Books: The Prospective Mother

J >> J. Morris Slemons >> The Prospective Mother

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Prolonged rest in bed, some will say, is debilitating. While that may
be true to a degree, untoward effects can always be avoided by
systematic massage of the extremities. The abdomen should not be
subjected to such manipulations, for they will occasionally provoke
painful contractions of the uterus and defeat the purpose of staying
in bed.

Patients who are not disposed to undergo a long period of enforced
rest, no matter what profit may be promised, should at least consent
to keep in bed during that period of pregnancy at which a previous
miscarriage took place. We know that the event is particularly apt to
recur at such a time. Specifically, it is important to remain in bed
one week before and one week after the date in question.

When pregnancies follow one another in rapid succession, the
liability to miscarriage is notably increased. A natural interval
between births has been provided, an interval which depends upon the
mother nursing her child. Ideally, menstruation, and with it the
ripening of the ova (egg-cells), does not occur while the breasts are
active; but when the infant does not suckle, the ovaries regularly
resume their function in a very short time. Since the circumstances
attending miscarriage always deprive the mother of the opportunity of
nursing, another pregnancy may quickly ensue unless these facts are
appreciated.

Those who anticipate the possibility of a premature interruption of
pregnancy should realize that the marital relation is inadvisable
after conception has taken place. For others, who have no reason to
expect irregularity in the course of pregnancy, such a precaution is
unnecessary. None the less, women who marry late in life or who first
conceive toward the time of the menopause will do well to follow the
same rule. The risk of accident may be very slight, but conservative
persons will not assume it when the likelihood of subsequent
conception is doubtful.

Not infrequently the fundamental reason for habitual miscarriage lies
in some anatomical abnormality which a surgical operation alone can
correct. As the necessity for interference can be determined only
after a careful examination, recommendations of wide application are
not possible. Nothing short of painstaking study of each case will
afford a basis for advice and action.

SYMPTOMS.--Very definite warning usually precedes a miscarriage, but
the threatening symptoms vary greatly in severity and duration. If
appropriate measures are taken promptly, these symptoms may disappear
with no harmful result Everyone concedes that bleeding and pain are
the chief indications of impending miscarriage, although an
occasional patient, profiting by former experience, may find other
signs prophetic in her own case.

Mature women, accustomed to the regular monthly function of their
sex, are prone to treat with indifference a slight discharge of blood
occurring during pregnancy. Indeed, it is widely believed that
menstruation frequently continues after conception. In point of fact,
however, it is very unusual in early pregnancy, and becomes entirely
impossible after the fourth month. Accordingly, whenever vaginal
bleeding is noticed, some other explanation should be sought; and the
patient who would adopt the wisest plan should assume that she is
threatened with miscarriage. There are other possibilities, but these
are for her doctor to consider.

It is true that small hemorrhages are not necessarily followed by
miscarriage. One may even experience slight loss of blood repeatedly,
and yet give birth to a healthy child at the natural end of
pregnancy. None the less, bleeding, however moderate, should always
excite suspicion, as we know it usually denotes the breaking to some
degree of the connection between mother and child. The extent of the
separation usually determines the degree of the hemorrhage, which in
turn indicates the seriousness of the accident. The fate of the fetus
will depend upon the area of placenta, which has been incapacitated.
Flooding, however, always imperils the fetus, and generally warrants
the inference that so much of the placenta has been separated as to
render further development impossible. On the other hand, so long as
the hemorrhage does not exceed the customary flow at the monthly
periods, the life of the child is rarely endangered; while a
chocolate-colored discharge, and even the loss of small clots, may
continue indefinitely without doing serious harm. Under such
circumstances, however, the patient should communicate with her
medical adviser, and should save for his inspection whatever may be
expelled.

Pain, the other conspicuous symptom of threatened miscarriage, has
not a uniform significance. Since it frequently occurs during the
course of pregnancy in association with a number of conditions, it is
not a reliable sign of danger. Moreover, the susceptibility to pain
varies; thus, of two patients in the same stage of threatened
miscarriage one may suffer intensely, while the other remains
comparatively comfortable.

