Although not the rule, it is by no means unusual for the membrane to rupture at the onset of labor, or at least before the mouth of the womb is fully dilated. Exceptionally, rupture occurs a few days before labor begins; and still longer intervals, though extremely rare, have been recorded. Whenever the membranes rupture prematurely, the pushing force of the uterine contractions becomes less effective, though the pulling force is never impaired. Under these circumstances, which occasion what is called a "dry labor," delivery is apt to proceed slowly, yet that does not follow necessarily, for the part of the fetus which happens to lie over the mouth of the womb may act as efficiently as the unruptured membrane would.
During the first stage, the longest of the three, the patient is comfortable between the contractions and generally interests herself in some diverting occupation. The presence of the physician can be of no assistance then, and patients rarely demand it. Usually, they are satisfied to know he is ready to come when called. It is wrong to deceive patients with various recommendations from which they will vainly expect help during this stage; their welfare is best served when they are left alone. Generally the advice of well-meaning friends will be as harmless as it is futile, yet I must emphasize that during the first stage straining to expel the fetus is ill advised. Such effort will surely be ineffective then and may exhaust the patient; in that event it becomes harmful, for she will be fatigued when she most needs strength.
Since, during the first stage, the progress of delivery is not influenced by what the patient may choose to do, she may follow her own inclinations. The average patient will be restless and will keep on her feet most of the time; alternately she will walk or stand still as one or the other happens to make her more comfortable. As a contraction begins she often seeks support, leaning upon a chair or bending over the foot of the bed, and presses with her hands against the lower part of her back. Patients may sit down or lie down whenever they wish; if so inclined they may even go to sleep.
Most patients take no food during the whole course of labor, but, if nourishment is desired, there is no reason for abstaining from it. They may always drink water as freely as they like, and may also have milk, weak tea or coffee, or broth; but alcoholic beverages should never be taken without the specific consent of the physician. This same caution applies to strong coffee and tea. If desired, crackers or toast and rice or other cereals may be eaten in reasonable quantity. For fear of vomiting a patient will occasionally be told not to partake of any food. This advice is given, not because the symptom is alarming, but to save her needless annoyance. Indeed, vomiting frequently indicates that dilatation is well advanced, and, therefore, may generally be regarded as an encouraging sign. Ordinarily a persistent inclination to have the bowels move has the same significance. On the other hand, a constant desire to empty the bladder is more prominent at the onset of labor than later.
To know the moment which marks the transition from the first to the second stage of labor can be of no benefit to the patient; but for the medical attendant the greatest interest centers about this point. Casual observation sometimes enables the physician to recognize it, for characteristically at the close of the first stage the whole picture changes. In a typical case the membranes will rupture at this instant, expulsive efforts will begin, and, as we have just learned, there may be symptoms referable to pressure. Moreover, a blood-tinged discharge, spoken of as the "show," usually makes its appearance about the same time. Since slight bleeding frequently occurs at the beginning of labor, or a little later, this manifestation, like all others, may not be implicitly trusted to indicate the end of the first stage. Such uncertainty, however, is a matter of no great consequence, for in the absence of all these symptoms the physician may, if necessary, accurately determine the degree of dilatation by an internal examination.
THE STAGE OF EXPULSION.—The term delivery has been broadly applied to include the whole of labor. More strictly, its use should be limited to the second stage, for this period alone is concerned with the actual birth of the child. Although dilatation has been completed, the uterine contractions continue, devoting their force to emptying the womb. In this they now receive assistance from the voluntary contractions of the abdominal muscles.
The second stage is very much shorter than the first; for this reason and others, too, it proves much less trying. As the child is moved downward through the birth-canal, the mother usually appreciates for herself that she is making headway; whereas in the first stage she may know of progress only through what she is told. Moreover, it is possible in this stage for the physician, by means of inhalations of chloroform, to relieve her of the pain attending the expulsion of the child.
Since the anesthetic properties of chloroform were discovered by an obstetrician who was searching for a drug with which to lessen the pain of childbirth, the facts connected with the discovery have a peculiar interest for mothers. Sir James Y. Simpson had always been anxious for some means to prevent the suffering endured during surgical operations "without interfering with the free and healthy play of the natural functions." He, therefore, welcomed the introduction of ether anesthesia from America; and in January, 1847, at the Edinburgh Medical School, administered ether to an obstetrical patient. This was the first instance in which an anesthetic was employed at the time of childbirth. Since ether, to his mind, had certain shortcomings, Simpson set about finding another anesthetic, and devoted all his spare time to testing the effect of numerous drugs upon himself. How he came to try chloroform has been vividly told by one of his neighbors. [Footnote: "Late one evening, it was the 4th of November, 1847, Dr. Simpson, with his two friends and assistants, Drs. Keith and Duncan, sat down to their somewhat hazardous work in Dr. Simpson's dining room. Having inhaled several substances, but without much effect, it occurred to Dr. Simpson to try a ponderous material which he had formerly set aside on a lumber- table, and which, on account of its great weight, he had hitherto regarded as of no likelihood whatever; that happened to be a small bottle of chloroform. It was searched for and recovered from beneath a heap of waste paper. And with each tumbler newly changed, the inhalers resumed their vocation. Immediately an unwonted hilarity seized the party—they became bright-eyed, very happy, and very loquacious—expatiating upon the delicious aroma of the new fluid. But suddenly there was talk of sounds being heard like those of a cotton mill, louder and louder; a moment more, and then all was quiet—and then a crash! On awakening, Dr. Simpson's first perception was mental—'This is far stronger and better than ether,' said he to himself. Hearing a noise, he turned round and saw Dr. Duncan beneath a chair, quite unconscious, and snoring in a most determined manner. More noise still and much motion. And then his eyes overtook Dr. Keith's feet and legs making valorous attempts to overturn the supper table. By and by Dr. Simpson having regained his seat, Dr. Duncan having finished his uncomfortable and unrefreshing slumber, Dr. Keith having come to an arrangement with the table and its contents, thesederuntwas resumed. Each expressed himself delighted with this new agent, and its inhalation was repeated many times that night. Miss Petrie, a niece of Mrs. Simpson, gallantly took her place and turn at the table, and fell asleep, crying: 'I'm an angel! Oh, I'm an angel!'"—Quoted from "The Life of Sir James Young Simpson," by H. Laing Gordon; Masters of Medicine Series.]
The introduction of chloroform met with violent opposition, not upon medical grounds alone, but also for moral and religious reasons. "To check the sensation of pain in connection with the visitations of God," zealous theologians announced, "was to contravene the decrees of an all-wise Creator." Simpson reminded them "that the Creator, during the process of extracting the rib from Adam, must necessarily have adopted a somewhat similar artifice—for did not God throw Adam in a deep sleep?" Nevertheless, a number of years passed before the prejudice against artificial sleep was overcome. Chloroform only became popular after Queen Victoria consented to its use at the birth of her seventh child, Prince Leopold, in 1853.
