Books: The Prospective Mother
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J. Morris Slemons >> The Prospective Mother
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Most cities now have institutions which provide a room and all the
essential care, exclusive of the doctor's services, at approximately
the cost of a trained nurse at home; luxuries will naturally add to
the expense in hospitals as quickly as elsewhere. If one considers
the various items connected with attention at home, such as the
maintenance of the nurse and of the patient, the cost of the
equipment necessary for confinement, the additional household
laundry, and the sundry other details, it is clear that hospital
treatment becomes distinctly economical. Moreover, the uncertainty of
the date of confinement may necessitate paying a nurse for a longer
or shorter period before the birth. Expense at the hospital, on the
contrary, usually begins when the patient enters; and if she lives in
the city it is rarely advisable for her to leave home until the
beginning of labor. Even aside from the matter of expense some women
prefer the hospital, since in this way they avoid the technical
preparations for the birth.
Much more vital, however, is the care patients receive in the
hospital, for rigid adherence to surgical cleanliness is exemplified
in the hospital as it can be nowhere else. Infections rarely develop
there. Formerly these accidents were more common in the hospital than
in the home, but conditions are now reversed and fatalities
predominate among those delivered in private houses. The modern
theory of asepsis has, to be sure, been widely accepted and is
practiced so far as possible wherever obstetrical patients are
attended, but only in the hospital can the underlying principles be
applied with complete thoroughness and persistence. The hospital is
constantly alert, whereas in private houses carelessness or
ignorance, or both, often lead to lax technique. As a result,
statistical evidence indicates that two to three infections occur
among those delivered at home for one at the hospital.
In the event of an emergency during labor, the hospital affords
another distinct advantage in its staff of trained attendants. Of
course they may be brought to one's home, yet not without some delay
and extra expense; whereas in the hospital their assistance is
instantly available. In institutions charity patients are often
delivered under more favorable auspices than are the wealthy at their
homes. Convalescence likewise is favored at the hospital, since the
rules which control the admission of visitors guard the mother from
exhaustion and annoyance. Moreover, isolation such as can only be
secured in a hospital is conducive to a well-trained baby.
Patients debating what course to follow often ask when they must
leave home, what they should take with them, and how long they ought
to remain at the hospital. The attending circumstances will alter the
answers to these questions, but in a general way the following
directions will serve as a guide.
Ordinarily, the patient may remain at home until the first warning of
labor. Departure from this rule is justified if the patient becomes
unduly anxious about reaching the hospital in time, especially when
she lives some distance from the institution, or if there is any
doubt of securing accommodations. In either event, she should go to
the hospital at least one week before the confinement is expected.
There is no danger in riding to the hospital after labor has begun;
frequently, the ride exerts a helpful influence and shortens the
labor.
Whatever is to be taken to the hospital should be packed in a bag
several weeks before the predicted date of confinement and put in a
convenient place so that one may be spared the trouble of gathering
it at the last minute. Beside her usual toilet articles, the mother
will require several gowns, a dressing-robe, and bedroom slippers.
Clothing for the child will also be needed since most institutions
stipulate that the infant use its own wearing apparel. If
impracticable to transport the entire wardrobe when the mother enters
the hospital, so much may be taken as will be needed during the first
few days, and other articles may be brought as the need of them
arises. The personal laundry of both mother and infant is usually
done outside the institution.
Surgical dressings of every description are provided by the hospital.
Those who intend to enter a hospital, therefore, may disregard the
list of articles necessary for confinement. Similarly, the
sterilization, the preparations of the room and of the bed, and
personal preparations will be of interest only to the patient who
intends to stay at home.
It is not always possible for the physician to say how long a patient
should remain at the hospital; the rapidity of the mother's
convalescence and the progress of the child, both important factors,
cannot be accurately foretold. Frequently, it is a good plan to
remain until the infant is four weeks old, but the majority of
patients are dismissed at a somewhat earlier date. In no instance,
however, should the mother be allowed to leave before the infant is
two weeks old. Even when given the privilege of leaving so early she
will always understand that competent assistance must be provided at
home, for the mother should not resume her routine duties until six
weeks after the birth.
