CHAPTER XV

NURSING CARE DURING THE NORMAL PUERPERIUM

In general, the nursing care during the puerperium is much the same as that which is given to a surgical patient, with special attention to the breasts and perineum and a sustained effort to prevent complications and restore the mother to a normal state of health in due time.

As the nurse doubtless realizes by this time, the principal complications to guard against during the puerperium are hemorrhage from the still raw area, where the placenta was attached to the inner surface of the uterus; infection of the birth canal; breast abscesses; displacement of the uterus and subinvolution, or failure of the uterus to return to its normal size and condition in the usual length of time.

In addition to guarding against these definite complications, the nurse must help to save her patient from the less tangible, but perhaps equally injurious effects of fatigue of mind and body. As many young mothers are in a more or less unstable, excitable condition after the baby’s birth, the beneficial effect of promoting a tranquil and contented state of mind can scarcely be overestimated.

The doctor may be ever so tactful and cheering and sustaining, but his contacts with the patient are short and infrequent as compared with the nurse’s constant companionship. She can, therefore, by her attitude, manner and conduct practically create or destroy the atmosphere that is necessary to her patient’s welfare.

In order to give the best and most helpful service the nurse must try from the very beginning to understand her patient as an individual and adapt herself to the patient’s temperament. Some women are rested and soothed by being talked with, read to, diverted and amused in one way or another, during most of the time, and will grow nervous and depressed if left to their own devices. Others, who have greater resources within themselves are happier and better off when left to themselves a good deal, and given an opportunity to think things over. Some women are much subdued as the consciousness of their motherhood grows upon them, and they feel a kind of awe and wonder about this baby that they begin to realize is their own. It is a big experience, this one of motherhood, full of promise and responsibilities, and the young mother herself very often wants to think it out. She will enjoy talking when she wants to talk, but may be irritated and exhausted by a nurse who tries to entertain her all of the time.

For this reason, the most conscientious and painstaking nurse imaginable may destroy her usefulness, by adopting the wrong attitude toward her patient during this period of enforced intimacy. Some women want, and even need to be indulged and petted; but, on the other hand, a certain type of reserved and dignified woman is affronted by such attention or by the easy air of familiarity that another courts; one patient is exhausted by the unvarying punctuality and precision of a conscientious, but unadaptable nurse, while that very punctuality and precision is satisfying and restful to another.

It is not a simple matter to sound the depths of a patient’s personality, for they are all complex and each one is peculiar to herself. That fact must not be overlooked for each patient is an entirely new and different problem and not like any other that the nurse has had before. But the nurse who is sincere and sympathetic and who earnestly tries to put herself in her patient’s place and see things from her standpoint, will, by virtue of that very attitude, accomplish much toward sensing the patient’s temperament and establishing harmonious relations. Moreover, the patient, herself, will all unconsciously make something of an adjustment to the nurse when she feels the nurse’s sincerity and her eagerness to be of service.

One factor in shaping the young mother’s state of mind, which the nurse must take into account is that the entire scheme and purpose of her patient’s life have been changed. She has been plunged very suddenly into a wholly new condition and her reaction to this change will depend upon her temperament, disposition and habits of adjustment.

She has spent nine months looking forward to an event that has been consummated; she has spent nine months in a state of more or less apprehension and suspense that have been abruptly ended, and we know that it is quite natural for any one to experience a letting down, or something akin to collapse, when long-continued uncertainty is ended, even though it ends happily.

And as recovery progresses the patient becomes aware, perhaps only vaguely, of another change which is not always a welcome one. For nine months she has been the centre of interest in her immediate circle; she has been the object of unremitting concern and solicitude, and much as she and her family may have tried to keep her life normal, she and her needs have constantly been given the first consideration. The very mystery of the child developing within her has created an attitude of respect, almost of reverence, which was never her portion before. In every way she has been shielded, protected and cared for, and all eyes, including her own, have steadily looked forward to the event for which this care has been preparing her—her ordeal of childbirth and the coming of her baby.

And now her ordeal is over. Her baby is here. Every one may be said to be breathing easily at last and they are no longer apprehensive and absorbingly interested in her. As a result the young mother will soon become simply one of the family and the community, and will cease to be the centre of reverential interest and solicitude.

It is scarcely human to welcome such a change in one’s state, and though in all probability very few mothers are conscious of resenting it, very many actually do. And for this reason very many unwittingly cling to a rôle of semi-invalidism. It is entirely unconscious on their part and it is also very human and natural.

To aid in the process of bracing up such a young woman to resume her former life and to meet the demands which it imposes; or to protect another patient of the eager, buoyant type from exposing herself too early to the onslaughts made by everyday life, is far from being a simple task, and to meet it no one rule can be laid down. There are all of the variations and degrees between the timid or self-indulgent woman, who must be encouraged and spurred on, and the too active, ambitious patient, who must be steadied and held back for a time.

But here, again, this is simply a part of the nurse’s duty; one aspect which makes nursing the gratifying service that it is.

Fortunately the majority of young mothers are happy and normal in their outlook and may be kept so by the exercise of an average amount of tact and amiability on the part of the nurse. The actual physical care of the patient during the puerperium is a fairly simple matter for the well trained nurse. She will find, however, that in hospitals, private practice and public-health work alike there will be wide differences in the treatment given by different doctors, during this period, just as there were during pregnancy and labor, and she will have to carry out the prescribed directions enthusiastically and loyally no matter how they vary from those of the doctors who helped in her training.

The details of the care will be indicated by the individual doctor, but the general, underlying principles—cleanliness, watchfulness, adaptability and sympathetic understanding will apply to the nursing of all patients. The most notable differences of opinion relate to the care of the breasts, the perineum and the use of abdominal binders, the accepted routine for the general nursing of average, normal cases being fairly uniform the country over.

