When to Send for the Physician in Confinement Cases—The Preparation of the Patient—The Beginning of Labor—The First Pains—The Meaning of the Term "Labor"—Length of the First Stage of Labor—What the First Stage of Labor Means—What the Second Stage of Labor Means—Length of the Second Stage—Duration of the First Confinement—Duration of Subsequent Confinements—Conduct of Patient During Second Stage of Labor—What a Labor Pain Means—How a Willful Woman Can Prolong Labor—Management of Actual Birth of Child—Position of Woman During Birth of Child—Duty of Nurse Immediately Following Birth of Child—Expulsion of After-birth—How to Expel After-birth—Cutting the Cord—Washing the Baby's Eyes Immediately After Birth—What to Do with Baby Immediately After Birth—Conduct Immediately After Labor—After Pains—Rest and Quiet After Labor—Position of Patient After Labor—The Lochia—The Events of the Following Day—The First Breakfast After Confinement—The Importance of Emptying the Bladder After Labor—How to Effect a Movement of the Bowels After Labor—Instructing the Nurse in Details—Douching After Labor—How to Give a Douche—"Colostrum," Its Uses—Advantagesof Putting Baby to Breast Early After Labor—The First Lunch—The First Dinner—Diet After Third Day.
When to Send for the Physician in Confinement Cases—The Preparation of the Patient—The Beginning of Labor—The First Pains—The Meaning of the Term "Labor"—Length of the First Stage of Labor—What the First Stage of Labor Means—What the Second Stage of Labor Means—Length of the Second Stage—Duration of the First Confinement—Duration of Subsequent Confinements—Conduct of Patient During Second Stage of Labor—What a Labor Pain Means—How a Willful Woman Can Prolong Labor—Management of Actual Birth of Child—Position of Woman During Birth of Child—Duty of Nurse Immediately Following Birth of Child—Expulsion of After-birth—How to Expel After-birth—Cutting the Cord—Washing the Baby's Eyes Immediately After Birth—What to Do with Baby Immediately After Birth—Conduct Immediately After Labor—After Pains—Rest and Quiet After Labor—Position of Patient After Labor—The Lochia—The Events of the Following Day—The First Breakfast After Confinement—The Importance of Emptying the Bladder After Labor—How to Effect a Movement of the Bowels After Labor—Instructing the Nurse in Details—Douching After Labor—How to Give a Douche—"Colostrum," Its Uses—Advantagesof Putting Baby to Breast Early After Labor—The First Lunch—The First Dinner—Diet After Third Day.
When to Send for the Physician in Confinement Cases.—The physician should be notified just as soon as it is known that labor has begun. The adoption of this course is necessary for a number of reasons. It is only just that he should have an opportunity to arrange his work so that he may be at liberty to give his whole time to your case when he is wanted. He may not be at home at the moment, but can be notified, and can arrange to be on hand when your case progresses far enough to need his personal attention. It will relieve your mind to be assured that he will be with you in plenty of time.
Don't worry unnecessarily if he does not come immediately when you notify him, provided you notify him at the beginning of labor. There is plenty of time. You have a lot of work to do before he can be of any help. Many women entertain the idea that a physician can immediately perform some kind of miracle to relieve them of all pains at any stage in labor. This is a mistaken idea. No physician can hasten, or would if he could, a natural confinement. He waits until nature accomplishes her work, and he simply watches to see that nature is not being interfered with. If something goes wrong, as it does now and again; or if the pains become too weak, or if the proper progress is not being made, he may help nature or take the case out of her hands and complete the confinement. If it is thought best to do this, there will be plenty of time.
The Preparation of the Patient and the Conduct of Actual Labor.—It is assumed that the patient has adhered to the instructions of the physician given during the early days of her pregnancy. These instructions included directions as to exercise, diet, bathing, etc.
Having calculated the probable date of the confinement, it is the better wisdom to curtail all out-of-door visiting, shopping, social engagements, etc.,—everything in fact out-of-doors except actual exercise, for two weeks previous to the confinement date. The usual walk in the open air should be continued up to the actual confinement day. The daily bath may be taken, and it is desirable that it should be taken, up to and on the confinement day.
The Meaning of the Term "Labor."—By labor is meant, the task or work involved in the progress by means of which a woman expels from her womb the matured ovum or child. After the child has been carried in the womb for a certain time (estimated to be 280 days) it is ripe, or fully matured, and is ready to be born. The womb itself becomes irritable because it has reached the limit of its growth and is becoming overstretched. Any slight jar, or physical effort on the part of the patient, or the taking of a cathartic, is apt to set up, or begin the contractions which nature has devised as the process of "labor" by which the womb empties itself.
The Beginning of Labor.—When the first so-called pains of actual labor begin they are not always recognized as such. The explanation of this seeming paradox is that the "pains" are not always painful. A woman will experience certain undefined sensations in her abdomen; to some, the feeling is as if gas were rumbling around in their bowels; to others, the feeling is as if they were having an attack of not very painful abdominal colic; while others complain of actual pain. The fact that these sensations continue, and that they grow a little worse; and that the day of the confinement is due, or actually here, impresses them that something unusual is taking place; then, and not till then, does the knowledge that labor is really approaching dawn upon them.
In due time one of these new sensations, which constitute the first stage of labor, will be more emphatic; there will be a little actual pain so that she will feel like standing still, holding her breath and bearing down. That is the first real labor pain and marks the beginning of the second stage of labor, and may be the first absolute sign that will leave no doubt in her mind that labor has begun.
