Chapter XII

, puts on sterile gloves, places a sterile towel over the patient’s abdomen and slips one under her hips. She should then separate the labia with the gloved fingers of the left hand, drawing the fingers upward a little to make the meatus more prominent. The inner surface of the labia is then bathed with pledgets soaked with the disinfecting solution, with downward strokes, each pledget being used but once. Five or six pledgets should be used, one after the other, to sponge the meatus, each pledget being placed squarely against the orifice, without touching the adjacent tissues, and given a slight, downward twisting motion and discarded. The bowl may then be placed in position to receive the urine, and the catheter picked up with the fingers, by its open end. The rounded end must be carefully inspected to insure against using one that is cracked or broken, after which it is slowly and gently introduced into the urethra for two or three inches. If the urine does not flow freely the catheter may be slightly withdrawn and light pressure made upon the bladder.

Before removing the catheter the nurse must locate the fundus and assure herself that it is in a proper position. If it is pushed up or to one side she will know that the bladder is still distended, and that more urine must be withdrawn. After the bladder has been emptied the nurse should place one finger over the open end of the catheter and remove it slowly.

Another method of catheterization differs from the one just described, in the preparation of the nurse’s hands. In this instance she simply washes her hands well with soap and hot water and wears neither gloves nor finger cots.

She bathes the vulva with pledgets and an antiseptic solution, using forceps, and then separates the labia with two dry pledgets, one each under forefinger and thumb of the left hand, and proceeds as above. It will be observed that the nurse avoids touching the inner surface of the labia or the meatus with anything but sterile pledgets and the sterile catheter. The advantage of this procedure is that it is accomplished quickly and with the minimum of disturbance to the patient.

A distended bladder may so easily occur unless the patient is carefully observed during the puerperium that the nurse should charge herself to watch for this complication. She should give the patient a bedpan every four hours, note the contour of the abdomen and measure the urine during the first week, remembering that the patient should void considerably more than the average amount, both because of the amount of milk and water that she is taking, and the fluid which she is eliminating from her tissues. The importance of measuring the urine lies in the fact that though the patient may void fairly regularly she may not empty her bladder, and thus enough urine may accumulate to distend it.

=The temperature, pulse and respirations= are usually taken and recorded every four hours for the first five or six days and then two or three times daily, if normal. If the temperature is above normal at any time, the nurse should take it every two hours until it becomes normal and notify the doctor immediately if it goes as high as 100.4° F., or if the pulse reaches 100.

=Care of the Perineum.= The best way of caring for the perineum, during the first week or ten days after delivery, is a moot question, and the nurse may find herself sorely perplexed by the widely divergent instructions of different doctors who have excellent results, unless she goes back of the details themselves and recognizes their purpose. She will then see that there is entire agreement about the importance of protecting the patient against infection, at this time, when infection may so easily occur. And so far as the nurse is concerned, this means cleanliness as to methods and appliances, when making perineal dressings, and extreme precaution against conveying infection to her patient. The minimum requisites for this are that the bedpan shall be sterilized, by steam or boiling, at least once a day, and well scrubbed and scalded after each time that it is used, and that the nurse shall at least scrub her hands with soap and hot water before making each perineal dressing, and apply only sterile pads.

After the perineum is bathed, immediately following delivery, the usual practice is to apply a sterile pad, after which a fresh one is applied as often as necessary at first, every four hours during the first week and subsequently every eight hours. When the dressing is changed, and after each voiding and defecation, the perineum is bathed with sterile pledgets and some such antiseptic solution as bichlorid 1–2,000 or lysol ½ per cent. or 1 per cent. (Figs. 117 and 118.) The soiled pad must always be removed from above downward and the bathing also directed toward the rectum, each pledget being used for one stroke only. The rectum is bathed last, a fresh sterile pad applied and the patient’s hips and back thoroughly dried.

The nurse may be required to scrub and soak her hands, wear sterile gloves and hold the pledgets in forceps when bathing the perineum, the object of such precautions being, quite clearly, to avoid infecting the patient from without, for the inner surface of the uterus is still regarded as an open wound.

