Management Of The Mother After Labor
( Originally Published Early 1900's )
Treatment During the First Few Hours — The Lochia -Necessity of the Level Posture —Care when First Sitting-up — Change of Room—Going out of Doors—Changing the Linen—The Binder—Washing, &c. —Avoidance of Excitement-Occupation—Diet-The Bowels—Flooding—Rigors—Suckling Sore Nipples —Abscess of Breast—Dispersion of Milk in the Event of Not Suckling.
After the patient has been made comfortable in the manner already described, it is above all things desirable that she should have several hours of undisturbed rest, and, if possible, sleep. There used to be a curious notion prevalent amongst nurses that a woman ought not to be allowed to fall asleep directly after delivery. This is altogether a mistake; sleep is to be encouraged by every possible means. To this end the room should be kept exceedingly quiet, and the blinds drawn down so as to subdue the light. In this way the patient will be best enabled to recover from the exhausting effects of labor. In the meantime the nurse should keep an eye on the patient's face, and if she observe that it is becoming unusually pale, she must at once ascertain whether there is any flooding.
For the first few days the patient will suffer more or less from after-pains, which only require to be brought under the notice of the medical attendant in case they are very severe or interfere with sleep. As a rule, no after-pains occur after a first confinement.
The Proper Food to be given directly after labor is a cup of tea, gruel, or warm milk; but if the patient prefers to wait is little before taking anything at all, there is no harm in allowing her to follow her inclination. When the patient has had a few hours' rest, and has recovered from her exhaustion, the child should be applied to the breast. The nipples can be drawn out much better before the breasts become filled with milk than afterwards.
Not more than six hours should elapse after labor before the patient is reminded to pass water. She should not be allowed to wait until she feels a desire to do this for, under these circumstances, the bladder may be quite full without the patient having any inclination to empty it. At the end of six hours, then, if it has not been already asked for, the slipper-pan should be passed, a little hot water having previously been poured into it and the vessel itself warmed before the fire. If she finds herself unable to use the slipper-pan, she may be allowed to turn herself gently on to her hands and knees, in which position she will almost always succeed, an ordinary chamber utensil being in in that case substituted for the slipper-pan. Should she, even after changing her position, still be unable to pass urine, she must not make forcing efforts, but lie down again, rest a little; and then make a further attempt. The patient herself frequently imagines that she has passed urine, when she has not; hence the nurse, knowing this, must not be satisfied without seeing for herself the contents of the vessel after its removal.
Should no urine be passed during the first twelve hours, sometimes to aid the patient to do so must be given, as recommended elsewhere; and probably it will be necessary to call a doctor to draw it off by means of the catheter.
For the first few hours after delivery the vagina and external genital organs are very sore and painful, and the discharge consists of pure blood. Ten or twelve napkins are required during the twenty-four hours succeeding labor. On the second day the discharge becomes less, and each day the equantity diminishes, the discharge itself gradually changing from pure blood to a thick dark fluid, and lastly to a thin serum, like soiled water. The discharge always possesses a peculiar and distinctive odor, but if the odor become offensive the medical attendant should be informed. Similarly he should be told if, after having once ceased to consist of pure blood, the discharge should again assume that character.
The discharges after labor are termed the lochia; they sometimes last only a few days, and at other times continue for three or four weeks. They vary, too, in quantity in different women, even when they are quite natural and healthy. When they have passed through the • changes I have named, they ought presently to cease, and if, instead of doing so, they continue, and if, especially, they become purulent in, character—that is, if they contain matter like that of an abscess—an examination is necessary and the medical attendant must be informed.
On the other hand, it is not very unusual for the lochia to cease rather early and suddenly, and although this often causes alarm both to patient and nurse, it need not do so provided there is no other sign of ill-health, such as shivering, thirst, and feverishness.
For the first three days after confinement a patient should on no account be raised to a sitting posture lest an attack of flooding should come on, or fainting and even sudden death occur. There is not the same danger in allowing her to turn on to the hands and knees; indeed, I have already said that this posture may be resorted to in the event of any difficulty in using the slipper-pan in the ordinary way.