There is still some difference of opinion regarding the routine employment of chloroform in obstetrical practice, though the weight of authority favors its use during the contractions at the end of the second stage, providing always that no preexisting organic derangement renders the drug dangerous. Under no circumstances, however, should chloroform be given in the first stage, and seldom at the beginning of the second. Prolonged administration will exert an injurious influence upon both mother and child; under these conditions it ultimately weakens the uterine contractions and delays the delivery. Such an effect must be avoided, since it would endanger the life of the child by asphyxiation as well as exhaust the mother. On the other hand, a few drops of chloroform inhaled with each pain toward the end of the second stage will dull sensibility, although consciousness remains unaffected. When the drug is thus administered, the uterine contractions are scarcely, if at all, altered, and the assistance which the patient is willing to give herself generally becomes more powerful. Should the anesthetic have the opposite effect, it must be withheld; but that is seldom necessary. As the head advances the anesthesia is deepened, and the mother sleeps soundly while the child is being born.
As long as dilatation is in progress, the patient may sit up or walk about; but with the advent of the second stage she should go to bed, for there she will be able to make the best use of the expulsive pains. The appropriate posture for delivery is still the subject of dispute, though modern views in no instance advocate the unnatural absurdities formerly supported by custom or superstition. Students of ethnology relate that among savage tribes almost every conceivable position was advocated for women in labor. Subsequently it became customary to have delivery take place in specially constructed chairs which are still used in semi-enlightened countries. With civilized nations at present women are always delivered in bed; yet national peculiarities still prevail. Some physicians favor what is known as the English position, in which the patient lies on her left side with her face inclined toward the chest, the trunk bent toward the knees, and the legs drawn up toward the abdomen. The majority of obstetricians, however, prefer that the patient should lie flat on her back. With the average case, and from the standpoint of facility in delivery, which of these postures happens to be chosen is a matter of indifference. But it is so much less awkward for the physician when the patient is on her back that this position has been widely adopted in America.
During the expulsion of the child the mother intuitively desires to help herself; generally she cannot resist straining, and rarely needs encouragement. Assisting the uterine contractions with voluntary muscular effort, the act commonly described as "bearing down," may be performed most effectively when the patient is lying on her back. The knees are drawn up and spread apart; the feet are braced against some firm object; the hands grasp straps fastened at the foot of the bed; and the head is slightly raised so as to bring the chin near the chest. When the contraction begins the patient takes a deep breath and holds it while she strains vigorously, as if to make her bowels move. All voluntary effort should cease as the contraction wears away, for straining between the contractions can accomplish nothing. Her own inclination to "bear down" will clearly indicate to the patient when she ought to act.
In the second stage patients regularly experience a feeling of pressure against the rectum, and this sensation, since it depends upon a low position of the child's head, is a welcome sign. Cramps in the legs also indicate progress, for they result from similar pressure against nerves adjacent to the lower part of the birth- canal. The cramps disappear immediately after the child is born, and are consequently never dangerous. Straightening out the legs or rubbing them usually gives relief. Most women, however, complain during the expulsive period only of pain in the back, and find nothing so grateful as firm pressure over this region.
Energetic efforts quickly bring the head to the outlet of the birth- canal, where it may be seen, at first only during the contractions, but later during the pauses as well. The crown of the child's head is generally directed upward and becomes fixed against the pubic bones of the mother, which lie just in front of the bladder. Around this firm pivot the child's head rotates upward, and, as a result of the movement, forehead, eyes, nose, mouth, and chin successively emerge from the birth-canal. Following the birth of the head, natural forces turn the body upon one side, the better to accommodate the shoulders to the passageway. After these are born, the rest of the body slips easily into the world, and the second stage ends.
THE PLACENTAL STAGE.—Although the third stage is chiefly concerned with the separation and the delivery of the after-birth, on which account it is known as the placental period, the description of other no less remarkable events belongs here. Even after the infant is born the umbilical cord extends from its navel to the placenta, just as it has done throughout pregnancy. Among larger mammals separation of the new-born from the mother is brought about in one of two ways; sometimes the activity of the young breaks the navel-string, though more frequently the mother bites it in two. Both these methods, we are told, have been employed by savages; but at the beginning of civilization it became customary to sever the cord with a cutting tool, and the tie thrown round it represents the first attempt of man to ligate blood-vessels. Ordinarily there is no need for haste in this operation. On the contrary, some delay is often of advantage, since an appreciable quantity of blood that otherwise would remain in the placenta is thus given opportunity to enter the infant's body. According to present ideas, as long as the heart-beat can be felt in the cord it should not be tied.
The sleep induced toward the close of the previous stage lasts for a few minutes, so that most patients are unconscious through the greater part of the brief placental stage. Before the influence of the anesthetic has worn off, the physician has an excellent opportunity to sew up any laceration which may have occurred in the course of delivery. Slight injuries are not uncommon, especially if the confinement be the first, for the most skillful treatment often fails to prevent them. Since superficial tears are never serious if promptly closed, it is not their occurrence, but the failure to recognize them, or to sew them up when they are recognized, that deserves condemnation.
After the birth of the child the womb becomes smaller, its walls grow thicker, and the cavity within is narrowed. This series of changes partly detaches the placenta, but the separation depends chiefly upon the uterine contractions. These contractions also force the after- birth into the vagina, whence it may ultimately be dislodged by the patient if she bears down again. Usually, however, it is preferable to save her further efforts of this kind, and, as a routine, the physician places one hand upon the abdominal wall, grasps the womb, and, during the contraction, makes firm pressure downward. The maneuver expels the after-birth, which consists of the placenta, the membranes, and the umbilical cord. Then the empty womb will form a hard, spherical mass about the size of the child's head, lying just above or to one side of the bladder.
Slight bleeding also occurs during the third stage, and further loss of blood follows the removal of the after-birth. The total loss varies between a half pint and a pint, though larger amounts may be noted occasionally without appreciable effect upon the mother. Naturally, large, robust women can spare much more blood than those who are anemic. And yet pregnancy invariably prepares the mother for a loss of blood that would alarm anyone unfamiliar with obstetrical practice. Often the woman just delivered is not harmed by a hemorrhage that would endanger the life of a healthy man. This may seem paradoxical, but it is not; for the surplus blood, which formerly performed important duties in connection with the nutrition of the fetus, must now be removed to readjust the mother's circulation.
In a very small number of cases an unduly large loss of blood follows the expulsion of the placenta. Fortunately, by treatment which consists usually in spurring Nature to more vigorous action we are well equipped to deal with this emergency. A wonderful mechanism has been provided by Nature to control excessive bleeding after delivery. If the forces upon which this mechanism depends are sluggish, the physician stimulates them. As in the preceding stages, the muscle fibers of the uterus supply the power in question, and because of this role an observant obstetrician once called them, "living ligatures." Certain of these fibers encircle the mouths of the blood- vessels which have been left open through the detachment of the placenta. When they contract the vessels are squeezed, impeding the escape of blood. The necessity of this action explains the contractions which continue even after the placenta has been expelled, when they are vigorous enough to cause discomfort they are spoken of as "after-pains." After-pains seldom follow the birth of the first child, but they regularly follow later confinements. In any case, such contractions do not persist very long, for tiny clots form within the blood vessels and effectually close them. As soon as the lining of the womb has been restored the clots are absorbed, leaving the organ in much the same condition as before conception took place.
THE EFFECT OF LABOR UPON THE CHILD.—Unless the experience of countless generations had taught us otherwise, we should fear the child would be injured by its passage through the birth-canal. Immediately after the birth evidence of the journey is seldom wanting, but it quickly disappears.