Typically, the onset of miscarriage is attended by discomfort in the
small of the back, which may be continuous, but more often is
intermittent. If preventive measures are instituted at the outset,
there is hope of relieving the discomfort and averting the
miscarriage; but if the warning goes unheeded, the pain will
gradually shift to the lower part of the abdomen and become more
severe. It often happens that the cramp-like abdominal pain of
threatened miscarriage is confused with that associated with
intestinal indigestion. A simple test will sometimes decide the
question. If due to the latter cause, the discomfort will usually
yield to a teaspoonful of paregoric, whereas it will be without
effect if miscarriage is imminent. Exceptions to this rule are not
uncommon, yet a better one cannot be given; as a physician, even
after considering the technical evidence, may find it impossible to
decide at once whether or not miscarriage is threatened.

No confidence can be placed in many so-called signs of miscarriage,
though implicitly trusted by the laity. Lassitude, depression of
spirits, and general bodily ill-feeling may forecast the interruption
of pregnancy; but more frequently they have no such significance. The
same estimate holds true of other symptoms, including diarrhea and a
persistent inclination to empty the bladder. Nor does fever always
lead to the termination of pregnancy. A moderate rise of temperature
is without significance; but high fever, persisting for several days,
may result in the death of the fetus and subsequent miscarriage.
Nevertheless, prolonged febrile affections, such as typhoid fever,
frequently leave pregnancy unharmed.

So long as the symptoms are confined to slight bleeding and mild
attacks of pain, physicians regard miscarriage merely as threatened.
If the bleeding increases, the outlook becomes less favorable, and,
as I have said, miscarriage is inevitable when it amounts to
flooding. Likewise, rupture of the sack containing the fetus, with
escape of the amniotic fluid, indicates that the culmination of
events will not long be delayed.

The most favorable outcome is when the entire contents of the womb
are spontaneously expelled, which unfortunately does not always
occur. There is, to be sure, rarely any difficulty in the natural
birth of the fetus, for its meager development prevents serious
complications. The separation and extrusion of the placenta, on the
contrary, are apt to be imperfect when pregnancy ends in the early
months, and medical attention is necessary to determine whether the
uterus has been emptied completely. This is particularly important,
because the retention of placental tissue affords opportunity for
several unpleasant complications; and neglect in this regard accounts
in part for the belief that miscarriage is certain to leave women
irreparably broken in health.

AFTER-EFFECTS.--No one will deny that invalidism follows the untimely
interruption of pregnancy more often than the birth of children at
full term. This is not due, as is sometimes said, to the fact that a
miscarriage differs from a normal birth in that it is unnatural, for
other reasons are apparent. One of them, the retention of placental
tissue, has just been mentioned, but serious consequences resulting
from it are almost inexcusable, for, although the placenta may
separate less readily and be cast off less thoroughly after
miscarriage, modern medical skill can successfully cope with such
conditions. Another fruitful source of unfortunate after-effects is
the imprudence of the patient. Women should remain in bed fully as
long after a miscarriage as after the birth of a mature infant; if
they would consent to do so, many ill-effects would be averted. But
physicians frequently encounter strong opposition to precautionary
measures such as this. Many patients argue, illogically, that less
precaution is necessary since pregnancy failed to attain its natural
conclusion, and infer that the earlier that it ends the more quickly
one may leave the bed. In point of fact, even greater precaution is
required than if all had gone normally. Still a third cause for ill-
health may be found in physical ailments which antedated the
miscarriage but were not recognized until after its occurrence.

Invalidism which follows pregnancy and which may be fairly regarded
as chargeable to it depends, in most instances, upon an infection
acquired at the time of delivery. Infection occurs more frequently
when pregnancy ends during the early months, because in this category
is included the great majority of criminal abortions, which are
usually induced without regard for surgical cleanliness. Fatal
complications, or serious consequences which narrowly escape a fatal
ending, are common among women who attempt to rid themselves of an
unwelcome pregnancy. As they are ignorant of aseptic precautions,
their manipulations must necessarily contaminate the site of
operation; for this reason and others as well women who attempt to
perform an abortion upon themselves imperil their lives. The danger
is scarcely less when abortion is induced unlawfully by incompetent
operators; for lack of skill, the need of secrecy, and the desire of
haste all interfere with necessary aseptic technique. Everyone knows
that sad accidents befall those who submit to such operations; but it
is not generally recognized that these cases are largely responsible
for the ill-repute borne by miscarriage in general. On the other
hand, properly supervised miscarriages are attended by no greater
danger and probably less than delivery at full term.