The nurse will now inquire into the condition of the patient's bowels. If they have not already moved freely that day, she will give the patient a rectal injection of one pint of warm soap suds into which one teaspoonful of turpentine is put. After the bowels have been thoroughly cleansed, the patient will be made ready for the confinement. The clothing necessary consists of dressing gown, night gown, stockings and slippers. These are worn as long as the patient is out of bed, when all but the night gown will be discarded. The entire body of the patient, from the waist line to the knees, should be thoroughly cleansed, paying particular attention to the private parts; first with warm water and castile soap, and then rendered aseptic by washing with four quarts warm boiled water into which has been put one teaspoonful of Pearson's Creolin. A soft napkin is then wrung out of water that has been boiled and cooled to a suitable temperature, and laid over the genital region, and heldin place by a dry clean napkin, and allowed to remain there until the physician takes personal charge of the case.
Length of the First Stage of Labor.—There is no definite or even approximate length of time for the first stage of labor,—that, you may recall, was the more or less painless stage, or as it has been termed, the "getting-ready" stage. Inasmuch as it is an unimportant and practically painless stage, most patients do not mind it. They continue to be up and around and work as usual.
The first stage of labor is utilized by nature in opening the mouth of the womb.
The second stage of labor is utilized by nature in expelling the child into the outer world.
Length of the Second Stage of Labor.—After the second stage has begun, the length of time necessary to end the labor, assuming everything is normal, depends upon the strength and frequency of the pains. The stronger and more frequent the pains, the quicker it will be over. First confinements necessarily take longer, because the parts take more time to open up, or dilate, to a degree sufficient to allow the child to be born. In subsequent confinements, these parts having once been dilated yield much easier, thus shortening the time and the pains of this, the most painful, stage of labor. The average duration of labor is eighteen hours in the case of the first child, and about twelve hours with women who have already borne children. The time, however, is subject to considerable variation, in individual cases, as has been pointed out.
Conduct of the Patient During the Second Stage of Labor.—She should remain up, out of bed, as long as she possibly can. The object of this is because experience shows that the labor pains are stronger, and more frequent, when in the upright position. Even though this procedure would seem to invite more constant suffering, it must be remember that labor is a physiological, natural process, that there is nothing to fear or dread; and if the patient is in good health, it is to her advantage to have it over soon, rather than to encourage a long drawn out, exhausting labor. When the pains comeshe should be told to hold on to something, to hold her breath as long as possible, and to bear down. A good plan is to roll up a sheet lengthwise, and throw it over the top of an open door and let her grasp both ends tightly and bear down; or she can put her arms over the shoulders of the nurse and bear down. Instruct her to hold her breath as long as she can, bearing down all the time, and when she can't hold it any longer, tell her to let up, and then take a quick deep breath and bear down again, repeating this programme until the pain ceases. Tell her specifically to be sure to keep bearing down till the end of the pain, because the most important time, and the few seconds during which each pain does most of its work during the second stage of labor, is at the very end of each pain. When a woman understands that these instructions are for her good, and that they are given with the one purpose of saving her pain, and shortening the length of labor, she will try to obey. Each pain is intended by nature to do a certain amount of work, and each pain will accomplish that work if the woman does not prevent it; and if she does prevent it, she is only fooling herself, because the next pain will have to do what she would not allow the former to do, and so on according to how she acts.
The Carriers of HeritageHere is the actual bridge from this generation to the next.Into these two little bodies—the larger not over one-twenty-fifth of an inch in diameter—is condensed the multitude of characteristics transmitted from one generation to another.The vital part of theOvumis theNucleus, which contains the actual bodies that carry heritage—the little grains that are the mother's characteristics—Chromosomes. This nucleus is nourished by oils, salts and other inclusions, known asCytoplasm. Floating in the cytoplasm may be found a tiny body known as theCentrosome, which acts as a magnet in certain phases of cell development. Around this whole mass is aCell Wall, more or less resisting and protective.TheSpermatozoanis structurally much different from the ovum, but it also has its nucleus and chromosomes, which carry to the child the transmittable characteristics of the father.The ovum is usually comparatively large and stationary, and whatever motion is therefore necessary to bring it into contact with the male cell devolves upon the latter, which possesses what is known as alocomotor tail. In addition there are usually many sperms to one ovum, so that the chances are that at least one male cell will reach the egg and effect fertilization, and the beginning of a new life.The diagrams on the opposite page show the actual steps by which the spermatozoan unites with the ovum. It is the very first stage of the process of cell multiplication that results in the offspring.
Here is the actual bridge from this generation to the next.
Into these two little bodies—the larger not over one-twenty-fifth of an inch in diameter—is condensed the multitude of characteristics transmitted from one generation to another.
The vital part of theOvumis theNucleus, which contains the actual bodies that carry heritage—the little grains that are the mother's characteristics—Chromosomes. This nucleus is nourished by oils, salts and other inclusions, known asCytoplasm. Floating in the cytoplasm may be found a tiny body known as theCentrosome, which acts as a magnet in certain phases of cell development. Around this whole mass is aCell Wall, more or less resisting and protective.
TheSpermatozoanis structurally much different from the ovum, but it also has its nucleus and chromosomes, which carry to the child the transmittable characteristics of the father.
The ovum is usually comparatively large and stationary, and whatever motion is therefore necessary to bring it into contact with the male cell devolves upon the latter, which possesses what is known as alocomotor tail. In addition there are usually many sperms to one ovum, so that the chances are that at least one male cell will reach the egg and effect fertilization, and the beginning of a new life.
The diagrams on the opposite page show the actual steps by which the spermatozoan unites with the ovum. It is the very first stage of the process of cell multiplication that results in the offspring.
The Formation of a New LifeReproduced by permission from "Genetics," Walters, The Macmillan Co.