The unusual size of the infant's brain requires the head to be large, and bestows upon it a contour which differs from that of the mother's pelvic cavity. Since the bones of the pelvis are rigid, while those of the fetal skull are malleable, the head is molded as it descends into the pelvic cavity, so that its passage may be made the easier. As the result of this process of accommodation the skull becomes relatively longer from crown to chin than in adults. Within a few weeks, however, the modification vanishes. If an infant is born with the buttocks first, the head does not linger in the birth-canal, a fact which in such cases explains the pleasing shape of the skull, which emerges with the contour determined by fetal growth.
Whenever a soft swelling appears over that portion of the scalp which was foremost during the birth, the curiosity of the family is aroused; but the swelling is harmless and subsides quickly. It originates for the same reason that a finger swells if too tight a ring is worn, which, as everyone knows, is because of interference with the circulation. Just as the swelling of the finger disappears when the constriction is removed, so the swelling of the scalp subsides shortly after the child is born. Usually no trace of it can be found the next day; but even when more persistent it will always vanish after a short time.
For the child the most notable result of labor relates to the revolutionary changes in its mode of existence. Up to the time of birth the fetus received nourishment by way of the placenta, but after separation from the mother another source of food must be found. The health of the tissues, perpetually in need of oxygen, requires that the lungs act very promptly. Contact with the air, which is cooler than the previous environment of the child, irritates the nerve-endings in the skin; in response to the sensation thus produced breathing is established automatically. Whenever the temperature stimulus proves insufficient, physicians employ a stronger one, spanking the child until it cries lustily. Crying not only expands the lungs, but also has a favorable influence upon needful alterations in the fetal circulation.
The lungs, since they must from this time on provide oxygen for the infant, need to receive more blood than formerly. The vessels leading toward them must be widely opened, and structures which previously diverted the blood-stream to the navel must be closed. The intricate shifting of forces which produces the change cannot be understood without a knowledge of anatomy; it will suffice for us to know that the blood is drawn into the vessels of the lungs with each inspiration. Other changes also occur. On account of some of these, namely, certain alterations in the blood current through the heart, physicians once taught that newly born infants should always be laid upon the right side. Except in very unusual cases, that precaution is now regarded as unnecessary.
Of all the elements essential to nutrition, oxygen is the only one required immediately after birth; as the child enters the world well stocked with all the others. Babies are not born hungry, as many people seem to think. Neither is their crying a proof of it, for, as we have observed, they have other very good reasons for crying; nor is their readiness to suck anything that comes in contact with the mouth, for they will behave in the same way while they are receiving an abundance of nourishment through the umbilical cord. Many hours pass before a newly born infant can possibly need food. Indeed, it could survive a week or longer without taking anything, by mouth, except water. The ability to suckle at birth merely indicates that the infant is prepared to utilize the mechanism which nature will now employ to sustain it.
After the umbilical cord has been severed the blood vessels within it can serve no further purpose. Consequently the remnant of this structure attached to the child's abdomen begins to shrivel. Formerly the care of the stump was considered a trivial matter; when cleanliness was neglected decomposition caused more rapid separation than takes place under the treatment which it now receives. No annoyance should be felt because the cord hangs on a long time; indeed, such an experience means it has been given exceptionally good care. Separation rarely occurs before the end of a week. It may be deferred for two weeks, or even longer, if the stump has been kept perfectly clean. After the shriveled cord drops off, the skin around the navel contracts, leaving a small raw area which discharges a yellow fluid for two or three days before the healing is complete.
MEDDLING.—In selecting a physician the patient will almost certainly have been guided by her confidence in his ability. It may seem strange, therefore, to insist that he be allowed to conduct the delivery as he thinks best. Nevertheless, suggestions from outsiders are so common, especially if the labor be at all prolonged, that it seems appropriate to warn patients to pay no attention to such advice. In the heat of excitement well-meaning relatives are sometimes inclined to interfere, and women who are not members of the family occasionally wish to discuss their experiences, irrelevant as they may be.
The patient's intimate friends, quite naturally, have the keenest personal interest in the event, an interest that of itself disqualifies them from reasoning calmly at the time. Their influence may be positively harmful if they persuade the physician to undertake procedures which his judgment convinces him are inadvisable. Should he turn a deaf ear, they will think him lacking in sympathy; but should he adopt their suggestions he would assume the full responsibility, and would perhaps be censured later by the very persons whom he sought to please. There can be no question of the proper course for him to pursue. Any influence which such entreaties may have will always be in the direction of too early interference, which is fraught with danger to mother and child alike. The master- word is patience, and it applies alike to the mother herself, to the doctor, and to her friends.
Almost always the whole duty of the doctor consists in watching the progress of labor, so that he may be ready to render assistance should it be needed. Until the second stage begins there is no real necessity for him to remain in the room. Indeed, it is better for him not to do so after he has made sure that satisfactory conditions prevail, for his judgment will be less biased if the patient is not continuously under his observation.
JUSTIFIABLE INTERVENTION.—It is quite true that in the progress of the birth difficulties now and then arise; yet they are far less common than rumor would lead us to believe. The unusual always attracts attention, often receiving greater emphasis than it merits. The particulars of confinement provide no exception to this rule; a delivery which requires artificial aid will be talked about, while hundreds that terminate naturally pass without comment. In this way the public gets an exaggerated notion of the frequency of difficult labors. Moreover, the nature of the trouble is usually distorted, for reports of medical events are apt to be incorrect, and errors multiply with each rehearsal. Obstetrical patients who wish, so far as possible, to escape the depressing influence of such inaccurate reports will be most likely to succeed if they follow the advice to select a physician at the beginning of pregnancy. When this is done the physician will have opportunity to explain or discredit alarming rumors, a task which it is usually necessary for him to perform, for there are always some persons who feel that a prospective mother should listen to everything that they have heard of childbirth.
The most frequent cause for intervention during labor is insufficiency of the muscular contractions to overcome the resistance of the birth-canal. Unusual resistance of this kind explains the longer labors of women who have passed middle life before becoming pregnant. They may need to exercise more patience than younger women, though they have no greater reason to apprehend serious difficulties. Whenever rigidity of the muscles adjacent to the birth-canal arrests delivery the physician may employ the obstetrical forceps, which have been in use since the seventeenth century.
Although it is widely known that physicians sometimes terminate labor in this way, the public estimate of the merits and of the limitations of the instrument is so inexact that the truth about it should be understood. Obstetrical forceps were devised by one of the Chamberlens, a family of French Huguenots who fled to England in 1569. The invention was long kept a secret; therefore its date cannot be fixed, nor even the inventor clearly identified, though everyone agrees that he was a member of this family. Clearly the instrument had been in use for some generations prior to Hugh Chamberlen, who translated from French into English the foremost obstetrical textbook of his time. The book, published in 1672, does not contain a description of the forceps, but in his preface Hugh Chamberlen refers to delay in delivery, saying, "My father, my brothers, and myself (though none else in Europe as I know) have by God's blessing and our own industry attained to and long practiced a way to deliver women without prejudice to them or their infants in this case." It is not questioned that the forceps was the secret that his ancestors and he himself employed so long and so profitably. About a century ago what are probably the original models of the instrument were discovered in a country home of Essex which once belonged to the Chamberlens; there they had been hidden in a trunk in the garret. The box in which they were concealed contained four pairs of forceps, representing different stages in their development, besides other instruments and a number of letters which established their ownership.
