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J. Morris Slemons >> The Prospective Mother
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21 Produced by Tricia Gilbert, Tiffany Vergon, Charles Aldarondo,
Charles Franks and the Online Distributed Proofreading Team.
THE PROSPECTIVE MOTHER
A Handbook for Women During Pregnancy
by
J. MORRIS SLEMONS
Associate Professor of Obstetrics,
The Johns Hopkins University.
* * * * *
PREFACE
This book, written for women who have no special knowledge of
medicine, aims to answer the questions which occur to them in the
course of pregnancy. Directions for safeguarding their health have
been given in detail, and emphasis has been placed upon such measures
as may serve to prevent serious complications. Treatment of such
conditions has not been discussed, as it can be judiciously carried
out only by a physician who has the opportunity to observe and study
the individual patient. Furthermore, if there is to be notable
improvement in the management of cases of childbirth, the appearance
of untoward symptoms should not be awaited before consulting a
physician; on the contrary, prospective mothers must be taught that
they should be under competent medical supervision throughout
pregnancy.
At present intelligent women demand some knowledge of the anatomical
and physiological changes incident to the development of the embryo
and the birth of the child. These subjects do not readily lend
themselves to popular description, but I have told the story as
simply as possible, following in a general way the text-book of my
teacher and friend, Professor J. Whitridge Williams; indeed, my main
purpose has been to reproduce his book "in words of one syllable."
The use of a number of technical words has been unavoidable, and,
though their meaning has been given in the context, it has not been
feasible to repeat the definition every time an unfamiliar term was
used. On that account a glossary has been provided.
It is with pleasure that I avail myself of this opportunity to
acknowledge the cheerfully given assistance of many friends. In
particular I wish to thank Doctor Henry M. Hurd, until recently
Superintendent of the Johns Hopkins Hospital, for his interest and
advice. I am also under deep obligation to my friend John C. French,
of the English Department of the Johns Hopkins University, for
helpful criticism of the manuscript, and to my colleagues, Doctors
Rupert Norton and Thomas R. Boggs, for valuable assistance. To many
others--doctors, nurses, and patients--I am indebted for numerous
suggestions which have been made either consciously or unconsciously.
J. MORRIS SLEMONS.
* * * * *
INTRODUCTION
In all branches of medicine the master word is _prophylaxis_, or
prevention, and its benefits are nowhere more strikingly illustrated
than in the practice of obstetrics. In former times every woman who
gave birth to a child or passed through a miscarriage was exposed to
grave danger of infection or child-bed fever; but at present--thanks
to the recognition of the bacterial origin of the disease and of its
identity with wound infection--this danger can be practically
eliminated by the rigid observance of surgical cleanliness and
aseptic technique. Physicians have also learned that the most
effective method of coping with other serious complications of
pregnancy and labor is by preventing their occurrence, or at least by
subjecting them to treatment in their earliest stages; for, if they
be allowed to go on to full development, the results are little
better than in times past. Furthermore, a careful examination some
weeks before the expected date of confinement enables us to recognize
the existence of abnormal presentations and of disproportion between
the size of the mother's pelvis and that of the child's head. Timely
recognition of such conditions makes appropriate treatment possible
and practically insures a successful outcome; while tardy recognition
is frequently followed by disastrous results.
These few examples give some idea of the benefits of prophylaxis in
the practice of obstetrics. Prospective mothers should understand not
only that there is an advantage in taking such precautions, but that
they may be risking their lives, or at least their future well-being,
unless they insist upon competent medical attention. It is true, of
course, that pregnancy and childbirth are generally normal processes,
but they are not always so. Fortunately, most of the abnormalities
give timely warning of their occurrence, and in most instances may be
relieved by comparatively simple measures; or, if not, they afford
indications for treatment which should lead to a happy termination.
The recognition of the existence of such conditions, however, is not
always easy, and their ideal treatment requires careful training and
sometimes the utmost nicety of judgment. Consequently, if prospective
mothers wish to be assured of the best care, they should be cautious
in the choice of their medical attendant. As the ordinary layman has
no means of determining the real qualifications of a physician, the
choice should not be made upon the advice of casual acquaintances;
but, instead, the family physician should be consulted, who, should
he feel unwilling to assume the responsibility of the case, will be
able to recommend a thoroughly competent substitute.