How a Willful Woman Can Prolong Labor.—For a certain time, during the second stage of labor, a willful, unreasonable woman, can work against nature and save herself a little pain by prolonging the issue; but there will come a time when, the head having reached a certain position, the expulsive pains will be so great that she won't be able to control them and nature then seems to take her revenge. So if a woman holds back, and begins to cry, and scream, when she feels a pain coming, she renders the pain to a large degree negative, she prolongs her labor, adds to the total number of pains, exhausts herself, and endangers the life of her child. It must, however, be remembered in all justice that this is a time when it is much easier to preach than to practice.
Every confinement is a new experience; no matter how many a physician may have seen, there are no twoalike. It is one of the interesting psychological problems in medicine to observe the conduct of women during their first confinement.
Some are calm, exhibiting a degree of self-control that is admirable. They are willing to be instructed, and they recognize that the advice is given for their benefit. They conscientiously try to obey suggestions, and they make praiseworthy efforts to keep themselves under control. They are stoics.
Others collapse at once; they go to pieces under the slightest excuse, and frequently without as much as an excuse. As soon as the pain begins, they willfully ignore all the instructions given and desperately and foolishly try to escape what they cannot escape. In this unreasonable selfishness they resent advice, and at the same time they implore you to "do something" for them. There is absolutely no excuse for this kind of conduct; and any prospective mother who, because of a willful trait in her disposition, refuses to profit by the kindly professional advice of her physician or nurse, should at least have some consideration for her unborn babe. It may seem unkind to criticise the conduct of any woman at such a time. It is not prompted by a lack of patience or justice however. These women permit, in spite of every assurance to the contrary, an unreasonable fear to overwhelm them; and because of this fear they refuse to be guided into a path of conduct that will save them suffering and shorten the pains which they complain of. It is our conviction that if a woman would try to follow the advice of the physician at this time, at least half of all the seeming suffering would be avoided. We are glad to be able to truthfully state that this type of woman is vastly in the minority.
When the second stage has advanced far enough, the patient will decide to go to bed. It may be necessary to put her in bed earlier, if her pains are very strong, as there is always a possibility of suddenly expelling the child under the influence of a strong pain. She will, as previously stated, discard all clothing, except her night gown, which can be folded up to her waist line and let down as far as necessary after the confinement is over. The obvious advantage of this arrangement isthat the gown remains unsoiled, and saves what would be needless trouble if it proved necessary to change the night gown at a time when the tired-out patient needs rest. Much aid may be afforded the woman at this stage by twisting an ordinary bed sheet and putting it around one of the posts or bars of the foot of the bed. The patient may then pull on the ends during the pain; she may also find much comfort and aid by bracing her feet on the foot of the bed while pulling. It is desirable to instruct the nurse to press on the small of the back during these pains. Some women appreciate a hot water bottle in this region. If the pains are hard the patient may perspire freely; it is always refreshing occasionally to wipe the face and brow off with a cloth wrung out of cold water. Cramps of the limbs may be relieved by forcibly stretching the leg and pulling the foot up toward the knee. From this time until the child and after-birth are born the physician will take active charge of the case.
The Management of the Actual Birth of the Child.—Near the end of the second stage of labor it will be observed that the pains have grown strong, expulsive, and more frequent. Very soon the advancing head will begin to push outward the space between the front and back passage; the rectum is pushed outward and the lips of the vagina open. If an anesthetic is to be used these are the pains that call for it. A few drops may be dropped singly on a small clean handkerchief held up by the middle over the nose, its ends falling over the face. A few drops will just take the edge off the pains, and render them quite bearable. As soon as the pain is over the patient should rest, relax completely, and not fret and exhaust herself worrying about the pains to come. It is astonishing how much actual rest a woman can get between pains if she will only try; and it is astonishing how much concentrated mischief a willful, unreasonable woman can do in the same time. She will not try to rest, but cries and moans and pleads for chloroform, until she succeeds in giving everyone except the physician and nurse the impression that she is suffering unnecessarily. Her husband or her mother,whichever is present, gets nervous; they begin to wonder if the physician is really trying to help; assume a long, sad, serious face! forget their promise to look cheerful, and mayhap offer sympathy to the woman. It is a trying moment and needs infinite patience and tact. The physician attends strictly to his duty, which will now be to guard the woman against exerting too great a force during the last few pains. About this time, or before it in many instances, the "waters will break." This means simply that the bag or membrane in the contents of which the child floated burst because of the pressure of a pain. This is a perfectly natural procedure and should not cause any worry: simply ignore it as if it had no bearing on the labor in any way. As soon as the oncoming head has dilated the passage sufficiently, so that the edges of the entrance to the vagina will slip over the head without tearing, the physician allows the head to be born. It takes some time to do this, and he must hold the head back until just the right moment. It is best not to let the head slip through at the height of a pain, or rupture is sure to occur. Wait till it will slip through as a pain is dying out, and if you have waited long enough and handled the head skillfully, the conditions will be just right at a certain moment to permit this without tearing the parts. There are some cases where a tear, and a good tear, is impossible to guard against. It is not a question of patience, or tact, or skill; it is a combination of conditions which patience, tact, and skill are powerless against.
Position of Woman During Birth of Child.—The position of the woman is a matter of choice and is not contributory to the results at all. She can lie on her back, which is the ordinary way, or on her side, as the physician or the patient prefer. As soon as the head is born the physician should see that the cord is not round the child's neck; if it is, release it. The shoulders will most likely be born with the next or succeeding pain. The physician will permit the lower shoulder to slip over the soft parts first; this is done by retarding the upper shoulder by pushing it gently behind the pubic bone of the mother. When the shoulders are through, therest of the body of the child slips out without effort.