After an unsuccessful attempt to sell the family secret in Paris, Hugh Chamberlen found a purchaser in Amsterdam. The privilege of using it in Holland was then granted physicians for a monetary consideration, and that practice continued until two philanthropists purchased the secret to make it public. It was ultimately learned, however, that the sale was a swindle, for the device which the purchasers obtained consisted of only half the genuine instrument. The real secret was revealed by a son of Hugh Chamberlen, who bore the same name as his father; but probably the first accurate printed description of the forceps was made by Samuel Chapman, in his treatise on obstetrics which appeared in 1733. Subsequently they came into general use, and, with many modifications, remain the most important instrument in the obstetrician's equipment. There can be no exaggeration in the claim that the instrument has done more to save human life than any other surgical appliance.
The obstetrical forceps have been of such great service in diminishing the number of still-born infants that they were once called the child's instrument. The need of its employment in behalf of the child may be determined by careful observation of the fetal heart-sounds, which are heard over the mother's abdomen, and by means of which one may learn the condition of the child. Signs of danger are extremely uncommon so long as dilatation of the womb is not complete, for any strain which labor may impose upon the child will usually occur during its passage through the pelvis. Most often, therefore, the head has reached the outermost part of the birth canal before extraction becomes advisable.
The forceps are used also on behalf of the mother, if the continuation of labor seems likely to throw undue stress upon her. On this account the physician frequently resorts to them if his patient is suffering from pneumonia, typhoid fever, or any acute illness at the time of labor. Other maternal indications for their use include various chronic derangements, well exemplified by certain diseases of the heart. Furthermore, even when there are no preexisting complications forceps are employed on account of exhaustion or other conditions which may develop during the course of labor. It must be clearly understood, however, that the physician alone can determine when intervention is justified, as well as what operative procedure is most appropriate; for even though good reasons for terminating labor exist, forceps cannot be properly used unless nature has already fulfilled very definite requirements. By no chance can the patient, much less her friends, decide this matter. And besides, none but a trained observer can detect the symptoms which clearly indicate Nature's incompetence to effect delivery. Disregard of these truths by the family with consequent urging that something be done must be held partly responsible for the reckless use of the instrument. It will be a step in the right direction, therefore, when the laity comes to understand that the value of the instrument generally pertains to the welfare of the child, and that, in any event, its use will be harmful if employed before the womb has been completely dilated.
Although forceps can be employed only in cases of head presentation, intervention may be warranted when some part of the fetus other than the head will be born first. Two or three times in every hundred patients we meet with breech presentations, that is, cases in which the buttocks precede; after their expulsion, the body, the arms, and the head follow. Breech presentations occur more frequently among women delivered prematurely, as might be expected since an examination eight to ten weeks before the calculated date reveals a larger percentage of breech presentations than a similar examination about the normal end of pregnancy. In explanation of these results we accept the view that the size of the fetus at the earlier date does not require nicety of adaptation to the cavity of the womb, whereas at term, unless the child is small, the best accommodation is secured when the head lies downward.
Most breech cases are delivered spontaneously; if not, the outlook for the mother is no less favorable on that account. Assistance, when undertaken, is usually prompted in the interest of the child, which will be seized by the legs and extracted if there are indications to terminate labor. Purely as a precautionary measure, a second physician will often be called about the time the stage of expulsion begins. Foresight of this kind must give the patient confidence rather than alarm her. Indeed, should operative intervention of any kind become necessary in the practice of obstetrics, the inclination of the doctor to call an assistant must be regarded as an evidence of superior judgment.
MANAGEMENT OF BIRTH WITHOUT A DOCTOR.—A prospective mother should not be left alone during the four weeks prior to the expected date of delivery, for it is important that during this period aid may be quickly summoned in the event of an emergency. However, if the confinement be the first, ample warning of delivery will always be given. Even in a later confinement several hours will probably elapse between the preliminary signs and the birth itself. It is extremely rare to have labor progress so rapidly that the child is born before the doctor arrives. Under such circumstances, if the nurse be present she will be master of the situation; whenever she has been unable to reach the patient, someone near by should be called to render what assistance may be needed. A labor which advances so rapidly that skilled assistance cannot be procured is proof in itself that everything is going in an ideal manner, and that interference is not necessary. Although the doctor may not arrive until after the child is born, he frequently renders valuable service in expelling the placenta or in sewing up lacerations. No one should presume then that there is never need for a physician after the second stage is over.
If the suggestions made in the preceding chapter are heeded, immediately after labor begins the room will be set in order and the bed will be properly protected; the patient will take a tub-bath and will put on a freshly laundered nightgown. The sterilized dressings are then placed where they can be easily reached, but are not opened until needed. Antiseptic tablets have been procured, and, following the directions on the bottle, it will be simple to make up a solution of bichlorid of mercury of a strength of 1-1,000.
After the contractions become strong and return at intervals of five minutes, or if the waters have broken, the patient should go to bed; the knees should be drawn up and spread apart, but bearing down with the pains should not begin until the inclination is irresistible, since this forbearance will make the delivery slower and thus afford protection against lacerations which physicians ordinarily seek to prevent by the use of chloroform. In the absence of a doctor it is never permissible to administer this or any other anesthetic. As long as a physician familiar with its action gives the chloroform untoward results need not be feared in obstetrical cases; but the risk would be too great to allow anyone to give it who was unacquainted with the early signs of an over-dose. Again, fear of accident should prevent patients from using the closet when labor is progressing rapidly, for an inclination to empty the bladder or the rectum often signifies that birth is about to take place. Even though this is true, if there is need, patients may try to use the bed-pan.
About the time when the patient goes to bed the attendant prepares to render such assistance as may be required. First she should scrub her hands thoroughly with soap and water and subsequently soak them in the bichlorid solution for five minutes, or longer if there be no need for haste. A large delivery-pad is then placed under the patient, the leggins put on, and, from this moment, the outlet of the birth-canal should be exposed to view. After the scalp of the child comes into sight, the attendant is not to leave the bed-side, though she must keep "hands off" until the head has been completely expelled.
A pause occurs between the birth of the head and of the rest of the body. It is usually safe to await further expulsive contractions, but should the child's face turn a dusky blue, which indicates that it needs to breathe, the patient is to be advised to strain vigorously and to make firm pressure over the womb with both her hands. At the same time the attendant must pull the child downward, having seized its chin with one hand and the back of its head with the other. The straining of the mother combined with traction by the attendant will be certain to effect delivery quickly. As soon as the child is born, it should take a breath and begin to cry. If it does not cry of its own accord, it can usually be made to do so by holding it up by the feet and slapping it on the back several times. Subsequently the child is placed between the patient's legs in such a way as to prevent stretching of the cord. Usually the nurse will leave it in this position and turn her attention to the mother.
After the birth of the child it is easy to feel through the mother's abdominal wall, which has now become lax and flabby, the organs which lie beneath it. The top of the womb, once just below the edge of the ribs, may now be found about the level of the uppermost part of the hip bones, a position which it keeps until detachment of the after- birth begins. As the after-birth peels off, the firmly contracted womb gradually rises in the abdominal cavity, and by the time when the separation has been completed reaches the region of the navel.
