CHAPTER VII. Labor. — Under the term labor includes the physi- (Part 1)

CHAPTER VII. Labor. — Under the term labor includes the physi- ological and mechanical process by means of which the removal of the child and its appendages from the body of the mother takes place. The expulsion of the fetus from the uterus either spontaneously or by artificial means. At the end of nine months the fetus is fully developed, and is expelled from the uterine cavity. This process is known as labor. The pro- cess should be gradual for the safety of both mother and child. Rapid labor is attended with danger tc both. For convenience it is divided into three stages In natural labor the child is expelled spontaneously by the contraction of the uterine and abdominal muscles. After the rupture of the amniotic sack the uterus contracts down directly on the child, forcing and propelling it along the pelvic canal. In mechani- cal or artificial labor the child is removed from the* mother by the use of forceps or other surgical pro- cedure. If such expulsion occurs before the seventh month it is known as abortion or miscarriage : be- tween the seventh and ninth months, premature birth. About two weeks before delivery symptoms of approaching labor manifest themselves. They are false pains, lightening, or the sinking of the fetus head in the pelvic canal, frequent urinations and dif- ficult locomotion. If you are engaged so as to be 59 with your patient several days before expectant labor commences, you should have everything in readiness so there will be no delay or excitement at the all important time. It is during the first stage of labor that the nurse is often summoned, and she should answer the call as promptly as possible so as to have time to make all necessary preparations for the birth of the child without hurry. The obstetrical bag of the nurse should contain : Clinical thermometer. Bath thermometer. Chloroform mask. Medicine dropper. Graduate medicine glass. Glass and rubber catheters. Combination hot water bag and fountain syringe. This is to economize space. A two ounce bottle of fluid extract of er- A four ounce bottle of chlo- roform. Rectal and douche n o z- zels. A sdass douche Fig-. 16 — Combination hot water bag- and foun- tain syringe. nozzel, some physicians prefer them. A pair of blunt-pointed scissors, for cutting the cord. Two pair of artery forceps. 60 A bottle of bichloride of mercury tablets, large size, for making solution. Two hand brushes, with plain wooden backs that can be boiled. Xarrow linen bobkin tape for tying the cord. Hypodermic syringe. Hypodermic tablets of ergotin, strychnine, glonoin, digataline and ergotole. Small package of sterilized cotton. Small package, about two yards of sterilized gauze. Six ounces of green soap. Boric acid, two ounces. Aromatic spirts of ammonia, two ounces. Brandy two ounces. Collodian, two ounces. Nitrate of silver, one ounce, in strength of Gr. V to one ounce of water. Alcohol, two ounces. A glass graduate, holding about four or five ounces for measuring the urine after confinement. One probe. One pair uterine forceps. A small pitcher or granite cup, holding about a pint, to use in irrigating. A pair of infant's scales, a nice little pair about four inches long can now be had at most surgical supply houses, costing about fant's scales. fifty cents. A little hammock, made of soft outing cloth to 61 weigh baby in. See description and illustration of the hammock. Fig-. 18 — Pattern of baby's ham- mock showing- the different parts of same. A pair of rubber gloves A nice little steri- lizer, the length of a pair of delivery for- ceps, and about the width of an ordinary shoe box, can now be had at most surg- gical supply houses, they are made of copper and are so Fig. 19 — Baby's hammock complete. Fig. 20 — A nice small sterilizer that can be conveniently carried. Cost $5.25. convenient, saving much time in trying to find some- thing suitable to boil the doctor's instruments in. All of the other necessities can be packed nicely in the sterilizer and thus it does not take up much space. I have found it very convenient. A pair of reins, see description of them elsewhere. A pair of leggins, made of soft outing cloth to be worn during labor. 62 Fig-. 21 — Obstetrical leggings showing outer and inner side. They are tied with tape back and in front to keep them from slipping down. Fig. 22 — Nurse's or doctor's obstetrical gown. 63 Three dozen safety pins, two dozen large, one dozen medium. Two obstretical gowns, two in case one should be- come very soiled, or in case the doctor may need a second one. A nail file. One soft outing flannel apron to be worn while bathing the baby. Two full uniforms. A supply of record sheets or bedside records for mother and child. Three aprons. Six pair of cuffs, if colored uniforms are worn. One cap ready to put on. One suit of underclothes. Two pair of stockings. Two nightgowns. A supply of handkerchiefs, collars and dress shields. A package of sanitary napkins. A kimona or wrapper of light material and a pair of bedroom slippers. Comb, brush, washcloth, soap, towels, toothbrush and powder. It may seem unnecessary and foolish to attempt such a supply. I have never found it so. Often I have been glad I was so equipped, especially for coun- try practice. It is best to go prepared for emergencies even if we never encounter them. Often life depends upon us being well supplied. Of course, if you are engaged for the case, and your patient has been fur- nished with a list of what she should have in readi- ness, it will not be necessary to furnish or carry in your dress suit