From my own experience as a teacher and consultant, I state without
hesitation that in no other branch of medicine or surgery are graver
emergencies encountered than in certain obstetrical complications
whose treatment involves the greatest responsibility and requires the
highest order of ability to insure a successful outcome for the
mother and her child. For these reasons a physician should be chosen
only after mature deliberation, and his services should be esteemed
much more highly than is usually the case.
In order that the principles of prevention may receive their fullest
application during pregnancy, labor, and the lying-in period, it is
also advisable that intelligent women should possess some knowledge
of the Reproductive Process in human beings. This information is
imparted by Doctor Slemons' book, which I can thoroughly recommend to
prospective mothers. The subject matter has been carefully chosen,
and the author has wisely refrained from giving advice with regard to
treatment which can be satisfactorily directed only after careful
study by a physician. At the same time he has given a clear account
of the physiology of pregnancy and labor, and has laid down sound
rules for the guidance of the patient.
One of the most important facts emphasized by Doctor Slemons is the
value of medical supervision for several weeks after the child is
born; this precaution contributes greatly toward a rapid and complete
convalescence. During the lying-in period the physician should
supervise the care of the mother and the child, should insist upon
the necessity for maternal nursing, and should keep the mother under
observation until perfectly normal conditions are regained. If the
latter duty is conscientiously fulfilled many years of invalidism may
be saved and thousands of operations rendered unnecessary.
Although there have been notable advances in the science and in the
art of obstetrics since the middle of the eighteenth century, a great
many fundamental facts must yet be learned. For example, we are
almost totally ignorant of the stimulus which causes the mother to
fall into labor approximately 280 days after the last normal
menstruation.
There are two points which I desire to impress especially upon the
readers of this book. Firstly, that the advance of the science of
obstetrics, and consequently improvements in its practice, must
depend greatly upon the cooperation of intelligent women. They must
come to realize that they will secure the best treatment only as they
demand the highest standard of excellence from their attendants; and
they can aid in securing this for their poorer sisters and their
children by interesting themselves in obstetrical charities.
Secondly, they must realize that real progress in the science of
obstetrics can be expected to proceed only from well equipped clinics
connected with strong universities, and in charge of thoroughly
trained and broad-minded men. As yet such institutions scarcely exist
in this country. Women who are anxious to promote the welfare of
their sex can find no better way of doing so than by bringing this
need to the attention of wealthy men interested in philanthropy and
education. Furthermore, they should bear in mind that most of our
important discoveries would not have been made had animal
experimentation not been available, as it is solely by this means
that modern surgical and obstetrical technique has been brought to
its present degree of perfection; and further progress can scarcely
be expected without its aid. They should remember also that whenever
they take such a well-known drug as ergot for the control of
bleeding, or make use of many other apparently simple measures, they
are unconsciously rendering tribute to this type of investigation.
J. WHITRIDGE WILLIAMS.
Johns Hopkins University,
September, 1912.
* * * * *
CONTENTS
I. THE SIGNS OF PREGNANCY AND THE DATE OF CONFINEMENT
II. THE DEVELOPMENT OF THE OVUM
III. THE EMBRYO
IV. THE FOOD REQUIREMENTS DURING PREGNANCY
V. THE CARE OF THE BODY
VI. GENERAL HYGIENIC MEASURES
VII. THE AILMENTS OF PREGNANCY
VIII. MISCARRIAGE
IX. THE PREPARATIONS FOR CONFINEMENT
X. THE BIRTH OF THE CHILD
XI. THE LYING-IN PERIOD
XII. THE NURSING MOTHER
GLOSSARY
* * * * *
The Prospective Mother
CHAPTER I
THE SIGNS OF PREGNANCY AND THE DATE OF CONFINEMENT
The Positive Signs--The Probable Signs--The Presumptive Signs: The
Cessation of Menstruation; Changes in the Breasts; Morning Sickness;
Disturbances in Urination--The Duration of Pregnancy--The Estimation
of the Date of Confinement--Prolonged Pregnancy.
