Chapter X.
COMPLICATIONS OF THE PUERPERIUM PERIOD.
Sepsis.
The mother, during the puerperal state, requires the most careful nursing. If we study the phenomena of labor we will see that it is a process that exposes the mother to wounds; that the detachment of the pla- centa leaves a raw wound the size of a saucer in the uterus. There are denuded places in the birth canal. If germs, which cause inflammation, are permitted to enter the birth canal they very liable to penetrate the raw surface and give rise to inflammation there. This constitutes that very dangerous condition known as puerperal sepsis. Our knowledge of wounds teach us that the mother is a surgical case, exposed to the same dangers as any other surgical case, to infection or puerperal sepsis. The nurse who sees only hospital work is apt to underestimate the danger ; antiseptic precautions are less strict in private homes. Sepsis may rarely occur even after care. Child-bed fever is caused by poisons produced by microbes or germs gaining an entrance to the genital tract and infecting wounds along the birth canal. The interior of the uterus is, after labor, in a condition fit for the recep- tion and development of septic germs. Death does not represent all the danger or damage that may be
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done. The patient may be sick long after. If we are to take proper care of such a case, the patient must have the same treatment, the same care, and the same surgical cleanliness must be observed that is given a patient upon whom a surgical operation has been performed. We must apply the principles of asepsis during labor and afterwards. And the nurse must observe the same aseptic precaution with regard to her hands and clothing and any article which she may use on or about the patient. Instruments, even
Fig. 45 — Ignatz Semmelweis, the discoverer of the cause of puer- peral infection.
sterile, may carry infection from without. This may be prevented by disinfecting the field of operation. Semmelweis, the discoverer of the cause and the in- ventor of the means of prevention, in 1847 first taught asepsis in labor. Semmelweis, then a young interne in the obstetric clinic of the General Hospital
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of Vienna, noticed, with appalling horror, the great mortality of the clinic in which he practiced. He worked hard and long to rind the cause. He noticed that the mortality was greater in the clinic where the students and physicians practiced who went from post-mortem cases to the confinement room and de- livered the expectant mother, than the midwives* clinic adjoining. He worked hard and long to solve the problem. He argued that the poisons were car- ried on the hands of the students and physicians to the lying-in woman. He made a rule that hands in- serted for examination should be washed in antisep- tics. Chlorin water, was the only antiseptic at that time. His method saved many lives. The death race decreased from fifteen to seven per cent. Nothing was known about antiseptics at that time. He taught that puerperal fever is caused by the introduc- tion of septic material from without. He was ridi- culed and abused by the profession, and almost un- aided he maintained this position for years, and to him belongs the undying credit of having pointed out the cause of this awful scourge and the means of prevention. He died insane with no other reward than the scorn and contempt of his contemporaries, but his good work lives and is used with benefit. Pu- erperal sepsis is nearly always due to failure to prop- erlv cleanse and disinfect the genitals before an ex- amination in labor : to making an examination with unclean hands : to the use of instruments which have not been properly disinfected: failure to keep genitals covered with sterile antiseptic dressings after labor : changing the dressings without properly cleaning and disinfecting the hands, and by there remaining in the uterus some pieces of the placenta or mem-
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branes. The occlusion dressing- should be aseptic and antiseptic as herein described to prevent and pro- tect the wound against infection. If these parts are prepared before and during labor, and protected af- ter labor as herein described, there is little fear of danger of this kind. Doctor C. S. Bacon, of Chicago, in a paper read before the Southern Illinois Medical Association. November 6. 1902. says. "The mortality from puerperal fever can be reduced to almost nothing by the proper management of labor and child-birth. This has been proven by the results obtained in the best maternity hospitals. Mild cases of infection can- not be entirely prevented, but they cease to be a source of great anxiety to the physician and of danger to the mother. In private practice these encouraging- results,, due to the aseptic management of labor, are not obtained because labor is not managed aseptic- ally. In Chicago the mortality from puerperal infec- tion has remained about stationary for the last ten or twelve years. From live to seven per cent of all death oi women of child-bearing age are from puer- peral infection. It is probable that the same ratio holds all over the state and country. Hence it ap- pears that puerperal infection carries off more women in the prime of life than any other disease except consumption. How much sickness, not fatal, is due the same cause can be easily imagined. These discouraging conditions are due in part, no doubt, to the fact that a considerable number of confinement cases are still in charge of incompetent midwives and women with no training whatever. So far as the responsibility of the profession is concerned the trou- ble is that the matter of the aseptic management of labor is not taken seriously enough. The frequently
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repeated observation that many women get along all right in the worse surroundings seems to create a doubt in the minds of many whether all the bother required to manage a labor aseptically is necessary. The source of all the trouble is, I believe, the failure of both the laity and the profession to recognize the importance of labor and its management." So the nurse will see how necesary it is to use all precaution. The treatment lies in the prevention, the source of the disease being known it is possible to avoid the cause. This lies in absolute surgical cleanliness.
Puerperal sepsis usually makes its appearance on the third or fourth day after delivery. It is commonly ushered in by a chill, followed by a high fever, the temperature rising as high as a hundred and three to a hundred and five degrees F. The pulse is rapid and running with an anxious expression of countenance. The patient is restless and uneasy. The lochia dis- charge is altered and suppressed. But it must be re- membered that because the obstetrical patient has fever it must not necessarily be septic ; it may be caused by the condition of her breast or bowels and many other causes, but, of course, the first thought that presents itself to us is that it is sepsis.
