SOME OF THE BEST PAPERS.

Kai Tiaki : the journal of the nurses of New Zealand, Volume III, Issue 3, 1 July 1910, Page 112

SOME OF THE BEST PAPERS.

Question I—Answer1 — Answer 8. 1. Position. 2. Presentation. 3. Dilation of the O.S. Uturi. 4. Condition of the vagina : If it is hot and dry, or moist and lax ; or if there are any cicatrices or tumours to be felt. 5. Condition of the cervix : If it is rigid ; or if there is any abnormality about it, i.e., the scars from previous lacerations, tumours, thinness or thickness of the edges. 6. Condition of the bony pelvis : If the promontory of the sacrum can be felt, or any other form of contraction be recognised.

7. Conditions of the membranes : If they have ruptured, or are intact ; their toughness, and the shape of their protrusion. 8. Notice if the rectum is loaded. 9. If the head (in vertex presentation) is fixed in the brim, or otherwise. 10. In some cases of malpresent ation the cord will be felt. (Prolapse of the cord.) 11. Examination by palpating the abdomen. The great danger of carrying septic infection from the outside into the vagina is avoided. Question II. — Answer by No. 9. The bag of membranes has various uses ; such as, during pregnancy, to protect foetus from injury during labour ; to act as a fluid wedge to dilate the genital canal ; then to flush out the tract to clear it from germs, the lactic acid generated in liquor amnui being an antiseptic. After the foetus has been delivered, there is again a rush of water to flush out canal. The bag of membranes consists of the amnion and chorion, within which is found the foetus, surrounded by a fluid derived partly from excretions, from foetus, from waste from uterus, etc. It would be necessary to rupture membrane in a case of normal labour at full dilation of the os, if it does not happen spontaneously through pressure ; in a case of transverse presentation, if version has been successfully peiformed ; in delivery of twins, 30 minutes after birth of first child, to avoiel the possibility of the retention for some time of the seconel child ; in haemorrhage (but then only if patient be in strong labour), to allow of foetus being driven down over os, and contractions to take place to close up placental sinures from which haemorrhage is occurring. It is necessary also in a case of hydranmios, if excessive ; the rupture being made very high up, and with a sharp instrument, such as a stillette of catheter, knitting needle, probe, etc., previously boiled. In no case but that of the rupture in normal labour, when the membranes fail to rupture themselves, should a nurse perform this operation, unless she is unable to get medical aid. Her chief eluty is to preserve them, sending for medical assistance, and waiting as long for it as possible. It is possible to rupture membranes prematurely if examination per vagina be not carefully made, especially during a " pain " or uterine

contraction ; so such examination must be carefully made. If it is necessar}*- to rupture membranes, friction can he kept up on one part of protruding membrane during a pain, but if it be too tough a sharp instrument must be used, the operator exercising great care to avoid injury to any surrounding part, or to the foetus contained within. It is seldom that this has to be resorted to as friction, while there is considerable pressure, is usually sufficient. Answer III. by No. 2. The third stage of labour is from the birth of the child till the expulsion of the placenta. After the birth of the child, there usually follows an interval of cessation of uterine contractions, this interval is a varying one. With a contraction of the uterus the placenta, with the membranes, are expelled into the vagina, and then through the vulva, where they are received into a vessel. Methoel : As soon as the child is separated from the mother, a hot swab wrung out of lotion should be placed over vulva, the uterus must be firmly grasped and held, care being taken not to knead it. If there be an assistant, the nurse should follow out the body of the child, and not relax her hold of the fundus ; failing an assistant, the patient may be able to grasp the funelus whilst the cords or ligatures are being tied — one near the vulva, the other about two inches from the child's umbilicus. Whilst grasping the uterus, the nurse should wait for a contraction of the uterus, and if at the end of 20 or 30 minutes the placenta is not expelled she may, if there be a contraction, press the placenta downwards and backwards in the axis of the pelvis, using the uterus as a pusher. As the placenta is being received at the vulva it should be grasped on the foetal side, and twisted round and round, outwards and upwards, towards the mother's abdomen. This is done in order to make the membranes knot, anel so avoid breaking them. Should they break, they may be held between the thumb and second finger, and twisted round and round the index finger ; if too short to do this, they must be tied with a ligature anel left. After the expulsion of the placenta the uterus should be kneaeled up till it is as hard a? a cricket ball. The temperature and pulse should be taken, particularly the