[Illustration:

FIG. 117.—Preparation and draping of patient for post-partum dressing. Note rack of equipment on table; bag of dry, sterile pledgets at head of bed; paper bag on floor for used pledgets. The nurse has scrubbed her hands. (From photograph taken at The Manhattan Maternity Hospital.) ]

Some obstetricians believe that the perineal pad is a menace, since it slips and moves about, and thus may transfer infective material from the anus to the vagina. Accordingly, they forbid the use of all perineal dressings and instead have large, sterile, absorbent pads slipped under the patient’s hips to receive the lochia, the pads being changed as often as necessary. This is the practice at the Brooklyn Hospital, for example, where the nurse bathes the vulva with lysol 1 per cent., placing the patient on a sterile bedpan, using sterile forceps and cotton swabs and wearing sterile gloves while making the dressing.

Another method is to place the patient on a sterile bedpan, remove the pad and with gloved hands pour from a sterile pitcher a warm antiseptic solution over the groin and outside of the vulva; then to separate the labia and pour the solution between them, in some instances pressing a dry, sterile pledgets to the vaginal orifice during the irrigation.

[Illustration:

FIG. 118.—Equipment, in rack, used at The Manhattan Maternity Hospital in bathing perineum. A, pitcher of lysol, 1%. B, basin of pledgets in lysol. C, sponge-sticks in alcohol. ]

When the urine is being measured, as it frequently is during the first week, the solution which is used for irrigating the vulva should be measured beforehand and the contents of the bedpan measured after the dressing, in order that the amount of urine passed, if any, may be ascertained.

Another method of bathing the perineum, that employed at Johns Hopkins Hospital, is simply to bathe the perineum with soap and warm water, without separating the labia, using a clean wash cloth and afterwards applying a sterile pad, the pads being changed every four hours, or oftener if necessary. The theory upon which this procedure is based is that the steady outward flow of the lochia constantly carries material, infective and otherwise, away from the generative tract, and that if nothing is introduced between the labia or into the vagina the patient will not be infected.

In caring for the perineum, the nurse must remember also the real danger of the patient infecting herself with her own fingers and should caution her against taking this risk. The patient should be told that if she feels uncomfortable, or thinks she is bleeding, she must lie quietly and summon a nurse, but on no account to try to find out for herself what is wrong. There is little doubt that cases of severe infection have been caused by the introduction of organisms into the vagina by means of the patient’s own fingers, after the most scrupulous precautions had been taken by doctors and nurses to avoid that very disaster.

In most instances the care of the perineum is the same whether or not there are stitches, and in any case the method employed will be specified by the doctor. The nurse’s responsibility is to appreciate the object of the care, whatever form it may take, and bring intelligence to bear in giving it.

When there are perineal stitches, it is a wise and harmless precaution to fasten a towel or bandage about the patient’s knees for a few days, to prevent her pulling apart the uniting edges of the tear as she moves about in bed.

=Douches.= In connection with perineal dressings, it may be well to caution the nurse against giving douches without explicit orders. Douches are seldom given early in the puerperium, for fear of carrying infective material up into the uterus, except occasionally in cases of hemorrhage, in which case they are given by the doctor.

Sometimes, however, a low vaginal douche is given daily for some time after the patient gets up, with the idea of increasing her comfort and promoting involution. About two quarts of some weak antiseptic solution at 110° F. is given with the nozzle introduced just within the vaginal outlet, and the container of the solution placed only slightly above the level of the patient’s hips, in order that the stream may be very gentle.

[Illustration:

FIG. 119.—Sterile gauze held in place over nipples by means of adhesive strips and tapes. (From photograph taken at Bellevue Hospital.) ]

=The Care of the Breasts.= There is a wide difference of opinion about the proper care of the breasts, also, but here again, although the details vary, the ultimate objects of the care are always the same, namely: to facilitate the baby’s nursing, promote the mother’s comfort and prevent breast abscesses. These ends are usually accomplished by keeping the nipples clean and intact and by giving support and rest to heavy, painful breasts.

The patient who has cared for her nipples during the latter part of pregnancy will usually have little or no trouble with them during the period of lactation, if the care is continued. But this attention is imperative.

It is very generally customary to have the nipples bathed before and after each nursing with a saturated solution of boracic acid, in either water or alcohol, using sterile pledgets and forceps, and to keep them clean between nursings by applying sterile gauze. This gauze may be held in place by means of a breast binder or by tapes tied through the ends of narrow strips of adhesive plaster, four being applied to each breast. (Fig. 119.) Strips of adhesive plaster about five inches long are folded over at one end, two adhesive surfaces being in contact for about an inch. Through a hole in the folded end a narrow tape or bobbin is tied and the strips applied to the breast, beginning at the margin of the areola and extending outward. The free ends of the tapes are tied over squares of sterile gauze, between nursings, and untied to expose the nipple at nursing time.

