Books: The Prospective Mother
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J. Morris Slemons >> The Prospective Mother
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The importance of the changes wrought by the adoption of aseptic
methods requires no emphasis, for the marvels of modern surgery are
even more impressive to laymen than to the medical profession.
Everybody now understands that strict cleanliness is indispensable to
the success of a surgical operation. But the general public has not
fully awakened to the same profound necessity in connection with
childbirth, although it was child-bed fever that called forth the
observations and experiments upon which modern surgical technique
rests.
Although most obstetrical patients appreciate the fact that there is
an advantage in sterilized dressings and sanitary surroundings, few
realize the risk they run without them. One must know the mournful
history of the past to be adequately impressed with that danger, for
we no longer see the epidemics of childbed fever which formerly swept
over communities, sacrificing ten of every hundred women as they
became mothers. Precaution is no less necessary on that account; the
scourge would be rampant again if the reins were loosened.
Most instances of puerperal infection are, it is true, referable to
lack of care. Nevertheless, the complication develops now and then
where all precautions have been conscientiously observed. Under such
conditions the infection will in all likelihood be a mild one, and a
tedious convalescence usually proves its most disagreeable feature.
Such stringent preventive measures as are now practiced in many
hospitals have reduced the frequency of infections to the point where
only one fatal case, or even less, occurs in a thousand deliveries.
These rare cases remind us that vigilance must never be relaxed, and
that patients who are confined at home require just as much care as
those in hospitals, where conditions are the best to prevent
infection and the complications, which follow.
The first essential toward the avoidance of infection in obstetrical
cases is clean dressings. Naturally, these should be clean to the
sight, but it is in invisible dirt that serious danger lurks;
bacteria are the causative agents of this disease. Experiments have
taught the bacteriologist that disease-producing organisms are killed
in half an hour when subjected to a high atmospheric pressure and the
temperature of steam. Special apparatus has been constructed for
carrying out the procedure. It is unnecessary for our purposes,
however, since the essential conditions may be secured, though with
less convenience, in any kitchen. If a prospective mother finds it
awkward to do the sterilizing at home, and her nurse is unable to
take charge of the matter, she may arrange with a local hospital or
the nearest nurses' directory to sterilize her dressings. Yet a very
little ingenuity suffices to do the work at home with perfect
satisfaction. Installments of the smaller bundles may be sterilized
in a galvanized bucket. To do this place an inverted bowl, with a
depth of three to four inches, at the bottom, and pour in water until
the bowl is almost covered. A breakfast plate rests on the bowl, and
upon this the dressings are stacked; a second larger plate which fits
the top of the bucket is utilized as a lid to close in the
sterilizing chamber. This will not accommodate the larger packages; a
more satisfactory method for all of them is to use a wash-boiler in
which has been swung a muslin hammock.
To arrange the latter form of home sterilizer, cut an oblong piece of
unbleached muslin large enough to sink far down into the boiler and
run a drawing-string of stout cord about the edge. Cover the bottom
of the boiler with several inches of water; tie the hammock in place,
passing the cord beneath the handles of the boiler to hold the muslin
securely. Pack in the dressings, which have been wrapped in
appropriate bundles; put the lid in place, thus closing the
sterilizing chamber, and leave the dressings exposed to the steam for
at least half an hour. After the operation has been completed, the
bundles are taken out of the boiler and allowed to dry in the air.
They must not be opened until the occasion for which the supplies
were prepared arrives; awaiting this event, they are laid away in a
convenient closet or drawer.
A word of caution may be added concerning a method of sterilization
employed at home more frequently, perhaps, than any other. According
to this procedure, the supplies are wrapped in paper, thrust into a
hot oven, and left there until the paper is scorched. From the
standpoint of economy as well as of thoroughness, this method is
likely to prove unsatisfactory. Frequently, the dressings themselves
are scorched; I have known patients to ruin several installments of
their supplies in this way. Moreover, dry heat is not so trustworthy
as steam for sterilizing purposes.