pulse, as it is a certain indication of the patient's condition. After the genital parts have been washed with antiseptic lotion, steriliseel diapers should be placeel over the vulva, the nurse having previously examined to see if there be any laceration or tears in vagina or perineum. After the patient is thoroughly cleansed, and the uterus contracted, a firm abdominal binder should be put on ; all soiled bed-linen being removed. A hot drink is given to the patient ; pulse anel temperature recoreled, anel after she is warm and comfortable, all soileel articles may be removed from the room. The placenta and membranes should then be examined to see if they are intact, and the nurse's attention may then be turned to the baby. Answer IV., by No. 2, A premature baby should not be exposed to sudden changes of temperature. At first it may be kept in a room at a temperature of 90 degrees Fah., the- temperature being gradually brought down to 70 degrees Fah. In order to keep an even heat, the baby may be placed in a basket lined with blankets, bottles containing hot water being placed round the basket, care being taken to place the blankets between the chilel and the hot bottles ; each bottle being refilleel with hot water every twenty minutes. The baby should be handled as little as possible ; the diapers being changed without lifting the child. The baby should be rolled in cotton- wool, and to obviate the difficulty of changing the soiled diapers, the part of the cotton- wool covering the buttocks may be cut round, arid as it is soileel a fresh piece may be slipped in. The bathing and feeding of the child will depend on its prematurity. If several mouths premature, it should not be bathed for at least a month, but it should be gradually accustomed to the conditions and treatment of a normal baby. During the first month it should be rubbed daily with olive oil, and it maj 7 " occasionally be rubbed with spirits. After the month, a bath may be given once or twice during the week, then every alternate day, till the child becomes stronger and is gradually accustomed to normal conditions. Food : The first drink may consist of milk drawn from the mother's breasts, and a drop at a time put in the child's mouth ; this may be done with a dropper, or pipette, every

quarter of an hour. This quantity is gradually increased till the baby is able to take half a teaspoonful every half- hour ; as it gets stronger the quantity of nourishment given, and the interval between the feeds, is increased, till finally it becomes strong enough to be put to the breast. If the baby were to be artificially fed, for the first 48 hours milk sugar solution, a drop at a time, would be given. Then humanised milk anel sugar solution, diluted in the strength of one of humanised milk to three of the solution, the quantity given being gradually increased, and the interval between the feedings lengthened. If only cow's milk were obtainable, it could be given diluted with barley-water, rice-water, oatmeal-water, or plain water — one of cow's milk to three of water, sugar of milk being added. Failing cow's milk, Swiss milk — one of milk to twelve of water — could be given ; or Allenbury food No. 1. All of the above-mentioned foods must be given at regularly increasing intervals, and the quantity and strength of the food should be increased very gradually. Answer IV. by No. 3. The three main points to be considered : (1) Keep the child in an even temperature, as near as possible corresponding with that in which it existed before its birth ; (2) Give nourishment in a suitable quantity, quality, and intervals of feeding ; (3) Handle as little and as gently as possible, to prevent exhaustion. When the child is born, carefully wipe the eyes with swabs of absorbent wool in boracic lotion. See that its mouth, nose, and trachea are cleared from mucus, anel that it breathes properly. When the cor el has finished pulsating, tie, and separate. If the child is fairly vigorous, very carefully and quickly bath it in warm water (100 degrees Fah.), and dry it with a well warmed towel before a fire, being careful to be well protected from draughts while doing so. Dress the cord in the usual way, anel keep the dressing in place with a layer of cottonwool, or a flannel binder. If the child seems very weakly do not give it a bath, instead, have a supply of warm salad oil, and gently clean off all the veimix caseosa. Have the cot well lined, in such a way as will cause it to retain the heat. Flannelette cot sheets, and soft, light blankets. For