Lead shields are sometimes used to protect the healthy nipple and not infrequently are applied to cracked nipples, being held in place by means of a breast binder. The secretion of milk which escapes into the shield is acted upon by the metal and the result is a lead wash which continuously bathes the nipple. The shields should be scrubbed with sapolio and boiled once daily.

Another method, and one widely employed, is to anoint the nipple after nursing with sterile albolene or a paste of sterile bismuth and castor oil, and apply squares of sterile paraffin paper. These bits of paper are pressed into place and held for a moment by the nurse’s hand, the warmth of which softens and moulds them to the breast after which they remain in place. In some instances the bismuth and castor oil paste is wiped off, with a sterile pledget, before nursing and in others it is not.

In some hospitals, neither gauze nor paper is used, the nipples being protected by putting sterile night-gowns on the patients.

The purpose of all of these methods is to keep the nipples clean, and here again the patient must be cautioned against infecting herself. No amount of care on the nurse’s part will protect the patient if she touches her nipples with her fingers.

The nurse will appreciate the reason for all of this painstaking care if she calls to mind the fact that the breast tissues are highly vascular and excessively active at this time and therefore very susceptible to infection, and also that the baby’s suckling is often very vigorous and accompanied by a good deal of chewing and gnawing of the nipples. Unless the nipples have been toughened, and sometimes even when they have, the skin becomes abraded or cracked as a result of the baby’s suckling, thus creating a portal of entry for infecting organisms, in addition to the milk ducts which lead back into the breast tissues. Unless the nipples are kept clean, constantly, they may become infected by organisms from the baby’s mouth or on the patient’s hands, bedding or gown with a breast abscess as a result. The important thing, then, is to keep the nipples clean and not allow anything unsterile, excepting the baby’s mouth, to come in contact with them at any time.

[Illustration:

FIG. 120.—Protecting cracked nipples by having the baby nurse through a shield. (From photograph taken at Johns Hopkins Hospital.) ]

It is sometimes the practice to swab the baby’s mouth with boric soaked cotton or gauze before each nursing, but many doctors hold that this is injurious to the delicate mucous lining of the baby’s mouth. The opinions for and against this routine seem to be about equally prevalent.

[Illustration:

FIG. 121.—Nipple shield used in Fig. 120. ]

If the nipples become painful or cracked, one can easily understand that continued suckling would only aggravate the condition and increase the danger of infection. But the baby must nurse, if possible, and so in the majority of cases a nipple shield is used (Figs. 120–121) as a protection, and after nursing the fissures or abraded areas are painted with bismuth and castor oil paste; compound tincture of benzoin; balsam of Peru; argyrol, silver nitrate or sometimes only alcohol. The application is made with sterile swabs prepared by twisting a wisp of cotton about the end of a toothpick. If the crack or abrasion is extensive enough to cause bleeding, even nursing through a shield is sometimes, but not necessarily discontinued, while the other treatment is the same as for a nipple that does not bleed.

Sound, uninjured nipples, then, are to be kept clean and protected from infection and those which are abraded or cracked are to be kept clean and also protected against further injury.

=Lactation.= About the third or fourth day after delivery, when milk replaces colostrum, the breasts become swollen, engorged and often very painful, and not infrequently, a hard, sensitive lump or “cake” may be felt. The growing tendency, now, is merely to support these heavy breasts by means of a binder which has straps passing over the shoulders, in order to hold them up without making pressure (Fig. 122) and to apply ice caps or hot compresses to the painful areas. It used to be customary to massage and pump caked breasts, to apply pressure and various kinds of lotions or ointments. Though one, or all of these measures are still employed, in some cases, the general practice is to avoid manipulating the breasts but to empty them regularly by the baby’s nursing; support them and allow Nature to make an adjustment between the amount secreted and the amount withdrawn.