Many puzzling questions occur to the woman who is about to become a
mother. Most of these questions are reasonable and natural, and
should be frankly answered; but a false conventionality has--until
recently, at least--forbidden any open discussion of facts connected
with childbirth. The inevitable result has been that, without
experience of their own to guide them, prospective mothers have
sought advice from older women, whose experience was at best very
narrow, and whose views were often biased by tradition. Or,
distrusting such sources of information, they have consulted
technical medical works which they could not understand. Either of
these methods is very likely to result in misinformation and to cause
unnecessary anxiety. Yet no one need be alarmed by a plain, accurate
account of Nature's plan to provide successive generations of human
beings. Some trustworthy knowledge of a process so fundamental should
be part of every person's education; it is especially helpful to
women who are pregnant because it affords a rational basis for
hygienic measures which they should adopt. A popular work, however,
no matter how frank and helpful it may be, will not enable one to
dispense with professional advice. For the prospective mother no
counsel is more important than this: _Put yourself at once under
the care of a physician_.
Insistence on the importance of medical advice should not be taken to
imply that pregnancy is to be regarded as other than a normal
process. Its dangers are comparatively slight, as we should expect,
since the property of all living matter to reproduce its kind is both
fundamental and essential; the continuance of living creatures in
this world, plants as well as animals, depends upon the Reproductive
Process. And yet, natural as it is, pregnancy may be attended by
complications. Such complications, though happily rare, are to be
guarded against in every case, and that may be most effectually done
if patients are taught to remain under competent medical supervision
from the time of conception until several weeks after the child is
born. This precaution greatly reduces the frequency of annoyances
during pregnancy and also assists materially toward conducting a
birth to a safe conclusion. Moreover, if this advice is followed,
when complications do arise they will be recognized and dealt with
promptly; they will not be permitted to grow more serious until,
perhaps, they may jeopardize the life of the mother or the child or
both.
The initial symptoms of pregnancy are so widely known that in most
instances the prospective mother herself makes the diagnosis shortly
after conception has taken place; but now and then pregnancy advances
for several months unrecognized and is then detected by a physician
who has been consulted on account of symptoms which the patient has
incorrectly attributed to some other condition. On the other hand,
women sometimes suspect that they are pregnant when they are not; and
such mistakes occur because certain symptoms which are implicitly
trusted by the laity as manifestations of pregnancy are occasionally
associated with conditions quite foreign to it. It is clear that one
interested in the matter must know not only what the manifestations
of pregnancy are and when they appear, but also how far the evidence
that they give is reliable.
The signs of pregnancy may be classified, according to their
reliability, as presumptive, probable, and positive. The doubtful
evidence appears first and the infallible proof last. No one need be
surprised, therefore, if, when her suspicion is first aroused, she is
unable to decide positively whether she is pregnant. Physicians of
broad experience, possessed of facilities for observation which their
patients cannot employ, may find it necessary to make more than one
examination before they commit themselves to a definite opinion; in
some cases, though very rarely, they must wait for two or three
months to be able to do this.
THE POSITIVE SIGNS.--The earliest absolutely trustworthy
manifestation of pregnancy is the motion of the fetus. The perception
by the mother of these movements, which is spoken of as "quickening,"
generally occurs toward the eighteenth week, if she has been told to
watch for them; otherwise they may pass unnoticed until the twentieth
week or later. At first the motion, felt in the lower part of the
abdomen, is very gentle; it has been variously likened to tapping, or
to quivering, or to the fluttering of a bird's wings. As time goes on
the movements grow stronger and occur more frequently; they are,
however, perceived but rarely throughout the day and seldom interfere
with sleep. Occasionally women are annoyed by the sensation and
complain that the child is hardly ever quiet. Even these troublesome
movements are never a cause for anxiety; but prolonged failure to
feel motion after it is once well established should be reported to
the doctor.