Duty of Nurse Immediately Following Birth of Child.—As soon as the child is born the nurse should sit by the side of the mother and hold the womb until the after-birth is expelled. The womb can be easily felt in the lower part of the woman's abdomen as a hard mass. It feels about the size of an extra large orange. The object of holding it is to prevent the possibility of an internal hemorrhage. It can be readily appreciated that the interior of a womb, immediately after a child is born, is simply a large bleeding wound. So long as the womb remains firmly contracted there is very little chance for an extensive bleeding to take place. As a rule the womb remains sufficiently contracted to preclude a hemorrhage until the after-birth is out. After the after-birth is expelled, the womb usually closes down firmly and the liability to bleed is very much reduced. Because there is a distinct chance or tendency for the womb to bleed freely during the time the after-birth remains in, it is customary, as stated above, to watch it closely and to hold it securely. It is best held with the right hand. The fingers should surround the top of the womb and exert a slight downward pressure. Should it show any tendency to dilate or fill with blood, get it between the fingers and the thumb and squeeze it, pushing downward at the same time.
Expulsion of After-Birth.—The after-birth is usually expelled in about twenty minutes after the child is born. Great care should be experienced in its expulsion. It should not be pulled at any stage of its expulsion. If it does not come easily give it a longer time,—it takes time for the womb to detach itself from the after-birth; and some after-births are very firmly attached. Eventually it will come out with a little encouragement in the way of frictional massage of the womb through the abdominal walls. If the membranes remain in the womb after the body of the after-birth is out, do not pull on them. Take the after-birth up in the palm of your hand and turn or twist it around, and keep turning it around gently, thereby loosening the membranes from the womb instead of pulling them, which would surely break them, leavingthe broken ends in the womb, and, as a result, the chance of developing serious trouble.
The patient should now be given one teaspoonful of the fluid extract of ergot, which should be repeated in an hour. Should there be an excessive flow of blood after this period it may be again repeated at the third hour.
Cutting the Cord.—As soon as the child is born, and of course long before the after-birth is expelled, the physician will tie the cord. This is best done at two places, one about two inches from the child, and the other two or three inches nearer the mother. Cut the cord about one-half inch beyond the first ligature, which will be between the two ligatures. The cord should be tied with sterile tape made for the purpose, or heavy twisted ligature silk, or a narrow, ordinary, strong tape, previously boiled. It should be tied firmly and inspected a number of times within one hour of its birth. It is possible for a baby to lose enough blood from a cord badly tied to cause its death. A very good way to ensure against such an accident is to cut the cord one inch from the ligature nearest the baby, then turn this inch backward and retie with the same ligature, thus making a double tie at the same spot. Cut the cord with scissors that have been boiled and reserved for this purpose.
Washing Baby's Eyes and Mouth Immediately After Birth.—As soon after birth as is practicable, wash the baby's eyes with a saturated solution of boracic acid.
Immediately after the eyes have been washed the physician will drop into them a solution of silver nitrate, three drops of a two per cent. solution in each eye, or argyrol, three drops 20 per cent. solution. This precaution is taken against possible infection during labor and, as explained elsewhere, it is a preventive against certain diseased conditions which, if present, would result in blindness.
The physician should then wind a little sterile cotton round his moistened little finger, dip it in the boracic solution, and holding the baby up by the feet head down, insert this finger into the throat, thus clearing it of mucus. The tongue and mouth may be gently washed with the same solution.
After the baby has cried lustily as an evidence of life and strength, he should be wrapped up in a warm blanket quickly, and immediately put in a cozy basket in a warm place, and left there undisturbed, with his eyes shaded from the light until the nurse is ready to attend to him. The baby should be laid on his right side.
Conduct Immediately Following Labor.—As soon as the physician is satisfied that the patient is well enough to be left in care of the nurse or attendant, every effort should be made to favor a long, refreshing sleep. Nothing will contribute to the patient's well-being so much as a quiet, restful sleep after labor. The nurse will therefore take the baby into another room, fix the mother comfortably, and give her a glass of warm milk,—draw the shades or lower the light and tell the tired-out mother to go to sleep. As a rule she will sleep easily, as she is sore and exhausted.
After-Pains.—In women who have had children the womb does not as a rule contract down as firmly as after the first confinement. This condition permits of slight relaxation of the muscular wall, at which times there is a slight oozing of blood. This blood collects and forms clots in the uterine cavity which acts as irritants, exciting contractions in the effort to expel them. These contractions cause what are commonly known as "after-pains." These pains last until the womb is free from blood-clots. They may be severe the first twenty-four hours and then gradually die out during the following two or three days. Ordinarily in uncomplicated confinements they rarely annoy the patient longer than a few hours. It is a rare exception to observe them after the first confinement.
Rest and Quiet After Labor.—Sometimes the birth chamber is the rendezvous for all the inquisitive ladies in the neighborhood. No one should be permitted in the lying-in chamber until the patient is sitting up, except the husband and the mother. This should be made an absolute rule in every confinement. This is a period that demands the maximum of uninterrupted rest and repose. The world and all its concerns should remain a blank to a woman during the whole period of her confinement. This is the only successful means ofobtaining mental rest. The husband and mother should be instructed to present themselves just often enough to demonstrate their interest in the welfare of the patient and the baby.
Position of the Patient After Labor.—After delivery a woman should be instructed to lie on her back, without a pillow, for the first night. On the following morning she may have a pillow, but she must remain on her back for the first week. Sometimes an exception may be made to this rule by letting the patient move around on the side, with a pillow supporting the back, on the fourth day. These exceptional cases are those whose womb has contracted firmly, as shown by the quick change in the amount and color of the lochia. Women should be told why they must remain on their backs as explained in the chapter: "How long should a woman remain in bed?"
