Chapter IX. COMPLICATIONS DURING LABOR. (Part 1)

Chapter IX. COMPLICATIONS DURING LABOR. Management of the Birth of the Child in the Ab- sence of the Physician. — The most common compli- cation the nurse is apt to meet is the deliver of the child before the arrival of the physician. It is perhaps more often in obstetrics than in any other illness that the nurse is called upon to assume, in the absence of the physician, the responsibilities that belong to him. She should understand the condition of things preceding labor. There are certain things she should know and understand. She should know how to tell the part presenting by external examination early in labor, and if it seems possible the child will be born before the arrival of the physician, she should know the position of the child. To make an internal examination introduce the fingers into the vagina during an interval be- tween pains until it reaches the open mouth of the uterus. The membranes are then lax, and the pre- senting part of the fetus head can be felt. Position refers to the part of the child's head presented. We can tell the position of the child by the anterior fon- tanelles, the soft, triangular opening in the skull. This name was given the opening because the beat- ing of the blood in the brain can be seen at this point in the rise and fall of the membranes covering the 132 brain, as this movement resembles the rise and fall of a fountain, it has been called the fountanelles. It often happens that the nurse will be alone with the patient during labor, the physician does not reach the house in time and the nurse is called upon to as- sist in the delivery of the child without the assistance of the doctor, and she should have sufficient knowl- edge of this branch of nursing to be able to conduct it without assistance in an emergency, as the life of both mother and child will often depend upon her skill. The nurse should not assume this responsibil- ity alone. It is best, when the physician cannot be had, to call someone else in. While in perfectly nor- mal cases everything may be alright and there is no danger, if the nurse should be unfortunate and lose the baby she might be unjustly blamed. And if she forceably holds back or prevents the birth of the head, it might injure both mother and child, she may hold it back as she has seen the physician do, so as to give the perineum time to stretch, and if the patient is having very hard bearing down pains, the nurse may place her on her side and ask her not to bear down during a pain, and give her a little chloroform, and the progress may be retarded if the head is not visible at the vulva. When the child is about to be born, and the physician has not arrived, place the patient on her back with knees drawn up. Then the nurse cleans her hands as for a surgical operation, ac- cording to directions already given. Be sure the}' are well scrubbed and clean. After immerging them for a few minutes in a one to two thousand bichloride of mercury solution, clean the patient's external geni- tals, after which the patient is brought across the bed towards the light. 133 The clothing should be thrown back and the nurse should watch the perineum. Place a basin of bi- chloride solution, in the strength of one in two thou- sand, with pieces of sterilized cotton in it to use to wipe away any discharges that may escape from the anus, care being taken in doing so not to soil the hands. The nurse disinfects her hands thoroughly and assumes the position of the physician. She should observe the same rules in regard to the preservation of the perineum as the physician does, namely, allow the head to come through slowly and between pains. About an hour and a half before the head is born the pelvic floor bulges out during a pain and the child's head becomes plainly visible. The nurse watches the rectum, which now opens, that no discharge escapes. The basins with the cotton and solution should be close at hand and she wipes all discharge from the vulva with antiseptic solution. As the child's head becomes visible at the vulva dur- ing a pain and causes it to bulge outward, the nurse should gentlv restrain the birth of the head by pres- sure on it with her fingers during a pain. Pressure upon the perineum during a pain to diminish the ten- sion in the medium line where rupture usually oc- curs. To accomplish this, when the presenting part begins to distend the vulva, the nurse should place the right hand against the perineum about half an inch from the orifice of the vulva, and as the head distends the vulva the nurse should support the peri- neum and pelvic floor by making firm upward and backward pressure, and if the head is being driven, as it were, with too much force, the nurse gently re- strains the birth of the head by pressure on it with the fingers of the left hand during a pain, asking 134 your patient not to bear down, but open her mouth wide and breathe during- a pain, and watch your op- portunity to let the head slip slowly out between pains. After the perineum is stretched so that it seems as though the head may come through in the interval between pains, ask the patient to bear down a little and the head will come. Thus the head is born gradually and the possibility of a tear is lessened. If the head sticks against the pubis, sometimes by a movement of the ringer Ave are able to relieve this pressure and the difficulty is adjusted. The head is the largest part, after it is born the rest of