CHAPTER X
THE BIRTH OF THE CHILD
The Cause of Labor--The Course of Labor--The Stage of Dilatation--The
Stage of Expulsion--The Placental Stage--The Effect of Labor upon
the Child--Meddling--Justifiable Intervention--Management of Birth
without the Doctor--Methods of Reviving the Child.
The birth of a child is an act of nature, an act generally performed
as satisfactorily as any other bodily function. Birth has, however,
so deep a meaning for the mother, as well as for her family and her
friends, and is, above all, so vital to the future of the race, that
it has naturally become the subject of many impressive superstitions.
Primitive peoples have invariably embodied in their religion their
views of the origin of life and the phenomena of its inception. With
these mysteries Greek and Roman mythology dealt extensively, as did
also the myths of the Phoenicians, the Egyptians, the Chinese, and
the people of ancient India. No race, indeed, has lacked its own
interpretation of childbirth, and no phase of the process has failed
to have attributed to it a supernatural significance. A number of
these superstitions still distress women on the eve of motherhood. To
correct exaggerations and to deny many utterly false impressions of
childbirth there is no better way than to give a frank account of
what does actually occur. I shall adhere to a purely physiological
description of the event, for, although I appreciate fully the fact
that its sociological and sentimental aspects are perhaps equally
important, these are not, in my opinion, pertinent to a medical
discussion.
In a scientific sense the act of birth may be described as a series
of muscular contractions which widen the birth-canal and expel the
contents of the pregnant womb. Since the process requires an
expenditure of energy, it has come to be called labor. Intrinsically,
labor does not differ from many other physiological acts. The heart
drives blood into the arteries; the bladder empties itself; the
intestine moves its contents and finally expels the undigested
residue. All these acts strongly resemble that of birth; but they
also differ from it, for the head of the fetus is a hard body which
resists being molded to the shape of the passageway through which it
enters the world. To this resistance the pain which accompanies
delivery is largely due. And yet even in this respect the act of
birth is not unique; certain circumstances lead to painful
contractions of the muscle fibers in the intestine and less
frequently of those in other organs.
It is natural to ask what purpose is served by the pain associated
with labor; and a moment's reflection will make it clear that one
reason for the discomfort is the warning which it gives of the
approach of birth. If the mother were not thus cautioned, she might
be delivered under very awkward circumstances, and even under such
conditions that occasionally the infant would perish the instant it
was born. All mammals suffer in giving birth to their young, though
with quadrupeds the period of suffering is shorter, for the upright
posture of man has changed the shape of the pelvis, rendering birth
somewhat more difficult. Anyone who observes the lower animals
preparing for delivery will be convinced that they also are
responding to pain, the most compelling call of nature.
That the suffering is at all essential to the mother's love for her
child I cannot believe. Under certain circumstances, as for example
when the Cesarean operation is performed before the onset of labor,
the delivery is painless; yet I have never known a mother less
devoted to her child on that account. Biology throws no light upon
the relation of the "curse of Eve" to present-day confinements.
THE CAUSE OF LABOR.--It is evident that, in a general way, the
muscular contractions of the womb cause the birth of the child; but
before we thoroughly understand the act, science must discover what
stimulates the muscle to contract. Although careful research has thus
far failed to disclose the source and character of the stimulus, it
has taught many properties of the contractions themselves. Their
force has been measured and found to increase as the end of labor is
approached; the pressure they exert varies between nine and twenty-
seven pounds. We also know that the patient can neither hasten nor
delay the contractions voluntarily. Strong emotions are believed to
accelerate them at times, and we find a very extraordinary
illustration of this effect recorded in I Samuel, IV, 19, where we
read: "Phineas' wife was with child, near to be delivered; and when
she heard the tidings that the ark of God was taken, and that her
father-in-law and her husband were dead, she bowed herself and
travailed; for her pains came upon her." On the other hand, and much
more familiarly, excitement checks the contractions after they have
begun. Every obstetrician has heard patients say that with his
arrival the pains died down. Yet such an influence is never
permanent; the contractions soon reappear, and labor advances as
though no interruption had occurred.