While these changes, which naturally require from ten to thirty minutes and occasionally longer, are taking place, the attendant must wait patiently; attempts to hurry the separation of the placenta are never wise, for they may lead to excessive bleeding. No effort should be made to bring away the after-birth by pulling upon the cord. It is equally unwise for inexperienced persons to press upon the womb in the hope of pushing out the placenta. To encourage the mother to strain just as she did in assisting the birth of the child would always be a safer plan. And if that is ineffective, further delay is necessary; in several instances a natural separation of the placenta has repaid me for waiting as long as two hours. Prolonged delay may be annoying, yet, provided that the doctor arrives within a reasonable time, it can scarcely lead to anything more serious than annoyance. Rather than authorize frantic efforts to remove the afterbirth, I should much prefer to have a patient of my own call another doctor.
If the after-birth comes away of its own accord, as will generally happen when due patience has been exercised, it may be severed from the child and put aside for the inspection of the doctor, for he should learn by examining it whether everything has come away properly. The cord must be securely tied in two places with the sterilized bobbin mentioned in the list of articles for confinement. One ligature is applied about two inches from the child's abdomen, the other an inch nearer the placenta; the cord is then cut between them with a pair of sterile scissors. Anyone fearful of injuring the infant may prevent accident by spreading a diaper under the part of the cord to be severed. This precaution also protects the bed from soiling, for there will be a single spurt of blood the instant the cord is cut. So long as the child is in good condition there is no urgent need of this operation. If the child is breathing satisfactorily it may generally be deferred until the doctor arrives. When this course is chosen the attendant will wrap the infant in a warm blanket, place it along with the after-birth in a safe spot, and subsequently devote herself to making the mother comfortable.
The vulva and neighboring parts are bathed with a 1-1000 bichlorid solution. Soiled dressings are removed, the gown changed, and, if necessary, clean sheets put on the bed. A sterile sanitary pad is placed over the vulva and a fresh one substituted as often as necessary, but none of the pads should be destroyed. All the dressings must be saved so that the doctor may see how much blood has been lost. As we have learned, bleeding regularly occurs while the placenta is separating and thereafter; excessive bleeding will rarely follow a normal delivery if the attendant has heeded the precaution to leave everything to nature. If ever the loss of blood should become alarming before the doctor arrives, it is advisable to raise the foot of the bed, to keep the patient quietly on her back, to grasp the womb through the abdominal wall, and to massage it constantly until the nearest physician can be gotten.
Of these directions the most important is that which relates to the management of the womb, for in cases in which labor has been normal in other respects the relaxation of its muscle is most often responsible for flooding. What to do in this event must therefore be made plain. First the patient should try to empty her bladder, and, if she cannot, pressure made above the organ will usually expel the urine. The attendant will then take her seat on the edge of the bed, facing the patient's feet, and will locate the womb. When there is flooding one may expect to recognize the womb as a large, rather soft mass lying in the mid-line of the abdomen with its upper margin somewhat above the navel. With one hand, or with both if necessary, the mass is grasped in such a way that the fingers cover the top of it and pass backward toward the spinal column; the thumb remains in contact with the front of the organ. The womb is stroked and squeezed much as one kneads dough, and for this reason the procedure is technically called kneading. Such manipulations cause the muscle fibers to contract firmly, and in consequence the blood vessels are tightly closed and bleeding ceases. Similarly, cold applications to the abdominal wall tend to provoke uterine contractions; placing over the womb an ice-cap or towels wrung out of cold water and doubled several times often have a beneficial influence when there is a tendency toward relaxation. Some physicians also recommend that the child be placed at the breast, since suckling is known to cause uterine contractions. There are other measures which are occasionally employed, but they should be used only by physicians, for in the hands of an inexperienced person they may do more harm than good.
Very often a slight chill follows labor. It has a nervous origin and need never give uneasiness; a drink of warm milk, hot-water bags to the feet, and extra blankets will be sure to make the mother comfortable. On the other hand, excitement of any kind aggravates this condition. In general, recently delivered patients must be kept quiet no matter how well they feel. A few hours of sleep, or, at least, of repose, are justified by the fatigue incident to labor, and nothing should be permitted to interfere with it.
METHODS OF REVIVING THE CHILD.—Complications which interfere with the child's vitality rarely occur when labor proceeds so rapidly that there is not time to get a doctor. Nevertheless a description of child-birth would be incomplete without reference to the measures intended to revive asphyxiated infants.
Such measures aim, first of all, to make the infant breathe for itself, and if breathing does not begin promptly we resort to artificial respiration. Mucus in the mouth or in the lower air- passages hinders the entrance of air into the lungs; consequently it is the duty of the attendant to remove this mucus by means of gauze or some light fabric wrapped about a finger and passed backward over the tongue. In most cases nothing else will be necessary. But if breathing is not immediately established, the child should be grasped by the feet with one hand and held downward while its back is vigorously slapped with the other. Usually, it gasps at once; when it does not, the attendant may stroke its face and chest with her hand, which has been previously held in cold water for a moment; or she may dash a handful of cold water upon its body. With very rare exceptions these procedures make the child cry.
One must always be alert to see the very first attempt at breathing, for unduly prolonged manipulations may defeat their own object; the natural inclination always is to do too much rather than not enough. In some instances, however, the measures thus far indicated will not prove successful, and, if not, the cord must be tied and cut through, for subsequent treatment cannot be conveniently carried out while the child remains attached to the placenta. As soon as the cord is severed the child is placed in a tub of warm water, about the normal temperature of the body, and is moved about in the bath for a few moments, the attendant watching closely all the while, for the breathing is often very superficial. Should signs of beginning respiration not appear, the attendant should grasp the child by the shoulders, dip it up to the neck in a basin of cold water and quickly return it to the warm tub. This operation may be repeated five or six times; generally the instant the child touches the cold water it draws up its feet, opens its eyes, and cries. One must take care that the plunge lasts but a moment; if the child becomes chilled efforts to revive it will likely be unsuccessful. Indeed, the necessity for keeping it warm must be constantly borne in mind.
With the very exceptional cases in which hot and cold tubs are ineffective, the following method becomes valuable. Wrap the child in a blanket and lay it face downward upon a table or chair, allowing the head to hang over the edge. Roll the body on one side or a little beyond; then slowly roll it back upon its face and onward to the other side. This maneuver is repeated fourteen times to the minute, but not more frequently. When properly performed it secures a flow of air to and from the lungs with the same rapidity as in the normal respiration of an infant. Efforts to revive the child must not be quickly given up, as a successful outcome occasionally requires half an hour of work or even longer. One method after another should be tried in the order which I have indicated. A physician always perseveres so long as the heart-sounds can be heard; but, since an inexperienced person might be unable to decide upon this point, the most reliable course for the layman is to persist in the resuscitation until the physician arrives.
The Changes in the Uterus—The Lochia—The Return of Menstruation—Other Restorative Changes: The Loss in Weight; The Abdominal Wall;The Pelvic Floor—The Care of the Patient: The Elimination of WasteMaterial; Cleanliness; The Diet; The Environment; The Time forGetting up—The Final Examination.