the body easily fol- lows. After the head is delivered insert the ringers in the passage and see if the cord is around the child's neck, and if so loosen it by drawing on the placental end until it can be slipped over the head or the shoul- ders can pass through the loop. If this is impossible, either because the cord is too short, or because it is wound several times around the child's body, a liga- ture should be applied and the cord tied, or if in a hurry, and the child is in danger, and you want to save time, a pair of artery forceps should be applied to both fetal and placental ends of the cord, these, of course, should have been sterilized by boiling 20 minutes, in anticipation of an emergency, and ready. and the cord cut between the ligatures or forceps, and labor hastened by artificial efforts. This con- sists in rubbing the uterus with the hand in circular movements through the abdominal wall. This ex- cites labor pains, during which ask your patient to hold her breath and bear down and the child is Usu- allv expelled spontaneously. 135 After the delivery of the head the first thing to do is to wipe the mucus from the nose and mouth with cotton, wet in a saturated solution of boric acid, and remove it from the throat by inserting the finger, so that when the child gasps nothing can be drawn into its lungs. The eyes should then be carefully cleaned. Wipe all the secretions carefully from the lids with little cotton balls or plegets and a saturated solution of boric acid, which has been prepared for that pur- pose. Wipe from the eye-ball or nose, never towards it, using a fresh cotton ball or pleget each time. Be sure they are clean. Children have gone blind from neglect of this kind. Support the head with the hand and see that it does not lie in the discharge. After the head is delivered insert the fingers and draw the arms of the child down, they are folded across the chest, and when drawn down aid much in the delivery of the body. If difficulty is experienced, hook the fin- gers in the arm pits and extract the shoulders. But it is best, nearly always, to let nature take its course, unless we are sure of the position. It usually comes safely. It requires an educated touch, and we might injure some of the membranes. When the shoulders of the child is born the head of the child should be raised up with the left hand while the right hand guards the perineum. If the child seems asphyxiated the nurse should use those methods to resuscitate the baby as Avill be found in chapter on "The ills of the baby," elsewhere in this book. If the nurse has to give her attention to the baby she should have someone to hold the fundus of the uterus, and see that it does not relax. In normal cases, as soon as the child is born, the nurse places it a short distance from the mother so she will not press 136 on the child or cord or injure it with her feet, on its right side, and covers it with a warm towel, and then grasps the fundus of the uterus through the abdomi- nal wall, but does not massage it unless there is a hemorrhage. The nurse should have an assistant to help her. if there is none in the house, call some mar- ried woman, in the neighborhood, that can hold the fundus, while the nurse gives her attention to the child. If the cord is not beating, it must be tied im- mediately and the baby made to cry or it will be as- phyiated. Tieing the Cord. — The cord should never be tied except in conditions described above, until the child breathes and cries lustily. If the child is white, or blue, don't interfere with the cord until the child cries. If it does not cry throw cold water on the chest or back, it will then gasp and catch its breath ; or catch it by the feet, hold it up, head downward, and spank it. This usually suffices. If. however, it does not respond to this treatment, artificial respiration must be given. There are several methods which are described in chapter on "The ills of baby." After baby is breathing properly and the pulsation has ceased, the nurse may wait until the delivery of the placenta before cutting the cord, unless the mother has a hemorrhage. In the meantime the doctor may arrive, and will appreciate this thoughtfulness on her part, and there is no dan- ger attached to it for the child. If, however, the pla- centa is expelled, or it is desirable to separate the child, the cord should be tied about two inches from the navel and again further down, and cut between, close to the umbilicus end, using sterile scissors. If the cord is not left long enough to fold over to one side, it is very difficult to dress it as it should be, and 137 often produces a "pouting" navel, and may result in an umbilicus hernia. Narrow, flat linen bobkin tape is the best ligature. The most important reasons for tieing the cord twice is the possibility of twins, if not tied securely the unborn child might be bled to death. The tieing of the placental end, also, prevents the placenta from becoming flat from the loss of blood. It is not so easily expelled when flat. The nurse should tie securely both the fetal and maternal end of every cord before cutting it. After the cord is cut it should be wiped free from all blood and a piece of sterilized absorbent cotton saturated with a one in two thousand bichloride solution is wrapped around the stump. The baby can then be Avrapped in the warm blanket prepared for it and removed to a place of safety. The medical profession defers tie- ing and cutting the cord in weak