[Illustration:

FIG. 122.—A simple method of supporting heavy breasts by means of three folded towels; one fastened about the waist, one over each shoulder, crossing front and back. ]

Free purging is sometimes employed and the amount of fluids reduced until the engorgement and discomfort subside. This happy issue is practically always reached if the baby nurses regularly and satisfactorily, as there is a spontaneous adjustment between the amount secreted by the mother and that withdrawn by the baby. But as abscesses may follow in the wake of caked breasts, particularly if the nipples are sore, it is of great importance that the nurse watch closely for the first evidence of painful lumps. The prompt application of a supporting bandage and ice bags (Fig. 123) or hot compresses will, in the majority of cases, give speedy and complete relief. So widely is this believed that many doctors regard the care of the breasts, including the prevention of breast abscesses, as a nursing question, entirely, and conversely are likely to regard the occurrence of a breast abscess as an evidence of careless nursing.

[Illustration:

FIG. 123.—Ice caps held in place on painful breasts by straight binder with darts pinned in under breasts and supported by shoulder straps of muslin bandage. ]

Certain it is that breast abscesses are almost never seen where the nurses have this sense of responsibility, and habitually watch the breasts closely and promptly use support and either heat or cold when the breasts become heavy and sensitive.

There are innumerable bandages and methods for supporting heavy breasts, any one of which is efficacious so long as it meets the two chief requirements: to lift the breasts, suspending their weight from the shoulders, and, while fitting snugly below to avoid making pressure at any point, particularly over the nipples. One of the most satisfactory and widely used supports is the Y-bandage, (Figs. 124, 125, 126), another, the Indian binder (Fig. 127.)

[Illustration:

FIG. 124.—Modified Richardson “Y” binder made of two strips of soft muslin, full width of material and 44 inches long, folded into strips of same width as distance from margin of patient’s breast to outer part of areola. One strip is folded in the middle at right angles and pinned to one end of the other strip as indicated. (Figs. 124, 125, 126, with captions, are from The Maternity Hospital, Cleveland, by courtesy of Miss Calvin MacDonald.) ]

The nurse must on no account massage or pump engorged breasts on her own responsibility, for there is a good deal of evidence to show that any such manipulation tends to increase the amount of the secretion and this in turn increases the engorgement and pain. It is possible, too, that massage may bruise the breasts and thus make them more susceptible to infection.

=Mastitis.= When infection occurs, the swollen, painful breasts may grow hot and red, the patient may complain of chilliness and have a slight fever, with or without there being an abscess. Even then the general treatment is most frequently found to consist of support; ice or heat; catharsis and restricted fluids, though in some cases the breasts are pumped and nursing is discontinued.

[Illustration:

FIG. 125.—Bandage in Fig. 124 applied. The long arm of binder is placed under patient’s shoulders, one end of the Y being brought around the top of the breasts and the other around the lower part, toward the nurse, crossed at right angles under the arm and pinned to long arm of bandage as indicated in Fig. 126. The nipples are covered with sterile gauze and the upper and lower parts of the Y fastened with a safety pin between the breasts. The remaining length of the long arm is brought across the breasts and fastened with a safety-pin to the opposite side. When the baby nurses this pin is removed as well as the one between the breasts. The entire binder should be snug and held in place by means of shoulder straps, pinned front and back. ]

When the inflammation so far progresses as to require that the breast be opened and drained, the subsequent nursing care will be outlined by the doctor to meet the needs of each case. It is a painful operation and often a serious one, for the destruction of breast tissue may be extensive enough to render the breasts valueless as milk-producing organs. The healing is slow and altogether the occurrence is a most lamentable one.

[Illustration:

FIG. 126.—Y bandage in Fig. 125 seen from the opposite side. ]

The nurse’s part in preventing this complication is cleanliness and gentleness in her attentions; unremitting watchfulness; immediate application of a suspensory bandage and either heat or cold, upon the first sign of engorgement and prompt reporting to the doctor.

[Illustration:

FIG. 127.—Indian Binder used at The Montreal Maternity Hospital for supporting heavy breasts. The tapering ends tie in a knot in front. ]

If the patient’s nipples have not been toughened during pregnancy or if flat or retracted nipples have not been satisfactorily brought out, it may be necessary for the nurse to employ the treatment to these ends which were described in the chapter on pre-natal care. In the meantime the baby may have to nurse through a shield until the nipple is brought out prominently enough for him to grasp it well.

=Stripping.= Sometimes in cases of depressed nipples, which the baby cannot grasp, or when the baby is too feeble, to nurse at the breast, milk is withdrawn from the breast by means of so-called “stripping.” The nurse should scrub her hands thoroughly with hot water and soap and dry them on a sterile towel before beginning. The breast is grasped by placing the thumb and forefinger of the right hand on the areola on opposite sides of the nipple but well below it. The nipple is then raised from the breast by a quick, lifting and rolling motion of the thumb and finger, accompanied by slight pressure. A sterile medicine glass should be held in position to receive the milk which spurts from the nipple, but the glass should not touch the breast. (Fig. 128.)

