rectal sphincter may become well united before being strained by a bowel movement. In these cases an enema of six or eight ounces of warm olive oil is often given and the patient encouraged to retain it over night, in order to soften the contents of the rectum and lessen the strain and irritation of evacuation.

The Bladder. The question of helping the patient to void after delivery is one of extreme importance, because she will almost certainly have difficulty in emptying her bladder, and yet catheterization is not to be resorted to unless absolutely necessary. As a rule the patient should be encouraged to try to void from four to eight hours after delivery. If she is unable to do so at first there are several aids which the nurse should employ before admitting the patient’s inability to empty her bladder. Inducing her to drink copious amounts of hot fluids is the first step. Very often she will then void if placed upon a bedpan containing water hot enough to give off steam, and more warm, sterile water is poured directly upon the urethral outlet; or hot and cold sterile water may be dashed, alternately, upon the meatus.

The sound of running water is often helpful as well as the application of hot stupes over the supra-pubic region. When everything else fails, success frequently follows the application of a partly filled hot-water bottle over the bladder, held in place by a tight binder, particularly if the patient rests upon a pan of steaming water at the same time.

The danger of infecting the bladder, by carrying lochia into it upon the catheter, is so great that some doctors choose what they regard as the lesser of two evils, and allow the patient to be assisted to the sitting position, if she has not a serious tear. Not infrequently the patient’s inability to void is due to the fact that she is unaccustomed to using a bedpan, and would have difficulty in using one under any conditions, but is able to void while sitting up. As the danger of infection is greater two or three days after delivery than at first, because of the beginning decomposition of the lochia, it is very evidently important to help the patient to establish the habit of voiding from the beginning, for if she is catheterized once there is great likelihood that she will need to have it continued for some days.

If the first attempts are unsuccessful, therefore, but the patient thinks that she may be able to void later, if the efforts are repeated, catheterization is sometimes delayed for as long as sixteen to eighteen hours after delivery in the hope that it may be avoided altogether.

When the most persistent and painstaking efforts fail, and catheterization is necessary, the nurse must remember the extreme gravity of her responsibility and preserve asepsis throughout the procedure. Although there is extreme danger of infection, it can be prevented as a rule, and its occurrence is therefore regarded as almost inexcusable.

In preparing for catheterization, the nurse should drape the patient as for a vaginal examination, making sure that she is warmly covered, and place her on a sterile douche- or bedpan. If it is done at night she should place the light in a position at once safe and advantageous. She should have at hand on a tray: sterile forceps; cotton pledgets; two glass catheters (in case one should be broken or become contaminated); a disinfecting solution such as bichlorid, 1–4,000 or lysol 1 per cent.; a sterile receptacle in which to receive the urine; sterile towels and a dressing basin or paper bag for the used pledgets.

The preparation of the nurse’s hands, at this point, varies in different hospitals, but always the greatest care is taken to bring nothing unsterile in contact with the vulva and meatus.

According to one method, the nurse scrubs her hands for three minutes and prepares the patient as for a vaginal examination, removes the douche pan and places a sterile towel over the vulva. She then scrubs and soaks her hands as described in Chapter XII, puts on sterile gloves, places a sterile towel over the patient’s abdomen and slips one under her hips. She should then separate the labia with the gloved fingers of the left hand, drawing the fingers upward a little to make the meatus more prominent. The inner surface of the labia is then bathed with pledgets soaked with the disinfecting solution, with downward strokes, each pledget being used but once. Five or six pledgets should be used, one after the other, to sponge the meatus, each pledget being placed squarely against the orifice, without touching the adjacent tissues, and given a slight, downward twisting motion and discarded. The bowl may then be placed in position to receive the urine, and the catheter picked up with the fingers, by its open end. The rounded end must be carefully inspected to insure against using one that is cracked or broken, after which it is slowly and gently introduced into the urethra for two or three inches. If the urine does not flow freely the catheter may be slightly withdrawn and light pressure made upon the bladder.