A generation ago physicians were accustomed to see their obstetrical patients only at the time of labor. No preliminary examination was thought necessary, and after the delivery visits were not made unless the family became alarmed and requested them. When thus asked to come back the physician sometimes found that an infection had developed; occasionally the breasts were giving trouble, or some other difficulty in the care of the mother or of the infant was baffling the nurse. It is now recognized that the medical attendant should not wait for the appearance of untoward symptoms. Although the strict observance of the various precautions which I have already emphasized should lead and usually do lead to an uneventful convalescence, it is none the less true that the danger of infection and of other immediate complication has not passed until several weeks after delivery. For this reason and also because skillful guidance of the mother at this time will prevent unwelcome sequels in the later years of life, physicians now extend their watchfulness beyond the hour of birth. The number of visits ordinarily required is not large. In each case, to be sure, the circumstances will determine the number; but, as a rule, ten visits, if properly distributed, will be sufficient. During the month succeeding delivery these visits should be made in about this order: a daily visit for the first five days, subsequently one upon the seventh, the tenth, the fourteenth, the twenty-first, and the twenty-eighth day.
At the conclusion of labor there begins a series of changes which are the reverse of those incident to pregnancy, and which restore the body to its original condition. Six weeks are generally required for these alterations. They should leave the mother inperfecthealth, but traces of pregnancy are not entirely effaced; even in the absence of outward evidence, if a woman has ever given birth to a child a thorough internal examination will disclose the fact.
The initial steps in these restorative processes are taken most promptly and effectively when patients remain in bed. The traditional custom of doing so has given to the first few weeks following delivery the popular name, "the Lying-in Period." To these weeks physicians usually apply the technical termpuerperium, the child's period, a designation which brings to mind the secretion of milk which, though not a retrogressive change, is, nevertheless, one of the most distinctive results of childbirth.
Radical as the bodily changes in progress at this time are, the lying-in period is not a period of illness. But there is, perhaps, no other time in a woman's life when she may cross the boundary between sickness and health so easily; for here nature tolerates no trifling. Not infrequently puerperal patients who are feeling well attempt too much, and suffer a more or less serious set-back; it is an all- important duty of the obstetrician, therefore, to restrain them from harmful activity. In my experience patients yield to restraint most readily, and secure the best results, if I explain to them the anatomical facts which should guide the management of the lying-in period.
THE CHANGES IN THE UTERUS.—Since of all the organs the uterus undergoes during pregnancy the most extensive development, it also holds the place of prominence during the lying-in period. Immediately after delivery the womb weighs two pounds and measures some eight inches in height, five in breadth, and four in thickness. In the course of a few days it begins to dwindle in size, gradually sinking in the abdomen until it lies entirely within the pelvic cavity. Toward the end of five or six weeks it resumes the position occupied before conception, regains approximately its original dimensions, and weighs two ounces. We speak of the process which leads to these results as theinvolutionof the uterus. Since a great deal depends upon the rapidity with which involution progresses, we must understand just what it is and how it may be influenced.
The muscle of the womb, to which this property of involution belongs, is an aggregation of thousands of individual fibers. In response to excellent nutrition during pregnancy, these fibers have grown thick and strong, in order that they may furnish the power needed at the time of labor. When this purpose has been fulfilled each fiber becomes smaller and gradually passes into a resting stage the better to preserve its vigor. It is the shrivelling of the individual fibers, therefore, which accounts for the total reduction in the size of the womb.
Although the source of the stimulus which causes the muscle-fibers to atrophy is not so clear as we should like it, we are acquainted with certain influences to which involution is susceptible. Of these none merits so much attention as the influence of the breasts. The intimate relation between the breasts and the uterus manifests itself in such a variety of ways and with such force that no one doubts its existence. Thus, if a nursing mother becomes pregnant her infant is usually deprived of sufficient nourishment or suffers some digestive disturbance; if not, and the mother, ignorant of her condition, continues with the breast feeding, she may jeopardize the newly begun pregnancy. Very likely she will be warned of the fact by the signs of threatened miscarriage. More frequently, but in quite the same way, we find that nursing causes uterine contractions in the early part of the lying-in period, when they are called after-pains. Women who experience them tell us they are more severe while the infant nurses; and they also say that the discomfort disappears after several days, a fact which indicates that involution has made notable headway. The physician is not dependent on such evidence, however; for a simple examination reveals at any time how far involution has progressed. By this means we have learned that nursing facilitates the involution process. On the other hand, it is found to be true, as we should naturally expect, that women who decline to suckle the infant recover from childbirth somewhat less rapidly than those who follow nature's plan. In this fact, therefore, is found a selfish motive, yet a very good one, which should impel mothers to perform this exceedingly important duty.
Aside from the change in the mass of the uterus, notable results of involution relate to its mouth and to its ligaments, for these structures are also chiefly muscle. The mouth of the womb, lately stretched to permit the exit of the child, gapes widely for a time; but ultimately its lips are drawn together, the tissues which compose them stiffen, and the canal which they enclose is narrowed to almost microscopical dimensions. When involution is complete, the uterus has so far regained its virginal character that no trace of childbirth remains other than a few small fissures in the margin of its mouth.
It is the office of the ligaments to hold the uterus in proper position. In consequence of pregnancy they have been stretched, and, as we might anticipate, after the contents of the womb are expelled the ligaments hang loosely from its sides, very much as sails hang when a breeze dies down. Immediately after delivery, therefore, the ligaments give the womb little or no support; eventually they shorten and tighten, readily accommodating themselves to the existing conditions. Until the accommodation is perfected, it is especially desirable to permit no pressure which might push the womb backward. It is for this reason that many obstetricians object to the time- honored custom of applying a tight bandage about the abdomen at the conclusion of labor; for, though bandaging is not always harmful, it has a distinct tendency to misplace the womb. A friend who has served as an assistant in one clinic where patients were bandaged regularly and in another where they were not, tells me that displacements of the womb were much more common among women treated by the former method.
While the process of involution is altering the shape and size of the womb, other forces are at work within the organ to provide its cavity with a new mucous membrane. In character and in extent the inner surface of the womb, left raw and bleeding at the conclusion of labor, is comparable to the wound which would result if some accident removed the skin from the palms of both hands. No one would question the wisdom of guarding such an injury to the hands; but cleanliness is even more necessary to the prompt and healthful restoration of the uterine mucous membrane. However, the wound within the uterus is so far from the surface of the body that it need not be directly covered with a surgical dressing; sterile pads are kept over the vulva to exclude contaminating material until the healing is completed. Since bleeding ceases after that point is reached, we have no difficulty in knowing when the mucous membrane has been restored.
THE LOCHIA.—The vaginal discharge which regularly follows the termination of pregnancy gets its name from the Greek wordlochia. At first the discharge is pure blood, because it issues exclusively from the vessels left open by the removal of the after-birth. The greater part of the blood flows out of the birth canal, but frequently some of it collects in the cavity of the uterus or of the vagina; there it coagulates, and the clots may not be expelled until several days later. In that event, as whatever effect the bleeding may have had has long since passed, the appearance of the clots is usually no occasion for alarm.