For the artificial induction of labor, the physician has at his
disposal means that resemble the method sometimes employed by nature.
Suitable appliances introduced into the womb provoke contractions,
and labor proceeds step by step as if the stimulus were a normal one.
Nature does not, however, ordinarily employ mechanical irritation to
start the uterine contractions. The initial factor is more remote
and, as I have said, is not yet well understood.
Since, as everyone admits, delivery occurs with conspicuous
regularity about the end of the fortieth week of pregnancy, and
pregnancy corresponds, therefore, to ten menstrual cycles, some have
been led to believe that labor and menstruation have a common basis.
The truth of this supposition, however, must be doubtful until we
know the cause of menstruation. Yet it is a matter of common
observation that the uterus becomes unusually irritable about the
time when the tenth menstrual period would be due. Strong purgatives
administered with other drugs on or after the calculated date
frequently bring about delivery, whereas previous attempts of this
kind prove unsuccessful. To account for this peculiar irritability of
the uterus about the fortieth-week of pregnancy, microscopical
changes in its tissues have been suggested but sought in vain. Nor
will the distention of the organ explain it.
A great many theories have been offered to explain the causation of
labor, but they have now only an historical interest. To-day we are
just beginning to learn the correct methods of studying the problem.
The experience of ages has firmly established the fact that the fetus
is expelled when ready to enter the world, or as we say, when it has
become mature. But how does the fetus assert its maturity? There is
the kernel of the matter; that is the real problem, a problem for the
solution of which, happily, we possess better facilities than have
heretofore existed. One solution that has been suggested assumes that
the fetus loses ultimately its power to assimilate the nourishment
provided through the mother's blood. In consequence, it is argued,
the material which previously enabled the fetus to grow now collects--
in the maternal circulation, stimulating the womb to contract.
A part of this explanation, namely, that the material which
stimulates the muscle fibers, whatever it may be, is a chemical
substance and that it circulates in the mother's blood, is almost
certainly true. There are, however, very weighty reasons for
believing that this substance has not the character of food. A more
plausible supposition is that the fetus produces this material in the
course of its natural living processes, and the substance would
accordingly be a waste-product.
THE COURSE OF LABOR.--The current view that labor begins in the early
evening and generally ends during the night is incorrect. This
impression has grown out of the fact that the whole process
frequently consumes twelve hours and must in such an event include
some part of the night. Statistical evidence indicates that almost as
many births occur at one hour of the twenty-four as another; to be
precise, only five per cent. more children are born between 6 P.M.
and 6 A.M. than between 6 A.M. and 6 P.M.
As already pointed out, labor commonly begins with transient
discomfort in the lower part of the back. At first the uterine
contractions are far apart; they last but a moment and cause only
twinges of pain. Gradually, the preliminary contractions give place
to others of more definite character, which appear at intervals of
five to ten minutes. Estimates of the total length of labor will vary
according as one counts from the first warning or from the advent of
typical contractions which we hear called "pains of the right kind."
These generally continue for about four hours, and this period
represents the average length of time the physician remains
constantly with his patient. Estimates which include the initial
symptoms are longer, varying from ten to eighteen hours. Prolonged
labors are rare; and extremely short labors are also infrequent,
though now and again it will be only an hour or two from the very
first pain until the child is born.
To predict absolutely the length of labor for any particular patient
is impossible. The averages calculated from large groups of cases
have no more than a broad scientific interest; when applied to any
individual they are apt to be very misleading. Thus, from statistics
we should expect the first labor to be longer than subsequent ones,
but we are often surprised by an unusually rapid delivery.
