Part 50

=Third Stage.=—The patient has a rest for some minutes. Then the contractions of the uterus continue until the membranes and placenta are expelled. The pains begin again; the uterus is smaller, firm, yet will recoil; it is rounded, and the fundus lies even with the umbilicus. If the fundus is above the umbilicus something is wrong. Painful contractions of the uterus follow and cause a squeezing off of the placenta. There is a flow of blood, the placenta follows, passes out of the vagina, dragging the membranes after it. The fundus sinks, and the uterus, hard, contracted and firm, lies in the pelvis. In some cases it becomes soft, rises up and then relaxes. If it becomes too soft, the relaxation which follows may induce hemorrhage. The uterus should be carefully massaged until it hardens.

=Period of Labor.=—Fourteen hours is a normal range. First stage usually lasts about twelve hours; second stage about one hour, and the third stage from fifteen to thirty minutes.

=Complications of Labor.=—Labor may be brought on by extreme mental anxiety. The child may be born without any actual pain. It may be expelled while the patient has an evacuation of the bowels, especially if the bowel movement has been induced by enemata or a purgative. Children may be born without the usual progression of labor, yet with all normal conditions present. In cases where the mother dies during labor the uterus continues to contract until the child is born about fifteen minutes later. The child in such cases is sometimes saved by a Cesarean section.

CARE OF THE OBSTETRIC PATIENT.

=Diet.=—Diet should be regulated and consist of light, nutritious and predigested foods. Milk should be prepared in various ways palatable to the patient. Wine and fruits and vegetables in season may be included. For malnutritious patients, malt and beef extracts may be added. Starches prepared in fat, and rich pastries should be avoided.

=Elimination.=—The bowels must move regularly, and laxatives may be given if necessary. Alkalies should be given before bedtime, and effervescent powders in the morning. Enemata should not be resorted to unless absolutely necessary, as the sudden expulsion of the contents may produce abortion. The kidneys may be regulated by giving simple diuretics; plenty of pure water is the best. The condition of the kidneys is a most important factor in pregnancy. The urine should be clear and of sufficient quantity. Meats should be eaten but sparingly, as they over-produce albumin.

=Baths.=—Daily bathing in tepid water is very essential to encourage the elimination through the skin and to promote cleanliness. A cold sponge is stimulating and very agreeable to some patients.

=Exercise.=—Exercise should be moderate. Light work about the home may be encouraged, care being had to avoid over-lifting, over-reaching, etc. Walking should be insisted upon, to maintain correct carriage and posture of the body. Outdoor enjoyments may be had if indulged in with discretion. Tiredness may be overcome by the patient lying down on an incline, the head lower than the body, thereby relieving all tension of the muscles and nerves. Any recumbent position for comfort is beneficial.

=Breasts and Nipples.=—Plenty of room should be given to permit full growth and to encourage the nipples to prominence. Their inversion or depression may be remedied by massage and manipulation. No alcohol or other strongly astringent washes should be used. The nipples must not be hardened, but should be kept soft and pliable; cocoa-butter or other healing ointments may be applied. Cracks and fissures not only render nursing difficult or impossible, but may lead to mastitis and subsequent abscess formations. There should be perfect cleanliness, to promote pure secretion and prevent sepsis.

=Pelvic Organs.=—Pelvic organs do not, under normal conditions, require douches. The normal vagina cleanses itself, and a hot douche may induce abortion.

LYING-IN PERIOD.