CRIMINAL ABORTION.--The destruction of a pregnancy, except when its
continuance threatens the life of the patient, is forbidden by law.
The important ethical and religious aspects of the act which the law
thus stigmatizes as criminal we may properly neglect. Although
various religions present a diversity of teaching relative to its
moral nature, all agree in regarding it as sinful. Equally important,
however, is the fact that no matter what opinion anyone may hold as
to the morality of the act he is bound to obey the law. This is
apparently not clearly understood by the laity, for many persons
think that a physician may terminate pregnancy whenever he is so
inclined. If the liability to criminal prosecution which a physician
would assume should he comply with a request for the means of
destroying pregnancy were clearly realized, patients would not
beseech him to incur the risk of heavy find and long imprisonment
merely to gratify their own convenience or to save them from
disgrace.

The Common Law, an inheritance from England, enriched with
authoritative decisions by our own courts, is the groundwork of the
law in all the States, and its principles are binding in the absence
of express statutes. At Common Law, abortion is punishable as
_homicide_ when the woman dies or when the operation results
fatally to the infant after it has been born alive. If performed for
the purpose of killing the child, the crime is _murder_; in the
absence of such intent, it is _manslaughter_. _The woman who
commits an abortion upon herself is likewise guilty of the crime._

The great majority of those who desire the interruption of pregnancy
feel they have not assumed an illegal position so long as they avoid
instrumental procedures. That is not correct, for even at Common Law
it is a misdemeanor to bring about the death of an unborn child _by
the use of drugs or by any other means_.

At Common Law there was a difference of opinion as to whether all
induced abortions were illegal. Many courts formerly held that
quickening was a necessary prerequisite; but under the modern
statutes, practically without exception, the law disregards the
period of pregnancy at which the abortion is provoked. Since the time
of conception determines the beginning of embryonic development, to
prove that the act was committed before fetal movements were
perceived is no longer a valid defense. This has been emphatically
stated by Judge Coulter, of Pennsylvania, who said: "_It is not the
murder of a living child which constitutes the offense, but the
destruction of gestation by wicked means and against nature. The
moment the womb is instinct with embryonic life and gestation has
begun, the crime may be perpetrated._"

Each commonwealth has enacted its own statutes for the regulation of
abortion. In many states, simply _to seek the means for destroying
pregnancy is a criminal act_. Thus, Indiana, perhaps the most
progressive of the States in reconstructing its criminal code to
accord with modern sociological teaching, has enacted a law which I
quote from Burn's Indiana Statutes, Revision of 1908, Vol. I, page
1029. "Every woman who shall solicit of any person any medicine, drug
or substance, or thing whatever and shall take the same, or shall
submit to any operation or other means whatever with intent thereby
to procure a miscarriage, except when done by a physician for the
purpose of saving the life of the mother or child, shall, on
conviction, be fined not less than ten dollars, and be imprisoned in
the county jail not less than thirty days nor more than one year." To
include the woman as a party to the crime is a signal mark of
progress toward bringing abortion under effective legal control.
Heretofore, the perpetrator alone has been responsible, and in most
States he remains so, while the woman is regarded as a victim.
Clearly, that is unjust, for criminal abortions are rarely, if ever,
performed without application by the subject of the operation.
According to most of the statutes no distinction is made between the
attempt at abortion and its accomplishment. Irrespective of the
outcome, those who supply drugs or employ instruments purposing the
destruction of pregnancy are guilty of the offense.