Judicious management means the preparation of the supplies necessary
for confinement before turning to the selection of the infant's
outfit. Ordinarily, both these tasks should be finished by the end of
the eighth month, and final arrangements for the approaching delivery
will then claim attention. If the patient expects to remain at home,
she must decide which is the best room to occupy; she will wonder how
it ought to be equipped, and she will be anxious to learn what
personal preparations are advisable at the beginning of labor.
Intelligent answers to these questions are important. A patient
should request the physician to criticize her plans when he pays the
preliminary visit four to five weeks prior to the expected date of
confinement. If she has acted unwisely in any respect, he will point
it out, and may suggest changes which will enable her to employ to
the best advantage the resources at hand.
THE CHOICE AND ARRANGEMENT OF A ROOM.--An old-fashioned custom, which
relegated obstetrical patients to the most secluded part of the
house, with little regard for comfort and still less for hygiene, has
now few, if any, adherents. There is an advantage, to be sure, in
having a quiet room; but this qualification may be secured in a room
well located with regard to other essentials. Selection of a suitable
room is not a trivial point. In most cases, since patients ordinarily
remain for convalescence in the same room in which the infant is
born, the chamber must serve a two-fold purpose. A number of
requirements, therefore, must be met, and they must all be kept in
mind when the room is chosen.
We have seen that the act of birth, natural as it is, may have a very
unnatural sequel if precautions against infection are treated
lightly. It is proper, therefore, that the delivery-room should be as
clean as care can make it. Such radical measures as may be employed
in sterilizing the dressings are here out of the question; if
possible, they would be absurd. Infection usually develops because
harmful bacteria come in contact with the patient. For that reason,
an infection is more likely to be communicated by the dressings than
by articles about the room, which only become a source of danger when
the dirt upon them is transferred by an attendant.
An acceptable delivery-room may be arranged in any home; it is by no
means necessary to duplicate the equipment of a modern hospital. To
choose a room convenient to the bathroom will be found advantageous
not only at the time of birth but throughout the lying-in period. The
furnishing should be simple and scrupulously clean; indeed, it is
improbable that one of these good points can be secured without the
other. Furthermore, the preparation of the room should be completed
well in advance of the date of confinement.
A large collection of furniture interferes with the nursing, and also
increases the difficulty of keeping the room free of dust. It is
sound advice, therefore, to remove everything which will not serve
some good purpose during the delivery. Should any article be wanted
later, it can be brought back to its accustomed place. The furniture
may be conveniently limited to a bed, a bureau, a washstand, a table,
and several chairs, one of them a large, comfortable rocker, which
will prove invaluable during the early part of labor.
To approach perfect conditions, bric-a-brac, needless hangings, and
everything that might collect dust should be temporarily removed. A
profusion of pictures does not accord with the best sanitation of a
room devoted to the treatment of obstetrical patients; those which
are to be left upon the wall ought to be taken down and wiped
carefully with a damp cloth. Other desirable preparations would be
instinctively undertaken by the modern housekeeper, and it may seem
presumption to mention that the room itself ought to be subjected to
most thorough cleaning. It is well to leave the floor bare or merely
covered with freshly cleaned rugs. Carpeting is difficult to protect
against soiling and is not sanitary. If left down, the carpet should
be covered with some suitable material, firmly stretched and tacked
in place.
We know that the air in most households does not contain disease-
producing bacteria; but the presence of any contagious disease
materially alters the situation, and may imperil the convalescence of
an obstetrical patient. Preferably, one should never select a room in
which there has lately been sickness, and under no circumstances may
such a room be used until carefully fumigated. The more conspicuous
diseases which for at least several months absolutely disqualify an
apartment for obstetrical purposes are diphtheria, pneumonia,
pleurisy, erysipelas, scarlet fever, typhoid fever, tuberculosis of
all varieties, and every sort of discharging sore.