=Confinement Room.=—A quiet room should be selected, in which there has been no recent sickness and which is not in proximity to any sewerage. The room should be well ventilated, with no draughts, and at a temperature from 65°-75° F. The furnishings should be plain and few as possible. They should consist of a table or two, a few chairs, and a narrow iron bed of medium height. If the bedspring is soft, a few boards may be placed under it to make it firm. If the patient is to be delivered in bed, it should be made up as follows: (1) Long rubber sheet; (2) long muslin sheet; (3) rubber draw-sheet; (4) muslin draw-sheet; (5) a large pad, 3 ft. square and 3 in. thick. All sheets should be fastened with large safety-pins, and the pad left free to draw the patient to either side, if the bed is of the low-and-wide variety commonly used in many homes. The ideal way is to deliver the patient on a settee, or on two tables, covered with a small mattress; the physicians and nurses have less work to do and they work to a better advantage. Moreover, when the patient is carried from the table to her clean, warm bed she gets immediate comfort and avoids the usual disturbance and uncleanliness attending the clearing away of soiled linen, etc.

=Preparatory Treatment for Patient.=—The patient should have a warm bath, and the genitals should be scrubbed thoroughly with soap and water. Shaving the parts is much to be desired if the patient has no objection, then an antiseptic pad should be applied. The nurse must be sure the bladder is empty; it is very important that a dribbling from an over-distended bladder should not be mistaken for frequent urinations; this is to prevent the danger of ruptured bladder from the constant pressure of a contracting uterus; also a distended bladder makes labor hard by interfering with the passage of the head.

=During the First Stage.=—The patient may be out of bed and encouraged to take exercise. She should not walk about too freely before the head is engaged, lest this induce a malpresentation or malposition. The patient’s crying should not be prevented, and she should be told not to press down. She may have a cup of hot water or tea, but no stimulant, as an anesthetic may become necessary.

=During the Second Stage.=—All clothing should be removed but the night-dress. Pin the gown up under the arm, put on perineal drawers, and a sheet around the body, then place the patient in bed. The pain in the back may be relieved by pressure over the sacrum, and the patient should be encouraged to hold her breath. The nurse should now use tact to quiet the patient, having hitherto managed, if possible, to encourage calmness. For cramps in the limbs, the muscles may be moved and firm pressure applied. A handkerchief bound tightly around the affected part may relieve it. A sheet may be tied to either side of the bed, for the patient to grasp, and a block placed at the foot of the bed for a brace for her feet.

=Patient After Labor.=—The soiled skin should be gently and quickly bathed with warm solution, the vulva and perineum carefully cleansed and an antiseptic pad applied. The binder should be pinned firmly about and below the hips, allowing freedom over the upper part of the abdomen. If there is any anxiety that the uterus may relax after kneading it, a tightly folded towel may be placed over the fundus, and kept in position by the binder. A vaginal douche is never given without orders from the physician. External douches of lysol, 1 or 2 per cent., are given three or four times daily until the lochia becomes scant. The patient should be watched during the first few hours for symptoms of hemorrhage. The room should be kept quiet and dark, and light, warm covering be used on the bed. The patient may have a cup of hot water or milk to induce sleep and relieve thirst.

=Diet.=—During the first twelve hours the patient should be kept on liquid diet. On the second day, butter toast, milk toast, oyster stew, and chocolate may be added. On the third day, if the bowels move freely, soups, with rice or barley, and cereal foods may be given. Stewed fruits (omitting those strongly acid) may be included. After the fourth day, fresh fish, a chop, chicken, and pigeon may be given. Even after ordinary diet is ordered, heavy meats and rich pastry should be avoided for a while.

=Bowels.=—The bowels are usually constipated for the first few days. A dose of castor oil may be given, to be followed in six hours by a saline enema. The patient should be encouraged to drink freely of pure water, to secure proper elimination of the kidneys. If the patient can not urinate, after the different methods to produce urination have been tried, she may be catheterized. The urine should be measured for some days to ascertain if the quantity is sufficient.

=Colostrum.=—The first secretion in the breasts contains no nourishment, but is a laxative for the child. The baby should be put to the nipple as soon as the mother has had some sleep and feels rested. Nursing assists the uterine contractions, preventing hemorrhage from the torn placental vessels and cleansing the organs from secretions still being discharged at intervals.