dressing the baby, have covers of cottonwool covered with muslin. W 7 hen the baby is cleaned, and the binder applied, place it in the cot, carefully wrapped in the cotton-wool covers. Place a piece of protective under the buttocks covered with cotton-wool, and a soft napkin, folded in the usual way. Have the little mattress, blankets, sheets, cotton-wool nicely warmed ready for baby, and three bottles filled with hot water (115 degrees Fah.) placed one each side and one at the foot of the cot. Re- fill alternately every half-hour. Keep the cot near a fire, well protected from draughts, in a well ventilated room, at a temperature of about 70 degrees Fah. Always keep a thermometer in the cot, and have temperature of baby's immediate surroundings about 99 degrees Fah. The child will require small quantities of fluids frequently. For the first two days give cholostrum, 1 dr. every six hours ; in the intervals give sterilised water, 3 drs., every one-and-a-half hours. If necessary, give brandy, say 3 to 5 minims., twice daily, as the doctor may order. After the third day, if the mother's milk is established, draw off and give baby 3 drs. every two-and-a-half hours, with feeds of sterilised water, 3 drs., every hour, and stimulant as orelered. Take notice if the child passes urine and meconim, if bowels do not act, fluid magnesia, as ordered by the doctor will have to be given. After the first fortnight the feeds can be generally increased in quantity, until by the ninth month it can take an ounce at a time. When a premature child is expected, always have everything in readiness ; an incubator, if possible, and get medical advice as to how it should be treated. Instead of bathing the baby each day, massage it with warm oil ; this may be done twice daily, moving as little as possible. Weigh baby weekly, to note its progress. To keep the milk in good order, the mother's breasts should be pumped off three times daily ; and a supply of milk should be pumped off to feed baby during the night, so that the mother may have her rest. Feed the baby with a pipette, by placing the small finger (well washed) in the mouth, and dropping the warm milk into the mouth ; this will teach the baby to suck until it is strong enough to be put to the mother's breast.

If for any reason the mother is not able to suckle her baby, it will need to be artificially fed ; chiefly on cream and whey, sweetened with sugar of milk, given in proportion and quantity as the doctor may order, or if the nurse is not able to get medical advice she will have to use her own judgment, as each child requires different treatment. Answer V, by No. 9. Abscess of the breast is caused by introduction of bacteria into milk elucts and glands, in the case of parenchymatous inflammation ; or directly into tissues, causing interstitial mastitis ; or from the transuelation through the walls of ducts, into tissues surrounding them from infected ducts. The introduction is usually by means of a fissure, so the greatest care must be taken to avoid any break in the skin ; but if such occurs it must not remain untreated. It must be protected from contact with air or clothing by an application of tine, benzoin co., or some similar dressing. If inflammation shows, medical aid must be obtained, or even if fissure be at all serious. The nipples must be always washed before and after nursing, so as to remove any excretion or milk, which would form a suitable nidus for the growth of germs. If parenchymatous mastitis occurs, it will be evidenced by inflammation of a triangular shape, beginning at nipple, and extending over that section of breast drained by infected g 1 ands. If interstitial mastitis,the inflammation will be of an irregular shape. In either case the breast must be kept free from secretion by artificial means ; a saline purgative administered, and medical aid obtained. Thc treatment probably ordered will be : fomentation of antiseptic lotion, the breast being bound up by binder. If an abscess should occur, it must be at once opened and drained. The patient must be kept upon a light diet ; avoiding, however, au excess of fluids, so as not to stimulate the lactation. The bowels must be kept free, and if temperature be raised, it must be reduced by tepid sponging. After inflammation has subsided a cooling application — such as evaporating lotion — is usually ordered, to assist in controlling lactation. During the attack of inflammation the lactation must De — though kept under for the time — not entirely done away with if possible, as it is necessary for the welfare of the child that nursing be resumed as soon as practicable.

Answer VI., by No. 13. The patient would complain of headache, dizziness ; she would probably have swellings of upper and lower extremities, puffiness around the eyes, perhaps oedema of the vulva. She would probably have attacks of vomiting. By obtaining a specimen of her urine, and exaniining it, the urine would be found to contain albumen. During the attack, send for a doctor, and in the meantime I would remove artificial teeth (if any), and put a gag between her teeth to prevent the tongue being bitten. Put the patient in a safe place to prevent her

from injuring herself. Keep her on her left side, to prevent any saliva getting into the trachea. Give a copious soap and water enema. Put the patient in a hot pack (being careful not to burn her) in a blanket bed. The doctor will probably give chloroform to alia} 7 the convulsions. W 7 hen the patient regains consciousness, and can swallow, a saline purgative is given. If she is unable to swallow, croton oil, 1 min., is given in butter. The main object is to lessen the toxin in the system by getting the skin and kidneys to act. Keep the patient on absolute milk diet.