The amount of lochia varies, and will likely fall below the average in small or anemic women and rise above it in those who are large or robust. Then again, the discharge is less profuse if considerable blood has been lost immediately after the labor. For the first ten days the total quantity seldom exceeds eight or ten ounces; after that time it is so small that it cannot be accurately estimated. Formerly much larger amounts were considered normal, and, therefore, it is probable that modern aseptic treatment of child-birth has lessened the subsequent loss of blood. Toward the end of a week the lochia changes from a bright red to a brownish color, because the discharge now includes certain products of disintegration. Somewhat later the lochia consists almost entirely of mucus, being only streaked with blood; but there will be an increase in the bleeding when the patient gets up; and injudicious activity may cause flooding. A slight bloody discharge may be expected to continue until five or six weeks after the child was born.
A faint but characteristic odor to the lochia proves very disagreeable to some patients, and on that account it was formerly customary to give them a daily douche throughout the lying-in period. This was before the characteristics of the puerperal uterus and the nature of infection were thoroughly understood. Most physicians are now convinced that the early use of douches is rarely beneficial; and since there is danger of washing infectious material from the lower part of the vagina into the uterus, they may, if given prior to the second week after delivery, actually do harm. Consequently douches are not now used in a routine way. Whenever irrigations are indicated the doctor will prescribe them. Late in the puerperium vaginal douches are unobjectionable, and patients may take them unassisted, for then the fluid will not penetrate the womb so long as it has a free escape from the outlet of the vagina. Moreover, it is immaterial if some of the fluid should pass into the womb, for its lining will have been largely restored by this time, and at points where restoration is incomplete defenses have been thrown up against infection.
THE RETURN OF MENSTRUATION.—On account of the dilatation at the time of labor women who have previously suffered with menstruation may look forward to relief after child-birth. Menstruation generally becomes as painless as the flow of the lochia; and so far as a patient can tell the two phenomena are identical. Actually, however, they bear no relation to each other. The fact that the cavity of the uterus has been deprived of its lining is responsible for the lochia, whereas the menstrual discharge occurs in spite of the lining, through which it breaks at regular intervals in response to a stimulus that is absent for a longer or shorter period after the birth of a child.
In the latter part of the puerperium there may be doubt as to whether a discharge is menstrual or lochial; though, if necessary, an examination of the interior of the womb would always settle the question, for structural changes in the uterine mucous membrane form the most characteristic feature of menstruation. If, therefore, small bits of this tissue are removed and studied under the microscope, a definite conclusion can be reached. Physicians may resort to such an examination when the significance of a discharge is not clear without it; but other evidence usually enables them to decide the matter.
The secretion of milk often exerts an influence upon the reestablishment of menstruation. Under ideal circumstances the mother does not menstruate while she nurses her infant; whereas, if the breasts are not in use, the menstrual function returns six to eight weeks after delivery. Other pertinent clinical facts also lend weight to the opinion that the activity of the breasts, more technically called lactation, should not only prevent menstruation but also hinder the ripening of egg-cells in the ovary. Thus, the nursing infant has a potent influence upon the reproductive function of its mother, enabling it to preserve its food supply; for in the event of conception the milk usually decreases in amount or becomes of an inferior quality. To secure this protective influence should prove a strong incentive for the mother to nurse her child; in barely half the cases, however, is it effective throughout a year. One-third of nursing mothers, statistics indicate, begin to menstruate about two months after delivery, and month by month the proportion gradually increases.
Since menstruation appears so frequently during lactation, it cannot be considered abnormal. It does not follow that the function will become permanently reestablished after a patient has menstruated once; in many instances several months elapse before there is another period, and in a few cases there will be only one period during the year the child suckles. Nevertheless, when the function has once made its appearance extraordinary precaution should be exercised to avert a return, and about the time its reappearance would be expected the woman should go to bed for several days. Although this measure may prove futile, we know of no other so likely to prove successful.
Menstruation is more apt to return prematurely after the birth of the first child than of later ones. This may be due in part to a kind of accommodation of the maternal organism to the reproductive process as one pregnancy follows another; but I am convinced that it is also due in part to the greater physical and mental composure of experienced mothers. Until a woman has learned the unwelcome consequences she is apt to take over household duties before she is equal to the task, or she may engage in too strenuous amusements; and most mothers err in a too energetic care of the baby.
OTHER RESTORATIVE CHANGES.—Many of the restorative changes in the mother's body are either so intricate or so devoid of practical significance that we may pass them by; though all of them have great interest for the specialist, and some have occasioned bitter controversy. The alterations in the heart, for instance, have been the subject of a prolonged dispute between French and German scientists. The former still assert that this organ regularly enlarges during pregnancy and subsequently returns to its normal size. The Germans deny both these contentions. Certainly the alterations are insignificant from a practical standpoint; otherwise competent observers would not disagree.
The really important changes in the body, other than those pertaining to the uterus, are familiar to women who have passed through pregnancy; but other prospective mothers may not understand that they will regain the bodily condition which existed before conception.
Loss in Weight.—While the weight lost during the lying-in period is not so vital as some other alterations, many have a keen interest in it. In addition to the loss of ten to fifteen pounds at the time of birth, a further loss occurs in the course of a few weeks. Diminution in the size of the uterus is responsible for the loss of nearly two pounds, and the lochial discharge for at least another; but the chief factor concerned is the removal of water from the tissues, many of which have become dropsical toward the end of pregnancy. Altogether patients do not lose less than ten pounds during the lying-in period, and often lose a great deal more. The average loss for the first week alone is said to equal one-twelfth of the patient's weight at the conclusion of labor; the total loss for the whole of the puerperium corresponds to one-tenth of her weight at the beginning of it. Variations from the rule are attributed to individual peculiarities of nutrition. In general, stout women lose more than slender ones, but with all types the loss is greater if the mother nurses her infant. On the other hand, a generous diet tends to counteract any loss in weight whatever.
The Abdominal Wall.—Much more important than the question of weight is the recovery of the abdominal wall from the strain imposed by the enlargement of the womb. In normal cases, to be sure, there is very slight disproportion between the size of the pregnant uterus at term and the capacity of the abdomen, yet the abdominal wall invariably suffers a little stretching and unless it retains its elasticity, the viscera are deprived of essential support, and cause more or less discomfort.
The restorative changes in the abdominal wall involve the skin, the fatty tissues, and the muscles. As soon as the distention has been relieved the skin falls into folds, less noticeable if the pregnancy was the first; and the muscles become so flabby that one has no difficulty in pushing the wall backward until it touches the tissues which cover the spinal column. Within a few weeks, if all goes well, the muscles regain their "tone." Coincidently, the excessive fat over the abdomen is absorbed. The skin becomes smooth, and its pigmentation fades completely; but the pregnancy streaks rarely vanish entirely, although they always become very much less noticeable.
Whether or not the abdominal wall will recover from the distention of pregnancy depends entirely upon the muscles. As the lying-in period advances each fiber should gradually shorten until the whole muscular structure becomes as firm and tight as it ever was. But this takes time, and no artifice can hasten the repair. Perfect recovery is most likely with the body in a recumbent position, which relieves the muscles from any strain. These facts are better appreciated than formerly, hence most physicians encourage their obstetrical patients to remain in bed somewhat longer than their mothers did. Generally nothing else will be required, and only under extraordinary circumstances will nature need assistance. Thus, if there has been unusual distention, as, for example, that due to twins, the muscular impairment may be extreme; or if pregnancies follow one another in quick succession the strain becomes so nearly continuous that there is not sufficient time for adequate repair. Whenever nature does need encouragement calisthenics of some kind are advisable. These systematic exercises, which the patient practices in bed and flat on her back, are usually begun about a week after delivery, though there may be some reason for beginning them earlier or later than this.