[Illustration:

FIG. 128.—Position of thumb and finger below nipple on areola, in stripping breasts. (From photograph taken at The Long Island College Hospital.) ]

There is a knack about stripping and it requires practice, but those doctors who advocate it feel that it empties the breast, when this is necessary, with less disturbance than that caused by pumping, and as the milk is projected directly from the nipple into the sterile glass, without any of it running over the nipple or breast as may happen in pumping, it has the additional advantage of always being sterile.

Extreme gentleness must be used; the openings of the milk ducts must not be touched by the fingers, and the thumb and finger must not press deeply enough to reach the glandular tissue itself. If done properly stripping neither stimulates nor bruises the breast tissue nor does it cause the patient even temporary discomfort.

=Abdominal Binders and Bed Exercises.= There is considerable difference of opinion about the advantage of using abdominal binders upon the puerperal patient while she is in bed, and the nurse will accordingly care for the patients of some doctors who use them and for those of others who do not.

The application of a moderately snug binder for the first day or two is a fairly common practice, for multiparæ, particularly, are often made very uncomfortable by the sudden release of tension on their flabby abdominal walls; a discomfort which a binder will relieve. And during the first few days after the patient gets up and walks about, she is sometimes given great comfort by a binder that is put on as she lies on her back, and is adjusted snugly about her hips and the lower part of her abdomen.

But the continued use of a binder after the first day or two, while the patient is still in bed, is not as general as it formerly was. Many women ask for binders in the belief that they help to “get the figure back” to its original outline, and some doctors feel that the use of the binder is helpful in restoring the tone to the abdominal muscles, which amounts to about the same thing. Both the straight swathe and the Scultetus binder are used for this purpose and they are put on in the usual manner; snugly and with even pressure, but not tight enough to bind.

Those doctors who disapprove of the binder believe that it interferes with involution and, by making pressure, tends to push the uterus back and cause a retro-position, in addition to retarding instead of promoting a return of normal tone to the abdominal muscles.

Accordingly, they instruct their patients to take exercises, instead of wearing binders, and they have these exercises started while the patient is still in bed. Their adoption, and the rate at which they are increased, are entirely dependent upon the individual patient’s condition, for they must never be continued to the point of fatigue. There are, therefore, no definite rules laid down, concerning these exercises, beyond a description of the positions and movements themselves, and their sequence.

Those which are taught to the patients at the Long Island College Hospital are so simple, and evidently productive of such happy results that they offer excellent examples of this form of treatment. They are, of course, taken only by the doctor’s order, but the nurse’s intelligent supervision increases their effectiveness.

[Illustration:

FIG. 129.

Figs. 129 to 135, inclusive, are bed exercises taken during the puerperium. For description see text. (From photographs taken at The Long Island College Hospital.) ]

The general purpose of these exercises is to strengthen the abdominal muscles, thus helping to prevent a large, pendulous abdomen; to increase the patient’s general strength and tone, just as exercise benefits the average person; to promote involution; to prevent retro-version and in a measure, increase intestinal tone and thus relieve constipation. To accomplish these much to be desired ends the exercises must be taken with moderation and judgment; started slowly; increased very gradually and constantly adapted to the strength of the individual patient. Otherwise they may do more harm than good. In the average, uncomplicated case in which the patient is doing well, she usually starts the chin-to-chest exercise from twelve to twenty-four hours after delivery. She should lie flat on her back and raise her head until her chin rests upon her chest. (Fig. 129.) If she rests her hand upon her abdomen, she will feel for herself that the abdominal muscles contract, and accordingly will be disposed to continue the exercises with more interest and confidence than she otherwise might. The movement is repeated twenty-five times, morning and evening, every day, and continued as long as the patient is in bed.

[Illustration:

FIG. 130. ]

[Illustration:

FIG. 131. ]

The familiar, deep-breathing exercise is ordinarily started on the third or fourth day. The patient should lie flat, with her arms at her sides, then extend them straight out from the shoulders (Fig. 130), raise them above her head (Fig. 131) and return them to the original position. This is repeated ten times morning and evening, daily, as long as the patient is in bed.

