Duties Of A Nurse During Second Stage Of Labor
( Originally Published Early 1900's )
What to do in the absence of the Medical Attendant—Supporting the perineum—Assisting at the Birth—Tying the Cord —Breech Cases - The Third Stage—Application of The Binder, &c.—Convulsions—Fainting-Falling Forward of the Womb.
When the pains alter in character, compelling the patient to make efforts to bear down, and the face begins to get flushed and the skin to become moist with perspiration, the nurse may feel pretty well assured that the first stage is over; and if the medical attendant has not arrived, she should request him to be summoned without delay. In the meantime, the patient must be put to bed, and encouraged to bear down and assist the pains. The binder, napkins, and receiver must be spread near the fire in readiness.
Should the child's head press upon the perineum before the arrival of the medical attendant, a warm folded napkin may be placed in the palm of the nurse's left hand and held against the bulging perineum, the fingers being directed backwards, so that the front edge of the perineum may receive the chief support. The object of this is to prevent the child's head passing too quickly' and suddenly forwards to the vaginal outlet and to preserve the perineum from being torn. The great point at this stage is to avoid doing too much. Nothing but harm is likely to result from attempts to enlarge the opening by stretching the lips apart 'with the fingers, or to push back the edge of the perincum in the hope of facilitating the escape of the head. Contrary to the popular belief, the attendant's duty is rather to keep back the head by gentle pressure, than to hasten its expulsion. Above all things there should be no pulling; Nature is to be allowed to do her own work.
If the medical attendant be still absent when the head is born, the nurse must spread the flannel receiver close up to the vaginal orifice, and receive the head of the child upon her right band, still keeping up the gentle pressure upon the stretched perineum until the shoulders have passed out. Even then the body and legs must be left to follow of themselves, the nurse meanwhile holding up the parts which are already born. The upper bed-clothes should be now turned back sufficiently to allow the child to breathe, without causing any exposure of the patient herself. If the navel-string is found coiled around the child's neck, it must be slipped over its head as quickly as possible, lest the life of the child should be sacrificed owing to a stoppage in the circulation of the blood through the cord. Very occasionally it happens that the child is born with the membranes unbroken; they will in such cases be found drawn tightly over the little face, and will, cause death from suffocation, unless quickly torn open and the mouth freed. Amongst some people this occurrence is known as being born with a veil or caul.
The cry which a child usually utters as soon as it is born, helps to fill the lungs with air, and is on, that account rather to be encouraged than checked. If the child does not cry, the nurse must examine the mouth to ascertain whether there is anything either over it or within it, preventing the breathing. Sometimes there is some frothy mucus in the mouth which can be cleared away with the finger. It is often useful, also, when breathing is delayed to turn the child on its face, and give it a few gentle slaps on the back with the flat hand.
The navel- string must not be tied until the breathing is established, unless it is quite evident that the child is still-born. The first ligature must be tied an inch and a half from the navel, and the knot must be pulled tightly two or three times so as to squeeze out of the way the jelly-like material which surrounds the blood-vessels of the cord; otherwise the vessels may not be closed by the ligature, and bleeding from the stump may occur to a fatal extent while the nurse is attending to the mother. The second ligature is placed an inch further from the child than the first one, and the cord is then divided with scissors mid-way between the two. All this must be done outside of the bed-clothes, lest some other part than the cord be cut in mistake.
Now and then it happens that a nurse has to take the temporary charge of cases where not the head, but the breech, passes out first. Delivery with the child in this position is full of danger to the life of the child. The nurse must not hasten matters by pulling, even when the legs are already born; but, when the whole of the child's body has passed except the head' and arms, and when these parts appear to be arrested, she may endeavor to assist Nature by bringing down the arms from the sides of the child's head in the following manner:—Passing her forefinger up the child's back, and over its shoulder, she draws the arm gently down across the front of the chest by hooking her finger into the bend of the elbow. The same manoeuvre is repeated with the other arm. The bead will then be the only part remaining unborn. It is possible that, now that the arms have been brought down, the efforts of Nature may be equal to the task of expelling the head. Should the pains, however, prove ineffectual, the nurse may render further assistance by pressing with the fingers of one hand against the back of the child's head and so tilting the head forwards, while with the two first fingers of the other hand, placed 'one on each side of the nose, she endeavors to draw, down the face. This plan is generally preferable to the one, not unfrequently adopted, in which traction is made by placing the fingers in the child's mouth. In all breech-cases a warm bath should be in readiness, in the event of the child requiring to be resuscitated.
The child, having been now separated, is to be wrapped In the receiver, with the face alone exposed, and placed out of harm's way on the other side of the bed. The patient must be warned to lie perfectly still, and to wait patiently for the one or two insignificant pains which accompany the expulsion of the after-birth. These generally occur from five to twenty minutes after the birth of the child. Meanwhile the nurse must provide the medical attendant with a basin or other vessel, previously warmed before the fire, to receive the after-birth, and one or two warm napkins.
Should the medical attendant, however, be still absent, the nurse must place her hand upon the abdomen of the mother and ascertain whether there is another child. If she should find such to be the case, she must convey the news to the mother very cautiously, assuring her that the second child will be born with much less pain than the first. If there is no second child to be felt, the nurse will do well to keep her hand laid upon the mother's abdomen until a slight pain occurs, when she must spread out her hand like a fan and gently press the uterus so long as the pain continues. Meantime, she is to hold a suitable vessel in her left hand ready to receive the placenta when it is expelled, taking care on no account to pull the cord. Sometimes the placenta and membranes are expelled during the first pain; more frequently two or three pains occur before this takes place.