When possible, two adjoining rooms should be given over to the mother
and the infant; if this is impracticable, the single room should be
large, easily ventilated, well lighted, and heated in such a way as
to permit a change of temperature without difficulty. All these
features help to make convalescence comfortable and free from petty
annoyances. A room which has a southern or eastern exposure proves
grateful for those who must remain indoors; frequently, this will be
beyond reach, but a room getting the sun's rays directly during part
of the day will always be available, and the selection should be made
with that requirement in mind. At the time of birth and for the first
few days which follow, a patient may not appreciate this feature;
ultimately she will understand the need of sunlight better than the
need for the more technical, and therefore the more impressive,
preparations.
THE BED.--Now that housekeepers recognize how easily such furniture
can be kept clean, few homes are without a brass or an iron bedstead;
they are equally sanitary. Undoubtedly, this kind of bedstead
fulfills the needs of an obstetrical patient much better than any
other; and, if at hand, it should be used. The single bedstead is the
most acceptable, and the mattress ought to be at least twenty inches
above the floor. A low, wide bed interferes with proper management of
the delivery and later handicaps the nurse in taking care of the
patient. Wooden blocks may be used to raise a bed which otherwise
would be too low. It is well worth while to provide them if one
desires good nursing, for no attendant can do her best when she must
continuously bend over a very low bed.
The location of the bed at the time of delivery is not an unimportant
matter; it must always be placed so that the brightest possible light
will shine over the foot. Since birth often occurs at night, one
should make certain that the artificial lighting of the room is good,
and place the bed most advantageously in reference to it; at the same
time the necessity of a good light from the windows, when delivery
occurs during the day, should not be forgotten. The head of the bed
may be placed against the wall, but both sides must remain freely
accessible not only at the time of delivery but also throughout the
lying-in period.
A smooth, firm mattress, made in one piece, should be provided. One
which has been used several years and possibly worn in a hollow will
require renovation to be made comfortable. A feather bed should not
be used under any circumstances. The mattress must be protected; and
protection is best secured by means of a large piece of rubber
sheeting. The regulation household sheet covering the rubber should
be tucked well under the mattress at the ends and sides; in that way
the rubber sheeting will be held firmly. Since the part of the bed
where the hips rest will be most exposed to soiling, the protection
of this area is usually reinforced by a "draw sheet." To arrange
this, a cotton sheet is doubled so as to make a strip about one yard
wide and two yards long; the smaller piece of rubber sheeting is laid
between the folds. The draw sheet will reach from the middle of the
back to the knees; its ends should be tucked under the sides of the
mattress, to which it is fastened by means of large safety pins.
After delivery, the draw sheet may be removed without disturbing the
mother, who will thus be assured a clean, dry, and comfortable bed.
The bed-clothes covering the patient during labor will vary with the
season of the year, but should always be light; in summer a single
sheet will suffice, and in winter a blanket will likely be needed.
For sanitary reasons, a freshly laundered sheet should also be placed
outside the blanket until the delivery has been completed; later, it
may be replaced with a light spread. Two pillows will be needed, and
it is very convenient to have one of hair, the other of feathers.
While there is no necessity for sterilizing the bed-clothes, it is
advisable to use linen which has been recently laundered and kept
well protected from dust. Among the poor, infection from soiled bed-
linen is not uncommon.
THE PRELIMINARY VISIT OF THE DOCTOR.--No teaching of medical science
has been given greater prominence of late than the principle of
prevention. In obstetrics it finds a particularly wide field of
application, and its practice is responsible for removing many of the
former terrors of childbirth. We have just learned that preventive
measures effectually reduce the frequency of puerperal infection, and
in an earlier chapter we saw the value of routine examination of the
urine as a means of anticipating other complications. Moreover, the
benefit of promptly reporting to the physician anything that does not
seem to be as it should has been urged constantly, for in this way is
afforded the earliest opportunity to treat complications. Similarly a
visit from the doctor about four weeks before the expected date of
confinement is indispensable to skillful management of the delivery;
neglect of this precaution is sometimes responsible for bad results.