This infection may be general or local. The later is confined to the vulva, vagina and uterus and is less serious. The former affects the whole system and is usually fatal.
THE BREAST.
Engorgment of the Breast. — This is the most com- mon complication affecting the breast, and at the same time a very painful complication. The breasts becomes very much engorged and are heavy and hot and very painful.
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Fig-. 46 — Breast bandage applied.
Treatment. — The usual treatment is to apply the breast binder tightly and regulate the flow of milk in
Fig. 47 — Breast bandage showing how to cut a jacket bandage from a straight piece.
this way. Some physicians order, if the case is severe, hot compresses, others ice bags. I have always found,
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by paying close attention to them on the third and fourth days; massaging them gently if they seem over-distended, and then controlling the flow by ap- plying a breast bandage, the glands will secrete evenly and this painful condition is prevented.
Fissures and Cracks of the Nipple. — These are very important because they render nursing difficult and sometimes impossible. The nipple should be washed with boric acid before each nursing, and after baby lias finished nursing the nipple should be washed off with a little witch hazel. If small or sunken, they should be pulled out with thumb and index finger and much trouble may be saved by putting the infant to the breast and teach- ing it how to take hold before they become engorged. If the patient complains of soreness or a tenderness when baby takes hold of it, the nurse should examine them carefully, and special care given them. They should be cleansed carefully after each nursing, and a nipple shield made of a glass bulb and a soft rubber nipple should be used to save the mother as much pain as possible. The nipple and shield is cleansed thoroughly after each nursing and kept in a five per cent boric acid solution, and both nipple and shield should be boiled once a day. The nurse should re- port to the physician as soon as she detects a crack in the nipple and get extract instructions from him in regard to treatment.
Mastitis. — Mastitis or inflamation of the breast is of microbic origin, and are of three kinds. Those in the eranular tissue itself called the parenchvmatous ; sec- ond, those in the connective tissue, just beneath the skin, called the subcutaneous ; and thirdly, those in the deep connective tissue beneath the gland, called the
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postmammary. This last is very serious and rare. They are caused by cracks or fissures upon the nipple. Germs, which are of microbic origin, get in and fol- low the milk glands. This causes inflammation, con- gestion of the parts and finally superation.
Symptoms. — Pain in the affected breast, and par- ticularly in one place. The part is inflamed and swol- len ; is hot and sensitive. As soon as the nurse de- tects any sensitiveness or redness of the breast she should inform the physician at once, and support the weight of the breast with a bandage.
Puerperal Insanity. — This condition is not often met with in obstetrical nursing, and when it does oc- cur, it is very sad. Melancholia and mania are both present. Suicidal tendencies are strong, also, often the desire to kill the child.
Symptoms. — The symptoms are the loss of love for the child ; the mother will not have it near her, she seems to hate the infant and will not nurse it and the sight of the child seems to excite her. She is restless and does not sleep well ; has delusions of sight and hearing and indistinctiveness of speech. In nursing such a patient the nurse must use great watchfulness that the patient does not destroy herself or child. She must not be left alone a single instant, two nurs- es are absolutely necessary. The room in which the patient lives should be arranged and furnished to pre- vent her jumping out of the window, and only the absolute furniture necessary in the room, in fact the general rules for the nursing and care of the in- sane are applicable here. The patient's nutrition must be kept up, like insane persons the patient may refuse food and have to be fed with the stomach tube. There
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is no other condition in which a conscientious trained nurse can be so valuable. Use great tact and kind- ness and try and win the confidence of the patient. Never use force, except when it is a question of life, it only excites the patient and nothing is gained. Re- covery is rather slow.
Paralysis. — Paralysis following labor is due to in- jury to the pelvic nerves, caused usually by pressure of the presenting part pressing on them, or the instru- ments, or failure to use forceps at the proper time. thus allowing the pelvic nerves to be injured by con- tinued pressure.
Septic Phlebitis. — Septic phlebitis or milk leg as it is commonly called by the laity, is caused either by obstruction of the femoral vein by a blood clot or an infection of the vein and cellular tissue. The former generally results from cold or overexertion, the lat- ter explains itself. The patient may first complain of pain in the neighborhood of the groin, the leg swells and becomes very painful, white and tense. It is usu- ally accompanied by a fever and often a chill.
Treatment. — The treatment is absolute rest, support the limb, do not let the bed clothes rest upon the foot Nothing must touch the limb, and keep it warm by wrapping it in cotton or flannel. Massage or rubbing is very dangerous. The immediate danger lies in the fact that a portion of the blood clot becoming broken off may be carried by the circulation and lodged in one of the vessels of the heart or lungs with fatal termi- nation. The conditions gradually subside, but some- times Aveeks elapse before convalescence is complete. Often there is a formation of serum or pus. This must be opened and drained.
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Subinvolution. — Subinvolution is the arrest, or hin- dered, or incomplete return of the uterus to the nor- mal size and condition after labor and child-birth, and gives rise later to much discomfort. It is due generally to severe lacerations of the cervix or a lack of tone in the uterine muscles, or the presence of large blood clots in the cavity of the uterus. A failure to nurse the child may predispose to subinvolution. The treatment lies in the removal of the cause which is the physician's duty.
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