The physician will always select the proper calisthenics, but the following "movements" generally prove satisfactory. To exercise the muscles at the front of the abdomen one leg after the other is raised and lowered; as this is being done the knee will be bent (flexed) at first, but later the leg may be held straight (extended). Other muscles come into play when the feet are alternately brought together and separated as widely as possible. A third movement which exercises the muscles at the side of the abdomen consists in raising the shoulders from the bed and twisting the trunk so that the weight of the chest rests now on the right, now on the left elbow. When these movements can be performed fifteen or twenty minutes without fatigue more vigorous exercises may be adopted. For example, the buttocks, together with the lower part of the back, are raised off the bed, while the shoulders, elbows, and the heels remain stationary. A day or so before getting up the patient should practice alternately raising herself from the recumbent to the sitting posture and returning to the above position without assistance from the arms.
The value of bandaging the abdomen immediately after delivery as a means of strengthening the abdominal muscles is questionable; though physicians agree to the advantages of a supporter after patients are out of bed. We constantly see perfect restoration of these muscles without the early use of a binder; in fact, women who have employed it throughout the lying-in period do not secure an efficient abdominal wall more frequently than others who began its use two weeks after they were delivered. Even those physicians who advocate an early application of the binder concede that it works harm in certain cases and do not recommend it indiscriminately.
Those who postpone for a fortnight the use of the binder will escape the tendency it has to cause displacements. By this time the involution will have advanced so far that the womb lies within the pelvic cavity, where it is surrounded by the hip bones, which protect it from external forces that otherwise would influence its position. When permitted to get up patients ought to use a binder, because it counteracts the feeling of "falling to pieces" of which some complain when the abdominal walls are not comfortably supported. But there is no evidence to show that a binder plays any part in restoring the figure. When, in spite of ample rest, the abdominal muscles fail to recover completely, we have no better way of strengthening them than by use of calisthenics or massage.
The Pelvic Floor.—Second only in importance to having the womb restored to its original position is the necessity of restoration of the pelvic floor. This structure, also called theperineum, we should know, lies between the thighs, shuts in the bottom of the abdomen, and prevents prolapse of the viscera. In women it forms the lower portion of the birth-canal, enclosing the aperture through which the child enters the world. Although intelligent management of labor is of the greatest value for the protection of the pelvic floor, under certain circumstances it may be impossible to preserve it intact; injury to it is the rule when the first child is born, and not unusual in later births. There can be no doubt regarding the advisability of uniting the edges of a tear; indeed, to do so immediately is the very first essential toward restoring the pelvic floor to its wonted integrity. But even though tears are sewn up successfully, there is invariably some relaxation of the perineum until the restorative process, which here again chiefly concerns the muscles, has been given opportunity to become effective.
As with all the restorative changes in the lying-in period, to rest calmly in bed favors the perfect recovery of the pelvic floor more than anything else. Keeping the thighs together during the first few days undoubtedly assists tears in healing, but that precaution is not always necessary, and when it is the physician will call attention to the fact. The really important matter, as I have said, is that the upright position should not be resumed until the pelvic floor has become firm.
THE CARE OF THE PATIENT.—Now we have learned enough of the manifold changes in the lying-in period to appreciate the fact that patients require medical direction even though they are feeling perfectly well. The view held by former generations that women can get along without a doctor and with any sort of nursing is partly responsible for the existence of gynecology, the branch of medicine which deals with the diseases of women. Recently delivered women should be treated as surgical patients, not because they are ill, but to keep them from becoming so.
If the patient desires the highest degree of protection an experienced nurse is indispensable, for she will make systematic observations which would consume too much of the doctor's time for his personal attention, yet without which he would not be sufficiently conversant with his patient's condition to guide her properly. The temperature, the rate of the pulse, and of the respiration should be recorded at regular intervals during the day and night. An elevation of temperature at the conclusion of labor need give no uneasiness, for experience has shown that it generally subsides within a few hours. Moreover, slight elevations in the course of the following week are so frequent that obstetricians have agreed to regard as a normal temperature for this period 100.4 degrees instead of the usual normal of 98.4 degrees. The pulse-rate most frequently does not depart from what is characteristic for the individual, though about one-fifth of puerperal women have a slowing of the pulse, a phenomenon of favorable significance. Any difficulty in breathing that may have existed in the latter part of pregnancy disappears when the abdominal distention is relieved, and the respiratory rate becomes normal. So long as the body is getting rid of the tissue-substance essential to pregnancy, but now without any purpose, more than the usual amount of waste material is present in the expired air.
The Elimination of Waste Material.—As we might expect from the loss in body weight, the excretory organs are particularly active during the lying-in period. In quantity the loss of water exceeds all the other waste-products together; and pronounced activity of the kidneys or of the sweat glands may become a source of annoyance. Since it is undesirable to interfere with these functions, whatever inconvenience either may cause will be borne with less complaint if the patient understands that a large loss of water at this time indicates a healthful condition of the body.
Shortly after delivery there may be difficulty in emptying the bladder; and, under such circumstances, the doctor or nurse used to catheterize the patient immediately; this habit once begun, it was often necessary to repeat the operation day after day, or, for that matter, several times a day. But as physicians came to know more of the relations of bacteria to inflammation of the bladder, they grew more cautious, and preferred to wait a long time before resorting to the catheter. The reward of this patience was to find that, with remarkably few exceptions, puerperal women ultimately void of their own accord. Accordingly catheterization after child-birth is now postponed, and is never performed until a number of devices to get the patient to void spontaneously have been tried without success. Often urination follows putting a hot-water bottle over the bladder; or pouring warm water over the vulva; or placing the patient upon a bed-pan from which steam is rising. When these and other devices well known to every nurse are not effective, catheterization becomes necessary. With the elaborate precautions taken to avoid infection of the bladder, catheterization is now performed with very slight risk.
Constipation, for various reasons, becomes a regular feature of the lying-in period. The confinement in bed, restricted diet, relaxation of the abdominal wall, and sensitiveness about the region of the rectum, all have a tendency to prevent spontaneous movements of the bowels. As one of these influences after another is removed the bowels begin to act naturally. Childbirth may cause chronic constipation, but this sequel would occur much less often if a little care were taken to prevent it.
The routine use of enemas deserves to be condemned. I see no objection to an occasional enema if purgative medicine has been taken without effect, but constant use of them, more than likely, will result in the enema habit. Similarly, long-continued administration of strong purgatives tends to make them a permanent necessity. While in bed if medicine is taken every other day the bowels will have opportunity on the intervening days to move spontaneously, though we do not really expect them to move naturally until six or eight weeks after the delivery, when the patient is able to take as much exercise as she likes. Toward the end of the second week, however, mild laxatives generally prove effective, and it is important to select one the dose of which may be gradually decreased. Senna prunes, which were described in Chapter V, fill the purpose very well. Six or eight of them may be needed at first, but the number may be gradually reduced, until finally none are necessary.