An extensive analysis of the various State laws is unnecessary; the
mention of a few statutes, selected from different sections of the
country, will suffice to indicate the character of prevalent
legislation. Massachusetts imprisons those found guilty of abortion
for a period of three years or less, and permits a fine of one
thousand dollars. In Pennsylvania the same prison sentence is
imposed, though the fine may not exceed five hundred dollars. Three
years is the minimum imprisonment in Virginia, and a maximum of ten
years is allowed. Colorado's law duplicates that of Massachusetts.
California imposes no fine, and prescribes a sentence of from two to
five years in the State prison. All the statutes make the offense
much graver when the woman dies as a result of the practice. Under
these circumstances, the crime never takes lower rank than
manslaughter; and generally it is murder.

Evidently we possess sufficiently stringent laws regarding criminal
abortion; yet, as everyone knows, they do not prevent perpetration of
the crime. On good authority, we are informed that eighty thousand
unlawful abortions are performed annually in New York, in spite of a
possible penalty of four years in the State prison. This is due in
part to difficulty in securing evidence and failure to prosecute when
evidence could be gathered, but more particularly to the fact that
the general public does not appreciate the gravity of the offense.
The same feeling is illustrated in the advertising of abortifacients.
Newspapers and magazines unhesitatingly carry, under the guise of
remedies to regulate the health of women, notices of drugs and
equipment intended to destroy pregnancy. This is expressly forbidden
by many statutes. [Footnote: Thus, the Maryland law provides that
"any person who shall knowingly advertise, print, publish, distribute
or circulate any pamphlet, printed paper, book, newspaper notice,
advertisement or reference containing words or language or conveying
any notice, hint, or reference to any person or to the name of any
person, real or fictitious, from whom, or to any place, house, shop,
or office, where any poison, drug, mixture, preparation, medicine, or
noxious thing or any instrument or means whatever; or from whom
advice, direction, information or knowledge may be obtained for the
purpose of causing the miscarriage or abortion of any woman pregnant
with child, at any period of pregnancy, shall be punished by
imprisonment in the penitentiary for not less than three years, by a
fine of not less than five hundred dollars, nor more than one
thousand dollars, or by both, in the discretion of the court."]

The knowledge that prohibitory laws exist is sufficient to deter
reputable physicians from illegal practice; whereas known laxity in
the enforcement of the law continually tempts unscrupulous persons to
provoke abortion. Among the poorer classes the procedure is
undertaken by ignorant women, while persons in more comfortable
circumstances avail themselves of the services of medical men who are
usually incompetent and value money above professional honor. The net
result is an unpardonable death-rate and a large proportion of
invalids. Aside from the legal aspect of the act, the element of
personal danger would seem a warning to be heeded by women who
contemplate becoming a party to this crime.

THERAPEUTIC ABORTION.--If a woman is suffering from tuberculosis or
some organic affection, pregnancy may add a serious strain upon the
already crippled machinery of her body. Occasionally gestation itself
may cause changes which threaten life. In either event the duty of
the physician is plain. The law is acquainted with such emergencies,
and explicitly permits the termination of pregnancy when undertaken
to relieve or cure such conditions. When performed to restore health
the operation is called therapeutic abortion.

The Maryland law, for example, grants the right to induce abortion
whenever two or more physicians see the patient and agree that "no
other method will secure the safety of the mother." Similar rules are
prescribed by the statutes of other States, but none concedes the
right of abortion as a means of keeping the woman from suicide.

Since therapeutic abortions are legal, they may be done openly; hence
the operation is performed in appropriate surroundings and with every
refinement of surgical technique. These fortunate conditions
materially alter the outlook; serious consequences of the operation
itself need not be feared. Competent surgeons, employing modern
methods, may perform hundreds of abortions without the loss of a
single patient. Moreover, pregnancy may be terminated safely and
expeditiously at any time; the lay view which regards abortion as
more serious after the second month than before it is a relic of days
gone by.

PREMATURE DELIVERY.--In the introduction to this chapter we noted
that the infant becomes viable after the twenty-eighth week, which
marks in a practical sense, the transition of the fetus from an
immature to a premature stage of development. In point of frequency,
premature delivery ranks far below either abortion or miscarriage.

Unlawful interference with pregnancy generally proceeds from a desire
to avoid offspring, and lacks incentive after the infant becomes
capable of living independently. Criminal operations, therefore, are
not a conspicuous cause of premature delivery. Occasionally
physicians resort to artificial means to end gestation during the
later months in order that organic complications may be relieved; but
most premature births occur spontaneously. Sometimes they are due to
ill-health, while in other instances no evidence of disease is found
in either mother or child. Careful study of the individual patient,
however, is generally helpful toward the prevention of repeated
premature delivery.