case the articles mentioned in the fore- going list that the mother may require for her use. 64 The list is furnished for emergency cases and country practice. The list of articles mentioned for a nurse's wardrobe is not sufficient for an out of town case, the nurse must judge for herself just what and the num- ber of each article needed. It is, also, well for the nurse to have an inventory pinned in the front of her suit case, and place the articles in her satchel in order as they are on the inventory list, in this way she is certain of leaving nothing out that may be needed. Answer an obstetrical call promptly so there will be plenty of time to have everything in readiness for the doctor's arrival without hurry or confusion. Recognition of Labor. — Certain symptoms proceed the outset of labor, beginning ten days or two weeks previous to it when the fetus descends somewhat in the pelvic cavity. At the expiration of two hundred and eighty days, the average woman experiences a different kind of a pain in the back. They stay a min- ute or two and then cease. They occur two or three hours apart. Contractions of the uterus takes place, and the uterus and abdomen gets very hard and tense. As labor approaches the pains become more and more severe and the neck of the womb gets larger. If you would make an examination, you will notice as the cervix, stretches the neck of the womb gets thinner and thinner until it disappears and only a thin ring remains. As soon as the nurse arrives at the house of the patient, she should ascertain if labor has really commenced. That is, of course, if the phy- sician has not been summoned. Sometimes a patient is deceived by false pains, and the sudden emptying of a full bladder involuntary is sometimes mistaken for the amniotic fluid. The accurate recognition of labor is a very important thing for a nurse to know. To [5] 65 ascertain if a patient is in labor or not, place her on her back on the bed. Place your hand on the ab- domen. If labor has commenced the uterus can be felt to contract and relax at almost regular intervals. If labor has not commenced the contractions will not be very pronounced, and if the amniotic sack has ruptured the uterus will assume more the shape of the child, and lose its globular form. The nurse can tell prett)'T well of the progress of labor by the regular- ity and severity of the Uterine contractions, and as soon as she is certain from the character of the pains that labor has commenced she should notify the phy- sician in charge of the case. He may not respond at once, but it is only just and proper he should know his patient is in labor so he can arrange his time and engagements accordingly, and be ready to come, and the nurse know where to find him when needed. In notifying the physician the nurse should tell him how long labor has been going on, how severe the pains are, and how often they occur. As soon as the phy- sician has been notified, the nurse should begin to arrange the room for labor which should be clean and warm, and ample preparations for delivery and after care should be made with strict attention to aseptic details. If labor occurs at night, ample pro- vision for lighting should be made. The best artificial light obtainable should be procured. A drop light is beSt* FALSE AND TRUE LABOR PAINS. True Labor Pains. — The symptom of labor which is noticeable to the patient are pains in the lower por- tion of the body. Expulsive uterine contractions. True pains usually begin in the back, and occur with a regularity almost perfect. In the first stage of labor this pain begins in the back and extends gradually 66 around the body to the pelvic region. These pains are at first faint but annoying, but they became more and more severe as labor proceeds. False Pains. — False pains occur at irregular inter- vals. They are chiefly confined to the lower front and/ sides of the abdomen, never extending around to the back, they are short and ineffective, and are never accompanied by any actual bearing down sensation. They are very often caused by constipation. A saline enema will usually give relief. THE DIFFERENT STAGES OF LABOR. First Stage. — The first stage of labor is the dilation of the cervix. This is a gradual process. It begins with the first pain and lasts until the full dilation of the os. As the os internum opens, the contractions Fig-. 23— Child in the uterus at the beginning- of labor. causes the membranes to descend and press upon the cervical canal. The effects of the uterine contractions is felt directly on the amniotic sack or bag of water in which the child is enclosed. The cervix being the 67 point of least resistance, when the uterus contracts it forces the amniotic sack in the direction of the os, from within outward. This bag of water has very important functions. First it dilates the cervix and vagina evenly and safely ; secondly, it protects the baby from injurious pressure on any one part, because when the uterus contracts, the force exerted presses equally in all directions, and after rupture it lubri- cates the downward passag-e, making the child descend with less effort, and lastly it flushes the vagina, and in case there is infection present, it washes it out. preventing it getting' into baby's eyes. With the advance of labor the pains increase in intensity and frequency. Each succeeding pain increases the dila- tation. In true labor the dilatation progresses gradu- ally. An examination at this period we could easily define the orific of the uterus ; the border of the os or ridge slit lip like opening of the uterus. This ridge becomes well