[Illustration:

FIG. 132. ]

The one-leg-flexion exercises are not done by patients with perineal stitches, but in other cases they are usually started about the fifth day. The thigh is flexed sharply on the abdomen and leg on thigh (Fig. 132), then extended and lowered to the bed. This is repeated ten times, with each leg, morning and evening for one, or possibly two days.

The next exercise replaces the one-leg-flexion and is started after the latter has been done for one or two days, according to the strength of the patient, and it in turn is continued for only one or two days. Both thighs are sharply flexed on abdomen and legs on thighs (Fig. 133), then extended and lowered but not far enough for the heels to rest upon the bed before being flexed again. This is repeated ten times morning and evening.

[Illustration:

FIG. 133. ]

[Illustration:

FIG. 134. ]

Next is the exercise for which the leg-flexion exercises prepare the patient, and which are discontinued when this one is adopted. It is started, as a rule, about the seventh day, or three or four days before the patient gets up. Both legs are slowly lifted to a position at right angles to the body (Fig. 134) and slowly lowered, but not far enough for the heels to touch the bed (Fig. 135), and the movement repeated. As this exercise requires a good deal of effort, it must be taken up very gradually, as follows: The legs should be raised on the first day, once in the morning and twice in the evening; second day, three times in the morning and four times in the evening; third day, five times in the morning and six times in the evening and so on, if the patient is not fatigued, until the exercise is repeated ten times each morning and evening. It is continued for several months.

[Illustration:

FIG. 135. ]

The knee chest position (Fig. 136) is intended to counteract the tendency toward retroversion, from which so many women suffer after childbirth. It is usually started about the seventh day and the patient begins by remaining in that position for a moment or two, gradually lengthening the time to about five minutes each morning and evening for about two months.

[Illustration:

FIG. 136.—Knee chest position. ]

[Illustration:

FIG. 137.—Walking on all fours. (From a photograph taken at the Long Island College Hospital.) ]

Walking on all fours is violent exercise and has to be taken up very gradually. Some patients are able to attempt it on the first day out of bed, if they have been taking the other exercises, but as a rule it is not started until the second or third day. The patient’s clothes should be free from all constrictions; the knees should be held stiff and straight with the feet widely separated, to allow a rush of air into the vagina, and the entire palmar surface of the hands should rest flat on the floor. (Fig. 137.) The patient should start by taking only a few steps each morning and evening, gradually lengthening the walk to five minutes twice daily and continuing it for about two months.

It is believed that as the patient walks in this position the uterus and rectum rub against each other producing something the same result as would be obtained by massage. The effect of the exercise is to promote involution and diminish the tendency toward constipation and retroversion, apparently preventing malposition entirely in a large percentage of cases. Though not widely used, its beneficial effects are unquestioned by those doctors who employ it.

In taking a general survey of the young mother and her needs, we realize that in a broad sense she is not ill, in so far as no pathological condition exists. But she is in a transitional state and may become acutely or chronically ill if not carefully watched and nursed. In general her mental, physical and nervous forces must be conserved and increased, and this requires thoughtful and devoted attention from the nurse. She must be scrupulously clean in her care of the nipples and perineum, and in order to be able promptly to inform the doctor of any departure from the normal in the patient’s condition, the nurse’s watchfulness should embrace regular observations upon the following:

1. The patient’s general condition; the amount and character of her sleep; her appetite; her nervous and mental condition.

2. The temperature, pulse and respiration.

3. The height and consistency of the fundus.

4. The quantity, color and odor of the lochia.

5. The persistence and severity of the after-pains.

6. The condition of the perineum.

7. The condition of the nipples and breasts.

8. The functions of the bladder and bowels.

If all goes well and there are no complications, the patient will usually be able to assume full charge of her baby by the sixth or eighth week, and practically return to her customary mode of living, with the difference that she now has the care of a baby which she did not have before. The care of that baby requires certain, definite care of herself, as a nursing mother, which will be described in detail in the next chapter.

To sum up the general principles of nursing the young mother during the puerperium, we find that just as during pregnancy and labor, the nurse must first be familiar with the normal changes that occur in order that she may recognize the abnormal. Then, as before, the nurse’s care of the individual patient must rest unfailingly upon a foundation of cleanliness in order to prevent infection; watchfulness, which implies ability to recognize normal changes and unfavorable symptoms; adjustment to the methods of the attending physician and to all of the circumstances surrounding the patient, and the wisest and tenderest consideration for her patient as an individual.

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