Before removing the catheter the nurse must locate the fundus and assure herself that it is in a proper position. If it is pushed up or to one side she will know that the bladder is still distended, and that more urine must be withdrawn. After the bladder has been emptied the nurse should place one finger over the open end of the catheter and remove it slowly.

Another method of catheterization differs from the one just described, in the preparation of the nurse’s hands. In this instance she simply washes her hands well with soap and hot water and wears neither gloves nor finger cots.

She bathes the vulva with pledgets and an antiseptic solution, using forceps, and then separates the labia with two dry pledgets, one each under forefinger and thumb of the left hand, and proceeds as above. It will be observed that the nurse avoids touching the inner surface of the labia or the meatus with anything but sterile pledgets and the sterile catheter. The advantage of this procedure is that it is accomplished quickly and with the minimum of disturbance to the patient.

A distended bladder may so easily occur unless the patient is carefully observed during the puerperium that the nurse should charge herself to watch for this complication. She should give the patient a bedpan every four hours, note the contour of the abdomen and measure the urine during the first week, remembering that the patient should void considerably more than the average amount, both because of the amount of milk and water that she is taking, and the fluid which she is eliminating from her tissues. The importance of measuring the urine lies in the fact that though the patient may void fairly regularly she may not empty her bladder, and thus enough urine may accumulate to distend it.

The temperature, pulse and respirations are usually taken and recorded every four hours for the first five or six days and then two or three times daily, if normal. If the temperature is above normal at any time, the nurse should take it every two hours until it becomes normal and notify the doctor immediately if it goes as high as 100.4° F., or if the pulse reaches 100.

Care of the Perineum. The best way of caring for the perineum, during the first week or ten days after delivery, is a moot question, and the nurse may find herself sorely perplexed by the widely divergent instructions of different doctors who have excellent results, unless she goes back of the details themselves and recognizes their purpose. She will then see that there is entire agreement about the importance of protecting the patient against infection, at this time, when infection may so easily occur. And so far as the nurse is concerned, this means cleanliness as to methods and appliances, when making perineal dressings, and extreme precaution against conveying infection to her patient. The minimum requisites for this are that the bedpan shall be sterilized, by steam or boiling, at least once a day, and well scrubbed and scalded after each time that it is used, and that the nurse shall at least scrub her hands with soap and hot water before making each perineal dressing, and apply only sterile pads.

After the perineum is bathed, immediately following delivery, the usual practice is to apply a sterile pad, after which a fresh one is applied as often as necessary at first, every four hours during the first week and subsequently every eight hours. When the dressing is changed, and after each voiding and defecation, the perineum is bathed with sterile pledgets and some such antiseptic solution as bichlorid 1–2,000 or lysol ½ per cent. or 1 per cent. (Figs. 117 and 118.) The soiled pad must always be removed from above downward and the bathing also directed toward the rectum, each pledget being used for one stroke only. The rectum is bathed last, a fresh sterile pad applied and the patient’s hips and back thoroughly dried.

The nurse may be required to scrub and soak her hands, wear sterile gloves and hold the pledgets in forceps when bathing the perineum, the object of such precautions being, quite clearly, to avoid infecting the patient from without, for the inner surface of the uterus is still regarded as an open wound.

Some obstetricians believe that the perineal pad is a menace, since it slips and moves about, and thus may transfer infective material from the anus to the vagina. Accordingly, they forbid the use of all perineal dressings and instead have large, sterile, absorbent pads slipped under the patient’s hips to receive the lochia, the pads being changed as often as necessary. This is the practice at the Brooklyn Hospital, for example, where the nurse bathes the vulva with lysol 1 per cent., placing the patient on a sterile bedpan, using sterile forceps and cotton swabs and wearing sterile gloves while making the dressing.

Another method is to place the patient on a sterile bedpan, remove the pad and with gloved hands pour from a sterile pitcher a warm antiseptic solution over the groin and outside of the vulva; then to separate the labia and pour the solution between them, in some instances pressing a dry, sterile pledgets to the vaginal orifice during the irrigation.