NURSING CARE

As has been stated, the general nursing care of the puerperal patient is much the same as that given to any surgical patient, with such adaptations as are indicated by the condition and needs of the young mother.

=Position in Bed.= The question of the patient’s position in bed is probably the first one that presents itself to the nurse after that first hour when the patient must be kept flat on her back and the fundus closely watched. She should continue to lie quietly on her back for a few hours, with only a small pillow under her head, as moving about may cause hemorrhage. Some doctors permit the patient to turn from side to side at will after a few hours of quiet, while others do not allow this for two or three days particularly if the patient has perineal stitches, unless her knees are tightly bound together. Their reason for this precaution is fear that the stitches may be torn out if the thighs are separated and also that air may gain access to the uterine vessels, through the relaxed and gaping birth canal, and produce air embolism. It is a routine in some hospitals to keep the head of the patient’s bed elevated during the first week, to promote drainage, but as a rule it is in the usual position.

[Illustration:

FIG. 116.—Height of fundus on each of the first ten days after delivery. ]

Quite commonly the patient is encouraged to lie first on one side and then on the other, after she begins to move about in bed unassisted, and then face downward at intervals, in order to change the position of the uterus and thus tend to prevent backward displacement.

In many hospitals, it is part of the daily routine to measure and record the height of the fundus (Fig. 116) above the symphysis, in addition to noting the character, amount and odor of the lochia, in order to judge if involution is progressing normally. A uterus that does not remain firm and does not steadily shrink in size and descend into the pelvis is not involuting properly, and the usual remedy is more rest and a longer stay in bed, with an icecap over the fundus.

=Sitting Up.= Except when there are perineal stitches or the temperature has been elevated at some time following delivery, the patient is ordinarily allowed to sit up in bed about the sixth or eighth day. If the lochia is normal, the uterus firm and in the proper position in the abdomen and her general condition satisfactory, she is allowed to sit up in a chair for a little while about the ninth or tenth day. Some patients are able to sit up for an hour the first time without being tired, but it is often better for them to sit up for a few moments morning and afternoon on the first day, than for a longer time at one stretch. The patient is usually allowed to sit up an hour longer on each successive day and to walk a few steps on the third or fourth day after getting up.

A patient with stitches does not usually sit up in bed until the ninth or tenth day, when the stitches are removed, sitting up in a chair for an hour, two or three days later. If she has had fever, the time at which she may sit up will of necessity depend upon her condition.

The return to normal life must be very gradual and this also must be regulated by the patient’s general condition and her recuperative powers. A pinkish or red discharge or backache should be taken as warnings against standing or walking or working. The possible consequences of ignoring these warnings and being up and about too soon, may be displacement, even prolapse of the uterus; hemorrhage, from dislodgment of clots in the uterine vessels; metritis or endometritis.

It is not a good plan, as a rule, for the patient to go up and down stairs until the baby is about four weeks old, nor wholly to resume her normal activities within six or eight weeks after delivery.

In addition to this sustained, general care, it is a customary preventive measure for the doctor to make a thorough pelvic examination from four to six weeks after delivery. A slight abnormality, if detected at this time may usually be corrected with little difficulty, but if allowed to persist may result in chronic invalidism or necessitate an operation. If the uterus is not properly involuted, for example, or the perineum is found to be flabby, more rest in bed is indicated; while a uterine displacement, which seems to be present in about a third of all cases, usually may be corrected by the adjustment of a pessary.

The time of sitting up, of getting up and of walking about varies so with the individual, therefore, that it is not possible to describe a definite routine, for some patients recover slowly and would be injured by getting up and about at a period which would be entirely safe and normal for the majority. It must be determined in each case by the condition of the uterus, the appearance and amount of the lochia and the patient’s general condition.

Quite evidently, then, much ill health and many gynecological operations may be prevented by caution, prudence and good care during the first few days and weeks after the baby’s birth, while the patient returns to a normal mode of living.

=The Daily Bath.= During the first week or two the patient’s skin must aid in excreting fluids from the edematous tissues throughout the body and broken down products from the involuting uterus. Therefore she should have a bath of warm water and soap every day, to remove material already on the surface and stimulate the skin to further activity, and an alcohol rub at night, if possible. It is important for the nurse to remember, while bathing her patient, that she is perspiring freely and therefore may be easily chilled if not well protected.

It is often a good plan to have the patient, without stitches, begin to bathe herself in bed, after the third or fourth day, for the sake of the exercise, and also the encouragement that it offers. When all is going well, tub-bathing is usually resumed by the third or fourth week.

=Diet.= Opinions as to diet vary slightly with different doctors and in different hospitals, but in general, a patient in good condition is given liquid food during the first twelve to twenty-four hours after delivery; then a soft diet for a day or two, a nourishing, light diet being resumed by the third or fourth day, or after the bowels have moved freely.

The patient will usually have little appetite, at first, and will have to be tempted by small amounts of invitingly served food. The factors which the nurse must bear in mind when arranging the patient’s dietary are the general nutrition of the mother; the desirability of minimizing her loss of weight during the puerperium; increasing her strength and,

## particularly, of promoting the function of her breasts, in order to

produce milk of a quality and quantity adequate to nourish the baby.

The best producer of such milk is a diet consisting largely of milk, eggs, leafy vegetables and fresh fruits, taken with an appetite that is made keen by constant fresh air. The nurse will do well to convince her patient of this, in addition to bearing it in mind herself, and to place little reliance on so-called milk producing foods.

The young mother’s dietary may well be made up from the groups of foods that are suitable for the expectant mother. (See