After the first three days, provided all is going on favorably, this rule as to the level position may be relaxed a little, by allowing the patient to be propped up by means of pillows or a bed-rest while she is taking food. At all other times, however, she must continue to lie down until the ninth day, when she may be assisted or carried to a couch and allowed to remain upon it for an hour or an hour and a half. At first very little dressing ought to be attempted on these occasions, the patient being protected from cold by wearing a warm dressing-grown, or by having a good blanket thrown over her. The length of time she is allowed to be out of bed may be increased day by day; and on the twelfth or thirteenth day she may be fully dressed. The temperature of the. room must be regulated most carefully when the patient first leaves her bed, it. being much more important for the room to be well warmed then, than during the time she remained in bed.
Should there be a suitable sitting-room on the same floor, the patient may take advantage of it as early as the fourteenth (lay; the lying-in chamber being meanwhile thoroughly freshened by opening the windows, spreading out the bedclothing, and leaving the mattress or bedding uncovered for some hours. If, on the other hand, the only available room is downstairs, it will be prudent to postpone the change for a few days longer.
If it happens to be mild, bright summer weather, and the patient's recovery has been rapid and satisfactory, the medical attendant may, in an exceptional case, consent to her taking a short walk or drive, at the end of three weeks.
After confinement a patient's linen requires to be frequently changed, both for health's sake and her own comfort. The patient must on no account be allowed to sit up or make any exertion while the clothes are being changed; the nurse must take off the soiled clothing by drawing down the sleeves from one arm, gathering up the clothes on that side into a handful, passing them gently over the head, and then drawing off the sleeves from the opposite arm. The clean linen, well aired, must then be put on as the patient lies.
The first binder should always be placed next to the patient's skin; after the first twenty-four hours this is a matter of less consequence. , Each morning during the first week a clean binder should be applied with moderate tightness, the nurse re-adjusting it from time to time during the day in case it should become wrinkled or loose.
The patient's bands and face should be washed, and' her hair straightened, as far as is possible without raising her, every morning. The hands and face having been attended to, the external genitals should be thoroughly cleansed over a bed-bath by means of a sponge and some water, In the absence of a bed-bath, a large slipper bed-pan may be made to answer the purpose, and if neither is obtainable, the patient must be made to turn on to the left side, with the thighs close to the edge of the bed, and the knees drawn up, when, the bed being duly protected by means of a rubber and warm folded sheet, the nurse can proceed with the sponging in the manner ordinarily adopted immediately after labor. For the first few days, while the lochia are somewhat abundant, it is well to repeat this process again in the evening.
Should the nurse while bathing the patient, discover a wound or raw surface, or any unusual swelling, she must quietly mention it to the doctor at his next visit; and so, too, if she finds any piles protruding. In the event of the patient complaining of severe pain from piles, the nurse must frequently foment the part, or apply a bread-poultice, until she receives instructions from the medical attendant.
Vaginal injections and douches are only to be used under medical direction.
The mind requires rest equally with the body. No painful news, or other exciting or disturbing influences, should be allowed to reach her. The visits of friends to the lying-in room must be entirely forbidden, except in the case of those who have obtained special permission.
It should never be forgotten that a peculiar and distressing form of mental derangement is liable to attack lying in patients. Hence, if a nurse finds her patient irritable in temper and difficult to manage, she must avoid anything like contention or direct contradiction By a firm, quiet, decided manner, a good nurse will be able to carry her point without exciting her patient.
As the patient grows a little stronger, there can be no objection to her occupying herself while in bed, if she is wishful to do so, with a little plain sewing or fancy work, and now and then with a little reading, so as to make the time pass more agreeably.
With regard to diet, many medical practitioners have rules of their own, which the nurse must always be prepared loyally to carry out. It is not now generally thought necessary for patients to be restricted to tea and gruel for a whole week. When a nurse is left to her own discretion she will find her patients recover their strength most rapidly by being allowed some variety in their food from the beginning. Boiled milk should always enter largely into the dietary of a woman who intends to suckle her child. An occasional cup -of good black tea is generally very grateful, with or without a little biscuit, toast, or bread-and-butter. From the first, beef-tea, chicken, mutton, or veal broth, rice-caudle, milk or oatmeal gruel, and other simple fluids, are perfectly allowable. If all is going on well, and the bowels have acted, there is no harm —in case the patient expresses a desire for more solid food—in giving, even on the second or third day, a slice of chicken, or tender roast beef, or a mutton chop. The diet, indeed, at this time needs to be nutritious and plentiful, while its kind may safely be regulated very much according to the patient's inclination. No stimulants of any soft, however, must be given, except under medical direction.
