E. M. Forster - "Howards End"

Sydney G. Fisher - "The Quaker Colonies"

J. L. Cherry - "Life and Remains of John Clare"

Upton Sinclair - "The Naturewoman"

New Philadelphia Book Publisher Highlights Local Talent
Book and Publishing News from Publishers Newswire(tm)

Looking for Child to be on Cover of a New Book, 'The Model Child'
PHILADELPHIA, Pa. -- The Philadelphia literary world will celebrate the launch of two new players today, April 10th: Kay Square Press, a new publishing company focused on Philadelphia-area artists, their stories, and their art; and Kay Square's first release, 'With the Rich and Mighty: Emlen Etting of Philadelphia' (ISBN: 978-0-9815129-0-7), a critical biography by Kenneth C. Kaleta.

FlatSigned Press Alleges Don Imus Remarks Damage Legacy of President Gerald R. Ford
NEW YORK, N.Y. -- Nathan Yungerberg, an accomplished model scout and professional child photographer is launching a nation-wide casting call to find the cover model for his highly anticipated book release, 'The Model Child: A Parents Guide to the Child Modeling Industry' (ISBN: 978-0-9817018-0-6).

Books: The Prospective Mother

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




Most breech cases are delivered spontaneously; if not, the outlook
for the mother is no less favorable on that account. Assistance, when
undertaken, is usually prompted in the interest of the child, which
will be seized by the legs and extracted if there are indications to
terminate labor. Purely as a precautionary measure, a second
physician will often be called about the time the stage of expulsion
begins. Foresight of this kind must give the patient confidence
rather than alarm her. Indeed, should operative intervention of any
kind become necessary in the practice of obstetrics, the inclination
of the doctor to call an assistant must be regarded as an evidence of
superior judgment.

MANAGEMENT OF BIRTH WITHOUT A DOCTOR.--A prospective mother should
not be left alone during the four weeks prior to the expected date of
delivery, for it is important that during this period aid may be
quickly summoned in the event of an emergency. However, if the
confinement be the first, ample warning of delivery will always be
given. Even in a later confinement several hours will probably elapse
between the preliminary signs and the birth itself. It is extremely
rare to have labor progress so rapidly that the child is born before
the doctor arrives. Under such circumstances, if the nurse be present
she will be master of the situation; whenever she has been unable to
reach the patient, someone near by should be called to render what
assistance may be needed. A labor which advances so rapidly that
skilled assistance cannot be procured is proof in itself that
everything is going in an ideal manner, and that interference is not
necessary. Although the doctor may not arrive until after the child
is born, he frequently renders valuable service in expelling the
placenta or in sewing up lacerations. No one should presume then that
there is never need for a physician after the second stage is over.

If the suggestions made in the preceding chapter are heeded,
immediately after labor begins the room will be set in order and the
bed will be properly protected; the patient will take a tub-bath and
will put on a freshly laundered nightgown. The sterilized dressings
are then placed where they can be easily reached, but are not opened
until needed. Antiseptic tablets have been procured, and, following
the directions on the bottle, it will be simple to make up a solution
of bichlorid of mercury of a strength of 1-1,000.

After the contractions become strong and return at intervals of five
minutes, or if the waters have broken, the patient should go to bed;
the knees should be drawn up and spread apart, but bearing down with
the pains should not begin until the inclination is irresistible,
since this forbearance will make the delivery slower and thus afford
protection against lacerations which physicians ordinarily seek to
prevent by the use of chloroform. In the absence of a doctor it is
never permissible to administer this or any other anesthetic. As long
as a physician familiar with its action gives the chloroform untoward
results need not be feared in obstetrical cases; but the risk would
be too great to allow anyone to give it who was unacquainted with the
early signs of an over-dose. Again, fear of accident should prevent
patients from using the closet when labor is progressing rapidly, for
an inclination to empty the bladder or the rectum often signifies
that birth is about to take place. Even though this is true, if there
is need, patients may try to use the bed-pan.