At this visit the physician not only becomes familiar with the
general health of his patient, but he also notes certain facts which
will have a direct bearing upon the course of labor. By means of a
few simple measurements he may accurately determine the character of
the pelvis, the bony structure through which the fetus passes. When
they are compared with what we know as the normal measurements, a
very good idea is gained as to whether the birth-canal will present
any obstacle to the passage of the child; and, if it will, there is
opportunity to deliberate what treatment may be necessary. Since
another factor in the problem, namely, the size of the child, cannot
be accurately predicted, occasionally the physician may hesitate to
express as definite an opinion as the patient may wish. Nevertheless,
though it may be impossible to learn every detail, the available
information well repays the time and trouble expended. In nine out of
ten cases nothing whatever is found out of the way; the result is an
assurance which always justifies the examination.
During this examination the position of the child is also
ascertained. By means of a series of painless manipulations through
the abdominal wall of the mother, the head, the body, and the
extremities of the child may be mapped out, and the conclusions
verified by locating the fetal heart-sounds. In this regard, also,
the physician usually finds normal conditions. The most favorable
presentation, that in which the head is the part to be born first,
occurs in ninety-seven of every hundred cases. When less favorable
conditions are recognized, they may frequently be corrected at once;
but should that prove impossible, with foreknowledge of the
presentation, the physician will be more competent to conduct the
delivery.
With a clear understanding of the character and value of the
information gathered at the preliminary examination, patients are not
likely to refuse it. If they do, the risks should be fully explained
to them. Some physicians decline to assume the responsibility of a
patient who will not permit these observations. Such a decision is
rarely necessary, for in my experience the patient's consent has
never been difficult to obtain. Many women now regard the visit as
part of the routine attention, and inquire when it will be made.
The appropriate time for this examination, as I have indicated, is
approximately one month prior to the calculated date of confinement.
Before this period, we have no assurance that the presentation which
is found will continue until the time of birth. The fetus frequently
alters its position as long as it is not large enough to fill out the
cavity of the womb, consequently it is only during the last month of
pregnancy that the final presentation can be determined. But to defer
the examination after the period I have specified is unsafe since we
lack an exact method of fixing the day of confinement, and too long a
delay might render a preliminary examination impossible.
Aside from its relation to the observations just outlined, the
preliminary visit provides an opportunity for the physician to
criticize the preparations which have been made, and for the patient
to inquire about the personal preparation advisable at the beginning
of labor. She will also learn the signs which indicate that labor has
begun and will be told what to do when they appear. Although
physicians may not agree in all these directions, there can be no
difference of opinion relative to the essential points. At least, the
rules given here will serve to bring the patient and the doctor to a
definite understanding as to the course he desires her to follow.
WHEN TO CALL THE DOCTOR.--During the last two or three weeks of
pregnancy not a few patients are more comfortable than they have been
for several months. About this time the womb usually drops somewhat
and relieves the pressure which has interfered with breathing. These
changes, however, do not promote comfort in every direction; more
freedom for the organs of the chest means compression of the
structures below the womb; consequently, the inclination to empty the
bladder and for the bowels to move becomes more frequent. Patients
complain also of cramps in the legs and experience difficulty on
walking. This order of events enables some women to recognize the
approach of delivery. Of course there is other evidence when labor
actually begins. Its onset may be indicated in one of three ways,
namely, by periodic pains, by a gush of water from the vagina, or by
a discharge of blood as though the patient were taken unwell. Each of
these unmistakable signs is a sufficient reason for notifying the
doctor.
At the onset of labor, dragging pains are usually felt at the back,
but sometimes in the lower part of the abdomen. The rhythm with which
they come and go identifies them more certainly than any other
feature, though this indication is not entirely reliable, for
intestinal colic also causes rhythmical pain. At first the uterine
contractions which occasion the discomfort are weak and appear at
long intervals. Gradually they become stronger and closer together.
When the interval between them has been shortened to half an hour or
less their significance is fairly certain, provided the abdomen
becomes tense and hard with each pain, remaining comparatively soft
between them.