The Lochia.—The discharge which occurs after every labor is called the lochia. Its color is red for the first four or five days; for the succeeding two or three days it is yellow; for the remainder of its existence it is of a whitish color. It lasts from ten days to three weeks.
The odor of the lochia is at first that of fresh blood; later it has the odor peculiar to these parts. If at any time the odor should become foul or putrid it is a danger signal to which the nurse should immediately draw the physician's attention.
If the amount of the lochia should be excessive it should be investigated.
The Events of the Day Following Labor.—We will assume that the patient enjoyed a long sleep and wakes up refreshed, and with a thankful feeling that all is over and that baby is safely here. She will want to see and caress baby, of course. Lay the baby down in bed beside her and let her love and mother it. Tell her not to lift it, for the strain might injure her, then quietly steal away for ten or fifteen minutes, for these are precious, sacred moments. Motherhood—that angel spirit, whose influence every human heart has felt—that guards and guides the world in its sheltering arms—is born in its divine sense, into the heart of every woman for thefirst time, as she gazes in ecstasy and wonder at her first-born. She feels that she has begotten a trust,—a trust direct from her Creator, and she makes a silent resolve, as she gently and timidly feels the softness of baby's cheek, that she will watch over it, and guide it, and do all a mother can for it, with God's help. It is good for the race that mothers do feel this way: and it is good for all concerned that they be given the opportunity to be so inspired.
Just as gently take the baby away at the expiration of the allotted time. Take it with a cheerful, smiling word, and do not comment upon mother's happy, thoughtful face, she will quickly collect herself and enter into the spirit of quiet congratulation that should now permeate the home.
The First Breakfast After Labor.—If the patient has passed a comfortable night, feels well, and is free from temperature, and has a normal pulse, breakfast will consist of a cup of warm milk, or a cup of cocoa made with milk, a piece of toasted bread, and a light boiled egg; or if preferred a cereal with milk and toasted bread. This will be the breakfast for the two following days also. The milk, or the cocoa (whichever is taken), must be sipped, while the attendant supports the patient's head. The cereal, or the egg (whichever is taken), must be fed to the patient out of a spoon. The patient must not make any physical effort to help herself; she must remain relaxed. Even when she sips her milk, or cocoa, she must not make any effort to raise her head; the nurse must support its entire weight. This will be the absolute routine of every meal until the physician gives permission to change the procedure. It is a waste of time to formulate rules only to disobey them.
Shortly after breakfast the patient's toilet should be attended to. She should have her hair combed, and her face and hands washed. The hair on the right half of her head should be combed while the head rests on the left side, and vice versa. The water used for washing the hands and face should be slightly warmed. It is best to keep the hair braided and to consult the wishes of the patient as to the frequency of combing it.
The Importance of Emptying the Bladder After Labor.—An effort should be made now to have the patient urinate. This is very important at this time, as it is not an uncommon experience to find that the abdominal muscles are so worn out and overstrained with the fatigue of labor that they refuse to act when an effort is made to urinate. As a consequence the bladder becomes distended and may have to be emptied by other means. This condition is a temporary and a painless one, and will rectify itself in a day or two; meantime, if this accident has occurred, it is essential that the bladder should be emptied from time to time until the patient can do it herself. To test this function place the patient on the bed pan into which a pint of hot water has been put, and give her a reasonable time to make the effort to pass her water. Should she fail, take an ordinary small bath towel and wring it out of very hot water, just as hot as she can tolerate, and spread it over the region of the bladder and genitals: if there is running water in the room, turn it on full and let it run while the towel is in position as above. If the bladder is full, there is a peculiar, irresistible desire to urinate when one hears running water. If this effort fails, report the fact to the physician when he makes his daily call; he will draw the urine and it will be part of his daily duty to give specific instructions regarding this function until nature reëstablishes it.
No particular attention need be paid to the bowels for the first two days. On the morning of the third day, if they have not acted of their own accord, the physician will give the necessary instructions to move them. The means necessary to accomplish the first movement after a confinement is a matter of choice. The old-time idea was to use castor oil, and while other remedies are now more or less fashionable, castor oil is still an excellent agent. Enemas are frequently used, but their use is questionable in this instance, inasmuch as a movement has not taken place for three days, the object is to clean out the whole length of the intestinal tract, and an enema is limited to part of the large intestine only,—according to how it is given. If the smallintestines are not thoroughly emptied, particles of food may remain there, and if so, they will putrify and the patient runs the risk of developing gas,—sometimes to an enormous extent. This affliction is painful, and dangerous, and nearly always unnecessary. It is always, therefore, more safe, and more desirable, to use some agent by the mouth, and we know of no better one than castor oil; and as castor oil can be so masked as to be practically tasteless at any drug-store soda fountain there can be small objection to it. My custom is to send the nurse or husband with an empty glass to the drug store to have the mixture made there and brought back ready for use. We have frequently obtained it in this way and given it to the patient without her knowing what it was. The best time to give castor oil is two hours after a meal, and two hours before the next meal—i.e., on an empty stomach. It works quicker and does not nauseate when the stomach is empty.
Instructing the Nurse in Details.—The nurse will attend to the patient's discharges by changing the napkins frequently. The bruised parts should be washed twice daily, for the first three or four days. If the nurse is a trained graduate nurse a few directions will suffice. If she is not a trained nurse the physician should be explicit in his instructions. It would be better if he actually showed her just how he wanted this work done. The best way to cleanse the vulvæ or privates is to take an ordinary douche bag at the proper height (about three feet) and allow the solution (1 to 2,000 bichlorid) to run over the parts into the douche pan, but do not touch any part of the patient with the nozzle of the douche bag. While she is directing the water with the left hand she should have a piece of sterile cotton in the right hand with which she will gently mop the parts. This method ensures disengaging any clotted blood and is aseptic. Dry the parts afterwards with a soft sterile piece of gauze and apply a clean sterile napkin.