About the time when the patient goes to bed the attendant prepares to
render such assistance as may be required. First she should scrub her
hands thoroughly with soap and water and subsequently soak them in
the bichlorid solution for five minutes, or longer if there be no
need for haste. A large delivery-pad is then placed under the
patient, the leggins put on, and, from this moment, the outlet of the
birth-canal should be exposed to view. After the scalp of the child
comes into sight, the attendant is not to leave the bed-side, though
she must keep "hands off" until the head has been completely
expelled.

A pause occurs between the birth of the head and of the rest of the
body. It is usually safe to await further expulsive contractions, but
should the child's face turn a dusky blue, which indicates that it
needs to breathe, the patient is to be advised to strain vigorously
and to make firm pressure over the womb with both her hands. At the
same time the attendant must pull the child downward, having seized
its chin with one hand and the back of its head with the other. The
straining of the mother combined with traction by the attendant will
be certain to effect delivery quickly. As soon as the child is born,
it should take a breath and begin to cry. If it does not cry of its
own accord, it can usually be made to do so by holding it up by the
feet and slapping it on the back several times. Subsequently the
child is placed between the patient's legs in such a way as to
prevent stretching of the cord. Usually the nurse will leave it in
this position and turn her attention to the mother.

After the birth of the child it is easy to feel through the mother's
abdominal wall, which has now become lax and flabby, the organs which
lie beneath it. The top of the womb, once just below the edge of the
ribs, may now be found about the level of the uppermost part of the
hip bones, a position which it keeps until detachment of the after-
birth begins. As the after-birth peels off, the firmly contracted
womb gradually rises in the abdominal cavity, and by the time when
the separation has been completed reaches the region of the navel.

While these changes, which naturally require from ten to thirty
minutes and occasionally longer, are taking place, the attendant must
wait patiently; attempts to hurry the separation of the placenta are
never wise, for they may lead to excessive bleeding. No effort should
be made to bring away the after-birth by pulling upon the cord. It is
equally unwise for inexperienced persons to press upon the womb in
the hope of pushing out the placenta. To encourage the mother to
strain just as she did in assisting the birth of the child would
always be a safer plan. And if that is ineffective, further delay is
necessary; in several instances a natural separation of the placenta
has repaid me for waiting as long as two hours. Prolonged delay may
be annoying, yet, provided that the doctor arrives within a
reasonable time, it can scarcely lead to anything more serious than
annoyance. Rather than authorize frantic efforts to remove the
afterbirth, I should much prefer to have a patient of my own call
another doctor.

If the after-birth comes away of its own accord, as will generally
happen when due patience has been exercised, it may be severed from
the child and put aside for the inspection of the doctor, for he
should learn by examining it whether everything has come away
properly. The cord must be securely tied in two places with the
sterilized bobbin mentioned in the list of articles for confinement.
One ligature is applied about two inches from the child's abdomen,
the other an inch nearer the placenta; the cord is then cut between
them with a pair of sterile scissors. Anyone fearful of injuring the
infant may prevent accident by spreading a diaper under the part of
the cord to be severed. This precaution also protects the bed from
soiling, for there will be a single spurt of blood the instant the
cord is cut. So long as the child is in good condition there is no
urgent need of this operation. If the child is breathing
satisfactorily it may generally be deferred until the doctor arrives.
When this course is chosen the attendant will wrap the infant in a
warm blanket, place it along with the after-birth in a safe spot, and
subsequently devote herself to making the mother comfortable.

The vulva and neighboring parts are bathed with a 1-1000 bichlorid
solution. Soiled dressings are removed, the gown changed, and, if
necessary, clean sheets put on the bed. A sterile sanitary pad is
placed over the vulva and a fresh one substituted as often as
necessary, but none of the pads should be destroyed. All the
dressings must be saved so that the doctor may see how much blood has
been lost. As we have learned, bleeding regularly occurs while the
placenta is separating and thereafter; excessive bleeding will rarely
follow a normal delivery if the attendant has heeded the precaution
to leave everything to nature. If ever the loss of blood should
become alarming before the doctor arrives, it is advisable to raise
the foot of the bed, to keep the patient quietly on her back, to
grasp the womb through the abdominal wall, and to massage it
constantly until the nearest physician can be gotten.