To facilitate description, labor is divided into stages which are
conveniently designated the first, the second, and the third. During
the first stage the way is prepared for the expulsion of the child;
at the end of the second stage the child is born; the third stage is
occupied with the separation and the expulsion of the after-birth.
The progress of labor may be ascertained from time to time by means
of suitable examinations. Whereas formerly vaginal examination was
the only method which served this purpose, we are now acquainted with
several. For example much of the information necessary for the proper
management of delivery may be gained from examination of the
patient's abdomen; and this may be supplemented by observations too
technical to consider here.
Occasionally I have heard doctors accused of negligence because they
failed to make numerous vaginal examinations. Censure of this kind
generally is unjust, for discretion in limiting the number of vaginal
examinations provides against infection a guarantee which cannot be
overestimated. In many cases, of course, they are still invaluable
toward determining what treatment should be pursued, yet they are
never employed to the extent once customary. Moreover, physicians
have learned to take extraordinary precautions whenever vaginal
examinations must be made.
Anyone who practices obstetrics in these days appreciates how careful
he must be, especially of the cleanliness of his hands. Energetic
scrubbing with soap and water and the free use of antiseptics, as
physicians now employ both these measures, appear ridiculous to some
women who have witnessed deliveries under a less stringent regime.
They may be bold enough to express their disapproval. They may remind
us that many women have been successfully delivered without such
care. And in this they are correct; we know that nine of every ten
mothers passed through childbirth uneventfully before modern
precautions were dreamed of. Such precautions as are now taken,
however, are necessary to secure the safety of the tenth patient. And
it is because they are anxious that all their patients shall enjoy
the greatest possible security that physicians dare not omit any
precaution.
Disinfection of the physician's hands does not entirely exclude the
danger of infection through vaginal examinations. Although he may
have been most conscientious, there is some risk of carrying
contaminating material into the birth-canal from the region about the
opening of the vagina. Unless that region has been satisfactorily
disinfected, sterilizing the dressings and cleansing the hands may
become a waste of time. Sensible patients, therefore, will never
object to the preparations which the nurse is instructed to make.
THE STAGE OF DILATATION.--For reasons which are sufficiently clear,
the womb must remain closed while fetal development is in progress;
but under normal conditions, when this development is complete, the
mouth of the womb dilates and the infant is expelled. The infant
never takes an active part in its birth, although physicians once
thought it did and attributed tedious labors to stubbornness on its
part. The error has been corrected in medical teaching, but many
persons unacquainted with the facts cling to the idea that the infant
forces its own way out of the womb.
At the end of pregnancy the mouth of the womb is small, too small,
often, to admit an instrument as broad as a lead pencil. It is
obvious, therefore, that very radical changes must be wrought before
the infant can pass. The door, as it were, must be widely opened.
This phenomenon, which we call dilatation of the womb, is brought
about by involuntary contractions of the muscle fibers in its wall,
every point of which they draw upward. Now, the top of the womb is
directly opposite its mouth, consequently the contractions inevitably
pull its lips wider and wider apart. Ordinarily another factor is
concerned in this mechanism. To understand the whole process we must
recall that a fluid surrounds the fetus, and that this fluid is
contained within elastic membranes. The uterine contractions compress
the fluid, drive the membranes, like a wedge, into the mouth of the
womb and spread its lips apart. Thus, to the pulling effect just
mentioned, a pushing force is added. After full dilatation has been
accomplished and the membranes can serve no further purpose, they
rupture; as the midwife puts it, "the bag of waters breaks." The
quantity of fluid which escapes will vary. Occasionally, a huge gush
will drench the patient's clothing; but more often what is lost at
first amounts to only a few teaspoonfuls, though small quantities of
fluid often dribble away with subsequent contractions.
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, the
_sederunt_ was 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.]
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