=Breast and Nipples.=—The nipples should be cleansed after each nursing with warm boric solution. If they are cracked and sore a lubricating ointment should be applied and a nipple shield should be used. If the breasts become distended they should be massaged gently every two or three hours, and they may be pumped if necessary. In this state the patient must not have regular liquid diet, and the bowels must be kept freely open with saline laxatives. A compressed binder is comforting and beneficial. If the child, for some reason, does not nurse, the secretion may be dried by an application of belladonna in the form of a plaster, permitting the nipples to protrude through an opening cut into the center of it. The belladonna ointment is good but very unclean. Atropin may be given internally.

=Conditions During which the Child Should Not Nurse.=—Depressed or cracked nipples; inflammation of the breasts; poor health of the mother; marked anemia; kidney or heart disease; nervous or general febrile afflictions; tuberculosis; syphilis.

Menstruation.—If the return flow of the menses occur during the nursing period the milk becomes impure, and the child may suffer from the effects of it. If menstruation takes place normally and the child does not become ill, it is because the mother is strong and can endure the drain upon her system with no other bad result than losing flesh. In such a case it is best to wean the baby, especially after it is nine months old.

CARE OF THE BABY.

=Upon Birth.=—As soon as the eyes are cared for, by flushing them with warm boric solution (the physician may use Credé’s method—1 to 2 per cent. nitrate of silver solution, followed by weak salt solution), the baby should be wrapped in a warm, soft, sterile cloth (cotton flannel), and placed in a warm crib until the mother has been attended to. After that the baby should be anointed with warm olive oil, especially in the groin, axilla, in the folds of the neck and behind the ears. The nurse should then wash and sterilize her hands to dress the cord. Apply alcohol, 95 per cent., and then boric acid powder or any other antiseptic dressing the physician may order; it may be kept in place by a thin flannel binder, going around the abdomen but once and be fastened in the back (not too tightly) by sewing it together. Pins of any kind should be used only where absolutely necessary. The baby should be dressed in as few garments as possible.

=Bathing.=—Until the umbilicus is healed the child should not be put in the full bath. The face, hands, and head may be sponged daily with tepid water. Gently massaging the body every day with warm olive oil, and rubbing with a soft towel, will not only keep the baby clean, but prove beneficial. The genitals should be washed well once daily and sponged after each evacuation of the bowels. During the first few weeks a little oil rubbed into the parts is better than powder; in most cases powder will dry the skin too quickly and rub off the delicate epithelium.

=General Care of the Baby.=—The eyes, the mouth, and navel should be given the usual daily attention. The bowels, if constipated, should be encouraged by small doses of castor oil given with a medicine dropper. If the urinations are not clear and of sufficient quantity the baby may have warm water, about 1 oz. at a time, three or four times daily. Leave the infant with the mother only during the nursing period.

=Nursing the Baby.=—Practical experience is daily upsetting the theory that a set of rules and regulations can be laid down and followed for the nursing of all babies; that nursing must be done at certain hours and after certain intervals. While babies are alike in nearly every respect, speaking physiologically, there are only a few who can be awakened at regular intervals to be nursed by the mother or fed by the bottle. Some babies can not be awakened sufficiently for nursing, even after four or five hours’ sleep. Others will nurse for twenty minutes (the rules say it should not be longer than ten minutes) at two- or three-hour intervals during the day and then sleep all night.

Of course, where the child can be fed regularly, this helps the mother to regulate her own habits, and is comforting to all concerned. Therefore, nurses should not lack in determination to encourage such a system. But no such regularity should be insisted upon where both baby and mother suffer during the interval when nursing is denied; the former, hungry and crying lustily, and the mother under a nervous strain that is harmful to both. Let there be no hard-and-fast rules. Babies who feed as often as they feel like it (being allowed proper, though not necessarily long, intervals for digestion) generally suffer no ill effects and are healthy and strong. Mother’s milk, the natural feeding, should always be given, rather than any artificial food, when the supply is sufficient and good.