In the first pregnancy the passage of gas through the intestines may
be mistaken for quickening long before the movements of the child are
really perceptible; but those who have once experienced quickening
will not be deceived. Whenever women who have borne children are in
doubt the sensation is almost surely not quickening. Furthermore, in
any doubtful case, the motion should be observed by a physician
before being accounted a positive sign of pregnancy. This precaution
will scarcely delay an absolutely positive diagnosis, since the
proper method of examination reveals these movements to the physician
almost as early as the patient feels them.
About the time these movements become perceptible another positive
sign is available. The physician whose ear has been trained to catch
such sounds when he listens over the lower part of the mother's
abdomen will hear the fetal heart-beat. Other sounds may be audible
there, but the character and the rate of the heart-sounds are
distinctive. Since the child's heart beats almost twice as fast as
the mother's, under ordinary conditions it is impossible to confuse
one with the other. The mother never feels the beating of the child's
heart, but occasionally she will mistake for it the throbbing of her
own blood vessels.
Ability to hear the fetal heart not only provides a means of
confirming the existence of pregnancy in doubtful cases, but also
enables the physician to reassure his patient if she fails
temporarily to feel the child move. Sometimes the presence of twins
is recognized in this way. Toward the end of pregnancy the heart
sounds are also of material assistance in determining what position
the child has permanently assumed.
There is a third positive sign of pregnancy to which the physician
has recourse, but generally it is inapplicable as early as those
already mentioned. In the latter months of pregnancy it is possible
to outline the child through the mother's abdominal wall. Although
this procedure adds little or nothing to our resources for making an
early diagnosis, the information it ultimately affords proves one of
the greatest aids in the practice of obstetrics.
THE PROBABLE SIGNS.--Obviously, phenomena for which the child is
responsible--such as have just been described--supply the most
trustworthy evidence of pregnancy; and these phenomena alone are
accepted as positive signs. But there are earlier manifestations
which intimate very strongly that conception has taken place. Shortly
after pregnancy has become established changes begin in the uterus,
as physicians call the womb, and soon reach the point where they may
be recognized by a simple examination which enables the physician to
express an opinion little less than positive. As one result of
pregnancy, for example, the supply of blood is increased to all the
organs concerned with the reproductive process. Partly on account of
this congestion and partly on account of embryonic development, the
uterus becomes altered in a number of ways. Although these changes
occur regularly in pregnancy, they may also occur when the womb is
enlarged from other causes; therefore, if a physician should make the
diagnosis of pregnancy whenever they were found, he would make it
somewhat too frequently. With a little patience, however, he excludes
the chance of being misled; a second examination, approximately four
weeks after the first, will generally place the existence of
pregnancy beyond question, for under normal conditions the degree of
enlargement which takes place in a pregnant womb during a given
interval is absolutely characteristic.
THE PRESUMPTIVE SIGNS.--Although women are most often led to suspect
that they are pregnant by symptoms which are of such doubtful
significance that they must be regarded as merely presumptive
evidence, the practical value of these symptoms is attested by the
fact that subsequent developments rarely fail to confirm the
suspicion. Perhaps they prove misleading once or twice in a hundred
cases; the number of mistakes is small, because the diagnosis is
commonly made not from only one of these doubtful signs but from a
group of them. In order of importance the doubtful or presumptive
signs of pregnancy are these: (1) cessation of menstruation, (2)
changes in the breasts, (3) morning sickness, (4) disturbances in
urination.
_The Cessation of Menstruation_.--The failure of menstruation to
appear when it is expected is nearly always the first symptom of
pregnancy to attract attention, and, as a rule, when this happens to
healthy women during the child-bearing period--which usually extends
from the fifteenth to the forty-fifth year--it may be taken to
indicate that conception has occurred. But there are exceptions to
this very good rule. Besides pregnancy we are acquainted with several
conditions that cause temporary suppression of menstruation; and to
understand its significance we must learn something of the menstrual
process itself.