When contractions begin during the day or early evening, the
physician will be glad to have immediate notification in order that
he may arrange his appointments and thus be free to attend the
patient when she needs his services. On the other hand, if they begin
between 11 P.M. and 7 A.M. the nurse, who will always be summoned
with the very first warning, should be allowed to decide when the
doctor is to be called. Unless other instructions have been given,
she will usually wait until the interval between the contractions is
five to ten minutes.
Usually the symptoms make it clear that labor has begun, but
occasionally the greatest difficulty will be experienced in deciding
whether the discomfort has not some other origin. Uncertainty may
prevail not only because of the similar effects of colic, but also
from the fact that uterine contractions do not always have the same
value. Preliminary pains may appear several days, or even weeks,
before the actual onset of labor. Now and then the "false" pains
cease, and after a period of comfort efficient contractions are
established. There is never difficulty in recognizing the latter;
doubt always relates to the preliminary pains, which may subside or
may pass into the efficient type. We lack a method of foretelling
which turn they will take; developments may be calmly awaited, with
the assurance that ample warning will precede the birth.
A slight mucous discharge from the vagina is frequently seen toward
the end of pregnancy and may be disregarded, but a gush of watery
fluid always means that the sac which contains the fetus has
ruptured. Uterine contractions generally follow within a few hours,
though in a few instances they will not appear for a number of days.
Under any circumstances the event ought to be promptly reported to
the doctor. Similarly, he should be notified whenever bleeding from
the vagina occurs, since it is important to have him determine its
significance.
Anyone who supposes that patients are more likely to be infected when
delivery occurs so quickly that there is not time for the doctor to
arrive overlooks the leading factor in the production of this
complication. Unless harmful bacteria are introduced into the birth-
canal and lodge there, infection is impossible. Bacteria never enter
of their own accord; they are usually carried into the vagina by
means of an examining finger or some other foreign body. Accordingly,
with the exception of those instances in which local inflammation
already exists, there is no reason to fear infection when delivery
proceeds so rapidly that internal examinations are not required.
PERSONAL PREPARATIONS.--Ordinarily, if the nurse is not already in
the house, she will arrive in time to assist the patient in making
the final arrangements for delivery. Should the nurse be delayed, the
patient herself may make certain preparations to insure personal
cleanliness, another very important factor in the prevention of
infection.
The presence of hair and the folding of the skin about the outlet to
the birth-canal render the disinfection of this area somewhat
difficult. It is advisable, therefore, to clip the hair as short as
possible and, while bathing the whole body, to scrub the region in
question with especial thoroughness. Before the bath an enema of
soap-suds should be taken to clear the rectum of material which
otherwise might be expelled during the birth and contaminate the
field of delivery. The bath-towels and the gown which are used should
have been freshly laundered.
Other especial preparation of the delivery-field will be made later
by the nurse. But whenever labor progresses so rapidly that neither
the nurse nor the doctor arrives before the child is born, such
preparations as I have indicated will be sufficient, for more minute
precautions are unnecessary unless an internal examination must be
made.
THE CARE OF OBSTETRICAL PATIENTS AT THE HOSPITAL.--The majority of
obstetrical patients are attended at home, and there is no reason why
this should not be. Generally it is unfair to urge a woman to go to a
hospital if she has already passed through a normal confinement and
there is no reason to anticipate trouble in the approaching one; on
the other hand, if any complication whatever is anticipated, the
patient should certainly enter a hospital. Furthermore, it frequently
proves advantageous to do so where the pregnancy is the first, though
no complication is expected and none develops. The average labor with
the first child lasts somewhat longer than with subsequent ones, and
in consequence there is greater opportunity for the patient's family
or friends to interfere with the management of the case, which never
benefits a patient, and is sometimes a serious handicap. Then again,
the cramped apartments, so common in these days, are poorly adapted
to the treatment of sickness of any sort and should induce many
obstetrical patients to choose the hospital. There are, besides,
other features which favor this course, such as economy, convenience,
and safety. From my own experience, which includes the care of
patients both at home and at the hospital, I am convinced that, as a
rule, the latter is much more satisfactory.
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