The course of premature labor closely resembles delivery at full
term. But it is shorter because the infant is small; and the
subsequent loss of blood is not so great. The recovery of the mother
is never retarded by the fact of earlier delivery, though the
conditions which caused it may prevent rapid convalescence.

The outlook for the infant depends upon a great many factors. Most
important among them is the perfection of its development, which may
be estimated most satisfactorily from its weight and length.
Occasionally children have been reared when they weighed as little as
three pounds, but hope that they will survive should not be
entertained unless they weigh four pounds or more. This is attained
about eight weeks before maturity, and corresponds to a length of
forty centimeters (16 inches), measured from the crown of the head to
the heel. Premature children perish, most frequently, either from
incomplete development of their heat-regulating apparatus, which
predisposes them to pneumonia, or from imperfections in the digestive
functions, which increase the liability to malnutrition. To overcome
the first danger, incubators have been devised and have become
familiar to everyone through public exhibitions. A basket or box
supplied with hot-water bottles answers the same purpose, and has the
advantage of better ventilation. The second danger can be overcome
only by proper feeding. Breast-milk provides the most reliable
nourishment for premature infants. If the mother cannot supply it, a
wet-nurse should be procured, and, if the infant has not the strength
to suckle, the milk should be drawn from the breast and fed with a
medicine-dropper or a spoon.

In addition to providing proper food and maintaining an even body-
temperature, care must also be taken to protect these infants from
various harmful influences such as too much handling, strong light,
and loud noises. Although every precaution be observed, frequently
all counts for nothing; but if the child does thrive, there is no
reason for worry about its ultimate development. When a premature
infant lives, the same chances for adult health await it as it would
have had if born in its due time.

CHAPTER IX

THE PREPARATIONS FOR CONFINEMENT

Engaging the Nurse--Desirable Qualities in the Nurse--Preliminary
Visits of the Nurse--The Necessary Supplies for Confinement--The
Baby's Outfit--Sterilization--The Choice and Arrangement of a Room--
The Bed--The Preliminary Visit of the Doctor--When to Call the
Doctor--Personal Preparations--The Care of Obstetrical Patients at
the Hospital.

Prospective mothers are anxious to learn how they shall prepare for
the approaching confinement. They desire their preparations to be
thorough, reliable, and in accord with the most approved methods of
treatment, for they realize that preparations along these lines will
not only prevent haste and confusion at the time of birth, but will
also promote a satisfactory convalescence. Apparently trivial details
often safeguard confinement against serious accident. Indeed,
measures which aim at the prevention of illness form the chief asset
of modern obstetrics, and of these none takes higher rank than the
maintenance of strict cleanliness during and after childbirth. This
fact fortunately is widely appreciated at present, and not a few
women inquire voluntarily the means of observing the proper
precautions. It is true, of course, that even today many women are
delivered in filthy rooms and upon dirty beds, and that in spite of
such surroundings some of them make a good recovery. Yet grave
complications develop much more frequently among those who have not
paid attention to the preparations for confinement.

The surgical dressings and other supplies do not require attention in
the early months of pregnancy. A number of articles, invaluable when
delivery occurs at full term, are useless if the fetus is immature
and cannot live, and therefore it is unnecessary to provide them
until two or three months before the confinement is expected. In the
event of a miscarriage what is needed can be procured upon very short
notice. But, on the other hand, delivery subsequent to the twenty-
eighth week may require all the equipment useful at full term so that
everything should be in readiness by that time.

ENGAGING THE NURSE.--As soon as the existence of pregnancy is clearly
recognized the patient should select the doctor and the nurse who
will attend her. Prompt selection of a nurse will assure the widest
choice, for proficient nurses are in demand and book engagements far
in advance of the date they will be needed. Furthermore, it is a
relief to the patient to have her attendants selected. The
possibility of premature delivery never interferes with engaging the
nurse very early in pregnancy, for that accident releases both
patient and nurse from their contract.

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