A nurse should not give opening medicine on her own responsibility. The medical attendant will order what is necessary and state when it is to be given. Very often, instead of medicines, he will prescribe a simple enema of soap and water.
Flooding after Delivery.—Whenever an attack of flooding comes on during the period of lying-in, the nurse must at once send for the medical attendant, stating clearly her reasons for sending, in order that he may know what will be required. In the meantime she must unfasten the binder, and make firm pressure with her outspread hand on the womb, which she will have no difficulty in finding, as it will not yet have returned to its natural size and position. She must also apply cloths dipped in cold water, or in vinegar and water, to the external genitals, keeping them applied not longer than a minute or two at a time. Where the flow is great it will be right for the nurse to try to check it by taking a dry napkin and pressing it firmly with her hand against the external parts, while the other hand is still engaged in compressing the womb from above. The patient must, of couse be kept all this time strictly lying down, with the head and shoulders low, and cool, fresh air must be admitted through the open window.
The occurrence of a shivering fit, especially if it is a severe one, or is followed by others, ought always to be regarded seriously. No time should be lost in acquainting the doctor, and the nurse must meanwhile do all in her power to produce a feeling of returning warm in her patient. With this object, a warm bottle should be put to her feet, an additional blanket thrown over her, and a cup of warm tea administered. This event is often the sign of approaching illness that, when it has shown itself, the patient should be watched with the utmost anxiety.
The secretion of milk is not usually established until the second or third day; new and then, however, it makes its appearance earlier. This event is sometimes accompanied with a little constitutional disturbance, which soon subsides. When the breasts are becoming so full and hard as to be painful, great relief will be afforded by fomenting them every few hours, and supporting them, in the meantime, as in a sling, by, a handkerchief tied over the opposite shoulder. (See page 193.) This condition will generally soon subside if the child be applied at regular intervals. Nurses must beware of meddling too much with the breasts, and especially avoid rubbing them, except under special direction from the doctor. The nipples and surrounding parts should be carefully washed each time the child leaves the breast, and should be excluded 'from the air by covering them with a small piece of linen rag on which a little vaseline or simple ointment has been spread.
As soon as it becomes clear that the supply of breast-milk is insufficient, it is unwise to keep putting the child to the breast, as this only produces irritation and is very liable to set up inflammation and abscess. Similarly, if the nipples are extremely sore, so that, even when they are protected by a nipple-shield, the application of the child is attended each time with intense pain, or if they are so depressed that neither the efforts of the child nor the cautious use of the breast-pump will draw them out, it is running a great risk of exciting breast-abscess to persevere beyond twenty-four hours in an attempt too suckle.
If the nurse notices a patch of redness on a patient's breast, and finds that the skin at that spot is painful and tender to the touch, she should take means to acquaint the medical attendant as soon as possible, for an abscess has actually formed; it should be opened with as little delay as possible, lest it spread and become much more formidable.
Still-Born.—When the child is still-born, or when, from any other cause, it is not going to be suckled, there is often great anxiety expressed about the dispersion of the milk. It is astonishing, however, how quickly it becomes absorbed if left to Nature. If the patient will only submit to the discomfort arising from the fullness of the breasts for a few hours, without insisting on their being partially emptied from time to time by the use of the breast-pump, or other similar means, whereby the breasts are stimulated to fresh secretion and the evil is aggravated, she will soon have the satisfaction of finding them softer and less painful, and will be amply rewarded for her patience. Should the feeling of tension be excessive, it will be best relieved by hot fomentations applied every few hours; if not .excessive, the application for a few days' of belladonna plasters with a hole in the centre for the nipple, is often all that is necessary. In ordering these plasters the nurse should furnish the druggist with paper patterns showing the size required.