Douching After Labor.—A nurse should never give a vaginal douche without instructions from the physician. Douches are not necessary in the convalescence of ordinary uncomplicated confinement cases. When it isnecessary to give vaginal douches after a confinement, there are good reasons why they should be given, and it is therefore absolutely essential that they should be given properly, and with the highest degree of aseptic precautions. If these rules are not observed, the danger of causing serious trouble is very great, and as the physician is directly responsible for the conduct of the case, he should in justice to himself and his patient, do the douching himself.
How to Give a Douche.—The proper way to give a vaginal douche after a confinement, when the parts are bruised and lacerated, and when, as a consequence, the possibility of infection is very great, is as follows:
Instruct the nurse to boil and cool about two quarts of water and have another kettle of water boiling. Boil the douche bag and its rubber tubing and the glass douche tube (do not use the hard rubber nozzle that comes with the ordinary douche bag). Drain off the water after it has boiled for ten minutes, but instruct the nurse not to touch the bag or tube, to leave them in the pan, covered, till the physician uses them. When the physician calls, place the patient on a clean warm douche pan while he is sterilizing his hands and making the solution ready. While he is douching the patient the nurse will hold the bag. The bag should not be held higher than two feet above the level of the patient.
Advantages of Putting Baby to the Breast Early After Birth.—The patient can now take, and will likely be ready for, an hour's nap. After the rest it is desirable to put the baby to the nipple, first carefully cleaning the nipple with a soft piece of sterile gauze dipped in a saturated solution of boracic acid. The reasons for this are as follows:
1st. There is in the breasts of every woman after confinement a secretion known as "colostrum" which has the property of acting as a laxative to the child, in addition to being a food.
2nd. It is advisable that the child's bowels should move during the first twenty-four hours and the colostrum was put there partly for that purpose.
3rd. The act of suckling has a well-known influenceon the womb, in that it distinctly aids in contracting it, and thereby expelling blood-clots and small shreds of the after-birth which might cause trouble if left in.
4th. By nursing the colostrum out of the breasts, it will favor and hasten the secretion of milk.
5th. It is frequently easier for the baby to get the nipple before the breast is full of milk, and having once had the nipple it will be easier to induce him to take it again when it is more difficult to get.
The First Lunch After Labor.—Lunch will be next in order, and that should consist of a clear soup,—chicken broth, mutton broth, beef broth with a few Graham wafers or biscuits, and a cup of custard or rice pudding. This will be the lunch for the two following days also. The same precautions are to be observed in giving this as were observed with breakfast and as will be observed with all other meals as clearly stated before, and repeated again, so that no mistake may be made. In the middle of the afternoon the patient can take a cup of beef tea or a cup of warm milk.
The First Dinner After Labor.—Dinner will consist of more broth, or a plate of clear consomme with a dropped egg, or a cereal, a little boiled rice with milk, and stewed prunes, or a baked apple.
After the bowels have moved, on the third day, and provided the temperature and pulse have been normal since the confinement, the patient can be put on an ordinary mixed diet, particulars regarding which are given on page121under the heading "Diet for the nursing mother."
Regarding the Dread and Fear of Childbirth—The Woman Who Dreads Childbirth—Regarding the Use of Anesthetics in Confinements—The Presence of Friends and Relatives in the Confinement Chamber—How Long Should a Woman Stay in Bed After a Confinement?—Why Do Physicians Permit Women to Get Out of Bed Before the Womb Is Back in Its Proper Place?—Lacerations, Their Meaning and Their Significance—The Advantage of an Examination Six Weeks After the Confinement—The Physician Who Does Not Tell All of the Truth
Regarding the Dread and Fear of Childbirth—The Woman Who Dreads Childbirth—Regarding the Use of Anesthetics in Confinements—The Presence of Friends and Relatives in the Confinement Chamber—How Long Should a Woman Stay in Bed After a Confinement?—Why Do Physicians Permit Women to Get Out of Bed Before the Womb Is Back in Its Proper Place?—Lacerations, Their Meaning and Their Significance—The Advantage of an Examination Six Weeks After the Confinement—The Physician Who Does Not Tell All of the Truth
Regarding the More or Less Prevalent Dread or Fear of Childbirth.—Much has been written, and much more could be written upon this subject. Inasmuch as this book is largely intended for prospective mothers to read and profit thereby, and is not for physicians and nurses whose actual acquaintance with confinement work would render such comments superfluous, it will not be out of place to consider this phase of the subject briefly, from a medical standpoint. When one considers that "a child is born every minute" as the saying goes, and which is approximately true, and at the same time remembers that statistics prove, as near as can be estimated, that there is only one death of a mother in twenty thousand confinements, it would really seem as though we were "looking for trouble" to even regard the subject as worthy of the smallest consideration. It is much more dangerous to ride five miles on a railroad, or on a street car, or even take a two-mile walk,—the percentage possibility of accident is decidedly in your favor to stay at home and have a baby. Almost any disease you can mention has a higher, a much higher fatality percentage than the risks run by a pregnantwoman. The real justification for actual fear of serious trouble is so small that it barely exists. These are facts that cannot be argued away by any specious if or and. Why, therefore, should there be any real fear?
Did you ever hear of the remarks made by a famous philosopher who was given a dinner by his friends in celebration of his 85th birthday? In replying to the eulogisms of his friends he said in part:
"As I look back into those blessed years that have faded away, I can recall a lot of troubles and many worries as well as much happiness and pleasure, and thinking of it all this evening I can truthfully say my worst troubles and worries never happened."