Menstruation is a function of the womb and in all probability is
brought about through the influence of the ovaries. The bleeding,
popularly regarded as the entire menstrual process, is, in fact,
indicative of only one of its stages; the others give rise to no
symptoms whatever. What the stages in the menstrual process are, what
relation they bear to each other, and what the significance of the
whole process is, are problems that have been solved with the aid of
the microscope. In this way the mucous membrane lining the womb has
been studied both at the time of the periods and in the interval
between them, and we have learned that it is constantly undergoing
changes intended to facilitate the reception and the maintenance of
an embryo. Anticipating these duties the mucous membrane receives a
more abundant supply of blood; it also increases in thickness and all
the structures which enter into its composition become more active.
Unless conception takes place these preparations, which represent the
most important phase in the menstrual process, are without value; and
therefore failure to conceive means that the mucous membrane will
return to the same condition as existed before the preparations were
begun. The congestion is relieved by rupture of the smallest blood
vessels, and there follow other retrogressive steps which completely
restore the various structures to their former state. Then there is a
pause, though it is not long, until preparatory changes are again
initiated, or, as we say, another Menstrual Cycle is begun. Each
cycle lasts twenty-eight days, and includes four stages, namely, a
stage of preparation, of bleeding, of restoration, and of rest.
Although pregnancy may become established at any time during the
interval between the periods of bleeding, it is more likely to be
established just before a period is expected or shortly after it has
ceased. Furthermore, whenever conception does take place, the
preliminary preparations for the reception of the embryo are followed
by much more elaborate arrangements for its protection and nutrition.
Under these circumstances the hemorrhagic discharge does not appear.
Were there no other condition to bring about the cessation of
menstruation, the diagnosis of pregnancy would be greatly simplified.
But any one can appreciate the fact that diseases of the womb may
interfere with the menstrual process. Menstruation is influenced,
also, by the ovaries. As a result of age, for example, the ovaries
undergo changes which invariably bring about the permanent cessation
of menstruation, called the menopause. This event occurs prematurely
if both the ovaries are removed by operation. In view of these facts
it is not surprising that sometimes ovarian disorders abolish
menstruation. An impoverished state of the blood, or nervous shock
and strain, or constitutional debility may also interrupt the regular
appearance of the menstrual discharge.
The value of menstrual suppression as an evidence of pregnancy is
not, however, to be discounted to the extent that we might expect.
This is true because the ailments which lead to confusion are
relatively infrequent, and also because they exhibit characteristic
symptoms which are foreign to pregnancy. Often these symptoms are
obvious to the patient herself; if not to her, they will be obvious
to her physician. It is about the doubtful cases, naturally, that a
professional opinion is sought, and on that account physicians are
perhaps inclined to overestimate the difficulty women have in
learning for themselves whether or not they are pregnant. As a matter
of fact, it is unusual for a prospective mother to fail to reach a
correct decision--a decision for which she relies chiefly upon the
suppression of her menstrual periods.
It is doubtful whether menstruation ever continues after conception
has taken place. Instances in which the menstrual function is
believed to persist are not uncommon, and yet in all probability the
discharge regarded as menstrual has a different origin. In most cases
it should be interpreted as meaning that there is some danger of
miscarriage. Since miscarriage often occurs about the time a
menstrual period would ordinarily be expected, there is unusual
opportunity for confusing the symptoms. At all events women err much
more frequently in suspecting that they are pregnant than in
overlooking the condition. Indeed, pregnancy is not likely to be
overlooked unless menstruation has been irregular or suppressed for a
month or more previous to conception. Thus, in the case of nursing
mothers in whom menstruation is already suppressed and who are,
moreover, deprived of certain evidence that the breasts give,
pregnancy may sometimes advance several months before it is
recognized.
_The Changes in the Breasts_.--Various sensations in the breasts
are accepted by women as a reliable sign of pregnancy; thus
throbbing, tingling, pricking, or a feeling of fullness will be
mentioned by one mother or another as having given her the first
intimation that she was pregnant. A few women also find their breasts
become tender immediately after they have conceived; this may be so
marked that they cannot bear pressure. But unless such symptoms are
accompanied by definite, visible changes, they have no value as signs
of pregnancy.
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