If the uterus can be felt, under the hand, hard, firm, and as small as a good-sized cricket-ball, the placenta, if it has not already made its appearance, will in all probability be found lying in the vagina. In order to make sure about this, the hand may be withdrawn from the front of the abdomen, and the fore-finger passed gently up by the side of the cord. If the insertion of the cord into the after-birth can be easily and distinctly made out, it is pretty certain that the placenta has escaped from the uterus into the vagina, and it may, there-fore be carefully hooked down with the finger. As the placenta passes out, it is a good precaution to twist it round once or twice, so as to make a wisp of the membrane and bring them all away at the same time. A slight discharge of clotted and fluid blood usually accompanies the termination of the third stage.
When the placenta and membranes have come away, the hand should again be placed over the uterus, in order to make sure that it is firm and well contracted. If, instead of this being the case, it is felt to be large, soft, and uncontracted, firm pressure should be continued, so as to excite contraction and prevent flooding, which, in such circumstances, is greatly to be feared.
Should a gush of blood make its appearance in spite of the pressure, the hand must still be kept over the uterus and the pressure increased, cold wet cloths being in the meantime repeatedly applied with suddenness to the external genitals. Of course, if the medical attendant has left the house, he must be again summoned at once.
The uterus being firmly contracted, and the flow of blood having ceased, the thighs and surrounding parts are to be gently sponged with warm water and dried by means of a soft warm napkin. i
If there has been no flooding, the soiled chemise and night-dress may now be drawn down, and, along with the folded sheet, blanket, and upper rubber, removed from beneath the patient, who must not be permitted to make the slightest effort while this is being done. Then she may be slowly rolled over on to her back, to allow of the application of the binder. The binder, well aired, must be rolled up to half its length, and the roll passed underneath the lower part of the patient's back. Being caught on the other side, it is then unrolled, and having been smoothed out free from wrinkles, it is so applied as to encircle the hips tightly, and the overlapping end is then secured by means of three or four good safety-pins. All this is to be done with as little exposure of the patient as possible. The pillows having been duly replaced, the patient may now be carefully lifted into her usual position in bed; a fresh warm napkin being applied against the vulva, and the clean chemise drawn down into its place.
If, however, there has been any flooding, the patient, must still remain undisturbed for some time after the discharge has ceased, the nurse from time to time examining the napkins to make sure that there is no return of the bleeding.
When the medical attendant is present, he will probably prefer to under-take many of these duties himself; at Any rate he, being the responsible person, will give instructions according to the requirements of each individual case, which instructions it will be the nurse's simple duty to obey.
During the passage of the child's head, it facilitates matters if the patient's knees are separated. This is sometimes effected by placing a pillow between them, but the pillow is apt to be in the way, and a better' plan is for the nurse to pass her hand beneath the right knee, and keep it well raised during each pain.
Sometimes the medical attendant desires the nurse to make pressure upon the womb during the third stage of labor, to assist it in expelling the after-birth. To do this she should stand behind the patient at the doctor's left hand, and passing the hand under the bedclothes, she should place it on the abdomen. where she will feel the round, firm body of the uterus above the pubes. Spreading out her hand over this organ, she should keep up a steady pressure downwards and backwards as long as the attendant desires it.
Convulsions, coming on during labor, are always alarming, and place the patient's life in great danger. Should they occur before the arrival of the medical attendant, no time should be lost in sending for him. In the meantime all that the nurse can do is to 'keep her patient lying flat down; to see that there is no tight clothing about her head and chest; to prevent biting the tongue by pushing it, if possible, behind the teeth, and placing a cork or piece of India-rubber between them; to admit plenty of fresh air into the room; and, lastly, to restrain the meddlesome interference of bystanders. It is altogether worse. than useless to attempt to force water or stimulants down the throat while the patient is struggling and unconscious; and although sprinkling the face with. water, rubbing the hands, and applying smelling salts to the nose, can do no. harm, it is more than doubtful whether they ever produce any benefit. When the fit is over, should. the medical attendant not have arrived, the nurse may administer a soap-and-water enema with advantage.
Fainting during labor should always lead to a suspicion that there is some loss of blood going on, and the medical attendant ought to be immediately summoned, even if there is no blood to be seen externally, for internal bleeding may be going on, notwithstanding. The important point to remember about fainting is, that the patient is on no account to be raised up, however much she may desire it. The level posture, plenty of cool, fresh air, sprinkling a little water on the face, and firm, steady pressure with the hand over the uterus, comprise all that it is desirable for a nurse to do in the way of treatment. If there is external hemorrhage, an endeavor must be made to control it in the manner described later on.
Some women, who have previously borne children, suffer from a falling forward of the womb, causing an unusual prominence of the lower part of the-abdomen. Such persons require to be put to bed at a very early stage of labor, and should either be allowed to lie flat on the back, or be supported in the half-sitting posture. The late Dr. Radford, of England, to whom I am indebted for the recommendations contained in this paragraph, has recorded two fatal cases in which this condition was present, and in each of which rupture of the uterus took place at the very moment of the patient rising to her feet during labor.
He suggests that, in order that the uterus may be safely guided into, and maintained in such a position as will facilitate labor, the nurse should, in all such cases, put on a broad bandage at a very early period of the labor, and tighten it as labor advances. After the membranes have ruptured and the waters have been discharged, this bandage should be applied as follows:-The end lying upon the bed is to be fastened to the side of the bed, so as to constitute a fixed point, while the other end is held obliquely by the nurse, and gradually tightened as the child, descends into the pelvis. The direction of the pressure will thus be slightly upwards as well as backwards.
This mode of support, by what he terms a "regulating bandage," effectually assists the entrance of the child's head into the pelvis.