So it is with the woman who for weeks or months has made her own life wretched, and possibly the life of her husband and friends, the same in imagining all kinds of dreadful things that never take place. It is undoubtedly an exhibition of weakness, an evidence of failure in the development of self-control. Childbirth is a natural process,—there is nothing mysterious about it. If you do your part you have no cause to fear,—the very fact, however, that you entertain a dread of it, shows that you are not doing your part. One of the saddest parts of life, one of the real tragedies of living, is the fact that most of us have to live so long before we really begin to profit by our experiences. Could we only be taught to learn the lesson of experience earlier, when life is younger and hope stronger, we would have so much more to live for and so many more satisfied moments to profit by. One of the most valuable lessons experience can teach any human being is not to worry and fret about the future. You can plant ahead of yourself a path of roses and be cheerful, or you can plant a bed of thorns and reap a thorny reward. Cultivate the spirit of contentment, devote all your energy to making the actual present comfortable. Don't fret about what is going to bother you next week, because, as the philosopher said, most of the troubles we anticipate and worry about never occur, but the worry kills.
Regarding the Use of Anesthetics in Confinements.—Anesthetics are as a rule given in allconfinements that are not normal. To make this statement more plain it may be said, that, when it is necessary to use instruments, or to perform any operation of a painful character, it is the invariable rule to give anesthetics. As to the wisdom of giving an anesthetic when labor is progressing in a normal and satisfactory manner, there is a difference of opinion. Much depends upon the disposition of the patient and the viewpoint of the physician in charge of the case. It is a fact that a large number of confinements are easy and are admitted to be so, by the patients themselves, and in which it would be medically wrong to give an anesthetic. In a normal confinement, however, when the pains are particularly severe and the progress slow, there is no medical reason why an anesthetic could not be given to ease the pain. In these cases it is not necessary to render the patient completely unconscious. Sufficient anesthetic to dull each pain is all that is necessary, and as this can be accomplished with absolute safety by the use of an anesthetic mixture of alcohol, ether and chloroform, there can be no possible objection to it. The use of an anesthetic, however, is a matter that must be left entirely to the judgment of the physician as there are frequently good reasons why it should not be given under any circumstances.
The Presence of Friends and Relatives in the Confinement Chamber.—It is a safe rule to exclude every one from the confinement room during the later stages of labor. Sometimes it is desirable to make an exception to this rule in the interest of the patient, by permitting the mother or husband to remain. If this exception is made, however, they must be told to conduct themselves in a way that will tend to keep the patient in cheerful spirits. They must not sympathize, or go around with solemn, gloomy faces. Cheerfulness and an encouraging word will tide over a trying moment when the reverse might prove disastrous.
Practically the same rule applies to the entire period of convalescence during which time the patient is confined to bed. This is a very important episode in a woman's life and the consequences may be serious if it is misused in any way. Friends and relatives do not appreciate theabsolute necessity of guarding the patient from small talk and gossip, and an unwitting remark may cause grave mental distress, which may retard the patient's convalescence and disastrously affect the quality and quantity of her milk, thereby injuring the child.
How Long Should a Woman Stay in Bed After a Confinement?—To answer this question by stating a specific number of days would be wrong, because, few women understand the need for staying in bed after they feel well enough to get up. If any answer was given, it should be at least fourteen days, and it would be nearer the truth medically to double that time. Let us consider what is going on at this period. The natural size of the unimpregnated womb is three by one and three-quarter inches, and its weight is one to two ounces. The average size of the pregnant womb just previous to labor is twenty by fourteen inches, and its weight about sixteen ounces. We have, therefore, an increase of about 600% to be got rid of before it assumes again its normal condition. This decrease cannot be accomplished quickly by any known medical miracle. Nature takes time and she will not be hurried: she will do it in an orderly, perfect manner if she is allowed to. The womb will again find its proper location and will resume its work, in a painless, natural way, in due time, if all goes well. The uterus or womb is held in its place by two bands or ligaments, one on either side, and is supported in front and back by the structures next to it. These bands keep the womb in place in much the same way as a clothes pin sits on a clothes line, and it will retain its proper place provided everything is just right. After labor, it is large and top heavy. If you put a weight on the top of a clothes pin as it sits on a clothes line, what will take place? It will tilt one way or the other, and if the weight is heavy, it will turn completely over. So long as the woman lies in bed the womb will gradually shrink back to its proper size and place; if she sits up or gets out of bed too soon, the weight of the womb, being top heavy, will cause it to tilt and sag out of its true position. As soon as it does this the weight of the bowels and other structures above will push and crowd it furtherout of place. This crowding and tilting interferes with the circulation in the womb and its proper contraction is interfered with, and thus is laid the foundation for the multitude of womb troubles that exist.
It is a mechanical as well as a medical problem. Being partly mechanical, it is subject to the rules that govern mechanical problems. The importance of this dual process will be appreciated by considering the following fact. Many medical conditions tend to cure or rectify themselves because nature is always working in our behalf if we give her a chance. Take for example an ordinary cold. You can have a very severe cold and you can neglect it, and in spite of your neglect you will get well. It is not wise to neglect colds, nevertheless, it is true that nature will cure, unaided, a great many diseased conditions, if she has half a chance. This, to a very large extent, is the secret of Christian Science, yet the principle is known to everyone. A mechanical condition, on the other hand, has absolutely no tendency to get well of its own accord, or without mechanical aid. This is why Christian Science cannot cure a broken leg. It is this principle that makes diseases of the womb so persistent, and so stubborn of cure. When a womb once becomes slightly displaced, the tendency always is for it to grow worse and never to cure itself. The longer it lasts the worse it gets. Its cure depends upon mechanically putting it back in place and holding it long enough there to permit nature to reëstablish its circulation, and by toning and strengthening it so that when the mechanical support is taken away it will retain its position. There is no other possible way of doing it. Now since it has been proved that nature takes many days to contract a pregnant womb, a woman is taking a risk, and inviting trouble by getting out of bed before that time.