babies until pulsa- tion has ceased, g-iving as the reasons that a certain quantitv of blood passes from the placenta to the child and thus increases its strength and resistive powers. To tie the cord immediately after the birth would rob the child of this blood, which would other- wise pass into its circulation, and a delicate, weak babv has need of all the blood it can take, and as a proof is found on experience which I have witnessed. Cases where the physician has deferred tieing the cord until pulsation had ceased. The cord is pale and when cut very little if any blood is lost. Where, as in some cases I have seen where the physician tied and cut the cord immediately after the birth of the child, the cord was red in color, and when cut quite a large amount of blood escaped. So in the absence of the physician it is best, and safer, if there are no complications, and the baby is weak, to wait until 138 pulsation has ceased. Late lagation is not dangerous. The child will take into its system only the amount of blood required for its needs. A strong, vigorous baby, the cord should be cut shortly after birth, as the little heart's functional activity is very great and too much blood is sent to the liver. This causes an enlarged, congested condition which often results in jaundice. Delivery of the Placenta. — From the time baby ar- rives, special attention should be directed towards uterine contractions, delivery of the placenta and avoidance oi hemorrhage. From the birth of the child there should be someone to hold the fundus of the uterus, to prevent it becoming lax. To hasten contraction of the uterus and expulsion of the placenta apply friction by circular movements through the abdominal wall to the fundus of the uterus until contraction is obtained. Make no effort to deliver the placenta until the mother has uterine contrac- tions. When the mother has pains and the uterus contracts down, the nurse should assist the pa- tient by grasping the fundus sc as it will rest in the palm of the hand, compressed between the thumb and hnger, and press downward in the direc- tion of the pelvic canal. "When the placenta appear at the vulva grasp it and twist the cord and mem- branes round and round. Never pull on the cord or you may have serious consequences. Continue the circular movements until the placenta is expelled. By twisting the cord and membranes you form a rope-like cord and nearly always all are expelled. The placenta will, as a rule, be expelled spontaneous- ly. The uterus, however, if left unaided is apt to re- lax and cause hemorrhage, or where expulsion does 139 not take place speedily, in a reasonable length of time, the uterus may close down so as to retain the placenta within the uterine cavity. So by contraction of the uterus hemorrhage is avoided, and speedy ex- pulsion guards against the danger of retention. Af- ter the expulsion of the placenta a teaspoonful of flu- id extract of ergot may be given as a safeguard and additional security against hemorrhage, and knead the uterus firmly until contraction is excited. The kneading should continue for one hour. This is a safeguard against hemorrhage, and by the prevention of the formation of blood clots, diminishes the severi- ty of the after pains. Save the placenta for the doc- tor's inspection. By this examination he is able to tell if any of it or the membranes are left in the uter- us. The smallest particle remaining in the uterus will decompose and may cause septic poisoning. The doctor usually reaches the house before the delivery of the placenta. If, however, the placenta is deliv- ered and the physician has not vet arrived, and the patient is bleeding considerable, 15 M, of ergotole hyperdermically may be given. Ergot, in any form is never given while the uterus contains either the fetus or the placenta, as it might close down tight and re- tain them in the uterine cavity. As soon as the uterus contracts down well the binder is applied. Mother's and baby's toilet according to directions given else- where. Other Presentations. — While the head is the normal and most frequent presentation, the infant may pre- sent any part of the body at the pelvic opening. Breech Presentation. — In breech presentation, the delivery of which requires more skill and labor than 140 Fig-. 40— Vertex presentation. (Pinard.) Fig-. 41— Presentation of the breech. 141 the normal position, the head. Position of the pa- tient the same as head presentation. When the breech appears at the vulva ask the patient to bear down during the pain, and by gentle pressure over the uterus, in the direction o;f the pelvic canal during the1 pain, assist the paitient if possible. As the breech emer- Fig. 42 — Delivery of after coming- head by flexion through seizure of lower jaw. ges the legs df the child drop out and the nurse should' receive and support the body as it is delivered. After the shoulders are born, the nurse should insert the finger of the right hand in the child's mouth, and with the left hand press upon the uterus and hasten the delivery of the head, or the child may be asphyxiated. Arm or Transverse Presentation. — In arm or transverse presentation send for the physician nearest at hand. The responsibility is too great for delay. The position must be changed or both lives may be lost. So if the nurse is not certain of the position, 142 and the conditions are not normal, if the physician cannot be had that has charge of the case, don't wait until it is too