marked. At first it simply separates ; a slit-like opening; gradually it assumes a circular shape. Labor then progresses more rapidly. With each new pain the amniotic sack is pressed down which pro- duces a gradual and even dilatation which continues until the tissues are fully relaxed. During this pro- cess the cervix is often slightly lacerated, and the mucus discharge becomes tinged with blood. This is called the "show." If there is much pure blood with the show, it is abnormal and the physician should be informed of the fact. The show may occur both be- fore or after the rupture of the amniotic sack. Some- times it is the first warning a patient has of approach- ing labor, the sack does not rupture until a few hours before delivery. Then again the sudden rupturing 68 of the amniotic sack is the first warning to the patient, the show does not appear until afterwards. The bursting of the amniotic sack often occurs suddenly, and a quantity of water, varying from a few ounces to several pints escape. Young patients, sometimes. become very much frightened when this occurs for want of knowledge of what is taking place. So it would be wise for the nurse who has a patient preg- nant for the first time to explain this condition to her. I know of two cases where the patient looked for- ward with terror to her approaching delivery, and af- ter thev were well and up again told me how they suffered and how frightened they were because of ignorance. They thought an incision was made in the abdomen and the child extracted in that manner. This only illustrates to us how often a patient must suffer for want of knowledge that a little thought on the part of the nurse may save them. The length of this stage varies a great deal from three to ten hours (Professional experiences). During this stage there is nothing the physician can do. and the nurse employs the time in getting ready for the birth of the child. The bursting of the water or the rupture of the amniotic sack usually marks the end of the first and the beginning of the second stage of labor. When the os is sufficiently dilated the bag usually ruptures and the amniotic fluid escapes. After this the head descends into the vagina. The Toilet of the Patient for Labor. — As soon as labor begins give the patient a warm soap suds enema followed by a warm pitcher bath. This is accomp- lished by the patient standing in the bath tub. The body is Avell drenched with warm water. To accomp- lish this use either a hand spray or pitcher. Then 69 with a bath brush or crash mitten or cloth and green soap all portions of the body are briskly lathered. Particular care is given the area between the ensiform cartilage and the knees. The patient then stands un- der the shower again and all lather is thoroughly re- moved with friction. Either hand spray or pitcher being used. The tub bath is not considered so sterile a procedure as this one, in fact it is now considered a means of infection. The particles washed off of the skin into the water, and the patient sitting in a tub of dirty water it is possible for infection to enter the vagina and cause trouble. If circumstances will not permit the pitcher bath, give a general sponge bath. If it is an emergency case, and there is no time for even a general sponge bath the lower abdomen, but- tocks and genital organs MUST be thoroughly cleaned and disinfected. It may, also, be necessary to use the catheter, owing to the closure of the urethra by pressure of the presenting part. This is, however, not a frequent occurence, and when it is necessary the physician should always be consulted, and great care must be exercised not only to have everything sur- gically clean, but that the secretions of the vagina do not come in contact with the Catheter or you may have serious trouble. The catheter is seldom used, the patient generally voids urine involutarily. Never give a vaginal douche unless directed to do so by the physician in charge of the case, and the nurse should never make a vaginal examination unless told to do so by the attending physician, and before making a vaginal examination the nurse's hands should be cleaned as for a surgical operation, according to di- rections that have been already given or sterile rubber gloves worn. The vulva should, also, be cleaned as 70 a field of operation, as the danger of carrying infection is great. After her bath the patient should have a clean night gown on. Her hair should be combed and braided in two braids. Then have your patient lie on her back in bed, place the douche pan under her, and scrub the lower abdomen, thighs, buttocks, perineum and genitals with green soap and a soft brush or gauze, and particular attention should be given to the removal of any smegma from the clitoris. The hair around the vaginal opening should be cut close to the skin, or better still, if the patient does not object too strongly, the vulva shaved. Then in case of a tear in the perineum there is no delay in repairs, it is easier to keep clean, and less danger of infection in case there are stitches. Care must be taken that no wash water or other solutions runs into the vagina, and in washing the anal region a cloth or cotton pleget that has passed over the anus must not be used around the vulva orifice, but should be thrown away, and a clean one used. The douche pan should now be removed and emptied and re- placed under your patient and she should remain on it while the nurse cleans her hands, according to directions already given. The cleaning of the hands requires about five minutes. After washing and disinfecting the hands throw the covers off