Why Do Physicians Permit Women to Get Up Before the Womb is Back in its Proper Place?—Without offering the excuse that a woman will not stay in bed as long as a physician knows she should, there is, however, a large degree of truth in this excuse. And we are of the opinion that, if a physician made it a rule to keep all his confinement cases in bed for one month,he would very soon find himself without these patients.
Experience has taught us, however, that it is safe, under proper restrictions, and in uncomplicated confinements, to allow patients to sit up in bed on the 12th and in certain cases on the 10th day, and to get out of bed on the 12th or 14th day. When the patient is allowed to sit up, out of bed, it should not be for longer than one or two hours, and during that time she should sit in a comfortable rocking or Morris chair, which should be placed by the side of the bed. Each day the time can be lengthened, and the distance of the chair from the bed increased. This procedure gives her the opportunity to walk a little further each day, thereby to test her strength and ability to use her limbs. On the fourth day, if all has gone well, she may stay up all day and she may walk more freely about the room. She should be just to herself, however. As soon as she is fatigued she should not make any effort to try to "work it off." When a feeling of fatigue appears she should rest completely. If she has any pain or distress she should acquaint the physician with it at once. She should not try to hide anything on the mistaken idea that "it isn't much." She does not know, and she is not supposed to know what the pain may mean; it may be exceedingly significant. Many women have saved themselves needless suffering, and their husbands unnecessary expenditure of money, by calling the physician's attention to conditions, which in time would have been serious, and would have necessitated long, expensive treatment.
Lacerations During Confinement, Their Meaning and Their Significance.—The only interest a laceration or a tear has to a physician, is whether the laceration or tear is of sufficient importance to need surgical interference. The laceration can take place at the mouth of the womb, or on the outside, between the vagina and rectum.
Those of the mouth of the womb always take place, in every confinement, to some degree. They are never given any attention at the time of the confinement, unless under extraordinary circumstances, such as a more or less complete rupture of the womb, and this is such arare accident that most physicians practice a lifetime and never see or hear of one single case. Those on the outside are always attended to immediately after labor, or should be, unless they are very extensive and the patient is not in condition to permit of any immediate operative work. In such a case it is best to leave it alone until the patient is in condition to have it operated on at a later date.
It is distinctly preferable to have it attended to immediately after labor when it is possible, and it is possible in a very large percentage of the cases. The explanation of this is because it is practically painless then, owing to the parts having been so stretched and bruised that they have little or no feeling. If it is left for a day or two and then repaired, it will be more painful, because the parts will have regained their sensitiveness. Another good reason in favor of immediate repair is that a much better and quicker union will take place than if postponed.
When a patient is torn, but not to the degree necessary to stitch, it is to her advantage to be told to lie on her back and keep her knees together for twelve hours, thus keeping the torn edges together and at rest, thereby favoring quick and healthy repair of the tear. Some physicians go as far as to bind the patient's knees together so she cannot separate them during sleep.
It is the custom of every conscientious physician to request every woman he confines to report at his office six or eight weeks after labor. The reason for this is to find out by examination the character and extent of the lacerations of the mouth of the womb. No physician can tell at the time of labor just how much damage has been done, because the mouth of the womb, at the time of labor, is so stretched and thinned out, that it is impossible to tell. After the womb has contracted to about its normal size, it is a very simple matter for any physician to tell exactly the character and extent of the lacerations. Most of these tears need absolutely no attention; there are a few however that do. This is a very important matter for two very good reasons.
1st. Every woman should know, and is entitled toknow, just what condition she is in, because if she has been torn to an extent that needs attention, and is left in ignorance of it, her physical health may be slowly and seriously undermined and the cause of it may not be understood or even guessed at. A woman who becomes nervous and irritable, loses vim and vitality, has headaches, backaches and anemia, and no symptoms, or few, that point to disease of the womb, will suffer a long time before she seeks relief of the right kind, and will be astonished and outraged when she is told that it all results from a bad tear of her womb that she knew nothing about.
2nd. A physician should in justice to himself insist on this late examination, because if a woman is told, at some subsequent time, by another physician that she is badly torn, and she was not told of it by the physician who confined her, she is very apt to form an unjust opinion of his work and to entertain an unfriendly feeling toward him as a man.
Some physicians also, to their discredit, are not slow in permitting an unjust opinion of a colleague to be spread around, by preserving a silence, when an explanation would result in an entirely different opinion by the patient. They permit it to be inferred that the physician was responsible for the tear, when such is not the case. No physician on earth can prevent a tear of the mouth of the womb and this should be explained to the patient. Where the physician is at fault is in the failure to examine his patients when it is possible to tell that a tear of any consequence exists. If such an examination is made, he is in a position to state that a tear exists of sufficient extent to justify careful attention. Immediate operation is seldom necessary, and if the patient is comparatively young, it may not be wise to operate, because if pregnancy takes place within a reasonable time the womb will again tear. She should be told, however, that should she not become pregnant during the next three years she should be examined from time to time, and if the condition of her womb, or her health suggest it, she should have the tear attended to. If after this explanation she neglects herself she must blameherself, she will at least have no cause to harbor any resentment against her physician who has done all any physician is called upon to do under the circumstances. Another important reason for finding out the character of the laceration is because these lacerations of the mouth of the womb frequently cause sterility.