Of these directions the most important is that which relates to the
management of the womb, for in cases in which labor has been normal
in other respects the relaxation of its muscle is most often
responsible for flooding. What to do in this event must therefore be
made plain. First the patient should try to empty her bladder, and,
if she cannot, pressure made above the organ will usually expel the
urine. The attendant will then take her seat on the edge of the bed,
facing the patient's feet, and will locate the womb. When there is
flooding one may expect to recognize the womb as a large, rather soft
mass lying in the mid-line of the abdomen with its upper margin
somewhat above the navel. With one hand, or with both if necessary,
the mass is grasped in such a way that the fingers cover the top of
it and pass backward toward the spinal column; the thumb remains in
contact with the front of the organ. The womb is stroked and squeezed
much as one kneads dough, and for this reason the procedure is
technically called kneading. Such manipulations cause the muscle
fibers to contract firmly, and in consequence the blood vessels are
tightly closed and bleeding ceases. Similarly, cold applications to
the abdominal wall tend to provoke uterine contractions; placing over
the womb an ice-cap or towels wrung out of cold water and doubled
several times often have a beneficial influence when there is a
tendency toward relaxation. Some physicians also recommend that the
child be placed at the breast, since suckling is known to cause
uterine contractions. There are other measures which are occasionally
employed, but they should be used only by physicians, for in the
hands of an inexperienced person they may do more harm than good.

Very often a slight chill follows labor. It has a nervous origin and
need never give uneasiness; a drink of warm milk, hot-water bags to
the feet, and extra blankets will be sure to make the mother
comfortable. On the other hand, excitement of any kind aggravates
this condition. In general, recently delivered patients must be kept
quiet no matter how well they feel. A few hours of sleep, or, at
least, of repose, are justified by the fatigue incident to labor, and
nothing should be permitted to interfere with it.

METHODS OF REVIVING THE CHILD.--Complications which interfere with
the child's vitality rarely occur when labor proceeds so rapidly that
there is not time to get a doctor. Nevertheless a description of
child-birth would be incomplete without reference to the measures
intended to revive asphyxiated infants.

Such measures aim, first of all, to make the infant breathe for
itself, and if breathing does not begin promptly we resort to
artificial respiration. Mucus in the mouth or in the lower air-
passages hinders the entrance of air into the lungs; consequently it
is the duty of the attendant to remove this mucus by means of gauze
or some light fabric wrapped about a finger and passed backward over
the tongue. In most cases nothing else will be necessary. But if
breathing is not immediately established, the child should be grasped
by the feet with one hand and held downward while its back is
vigorously slapped with the other. Usually, it gasps at once; when it
does not, the attendant may stroke its face and chest with her hand,
which has been previously held in cold water for a moment; or she may
dash a handful of cold water upon its body. With very rare exceptions
these procedures make the child cry.

One must always be alert to see the very first attempt at breathing,
for unduly prolonged manipulations may defeat their own object; the
natural inclination always is to do too much rather than not enough.
In some instances, however, the measures thus far indicated will not
prove successful, and, if not, the cord must be tied and cut through,
for subsequent treatment cannot be conveniently carried out while the
child remains attached to the placenta. As soon as the cord is
severed the child is placed in a tub of warm water, about the normal
temperature of the body, and is moved about in the bath for a few
moments, the attendant watching closely all the while, for the
breathing is often very superficial. Should signs of beginning
respiration not appear, the attendant should grasp the child by the
shoulders, dip it up to the neck in a basin of cold water and quickly
return it to the warm tub. This operation may be repeated five or six
times; generally the instant the child touches the cold water it
draws up its feet, opens its eyes, and cries. One must take care that
the plunge lasts but a moment; if the child becomes chilled efforts
to revive it will likely be unsuccessful. Indeed, the necessity for
keeping it warm must be constantly borne in mind.

With the very exceptional cases in which hot and cold tubs are
ineffective, the following method becomes valuable. Wrap the child in
a blanket and lay it face downward upon a table or chair, allowing
the head to hang over the edge. Roll the body on one side or a little
beyond; then slowly roll it back upon its face and onward to the
other side. This maneuver is repeated fourteen times to the minute,
but not more frequently. When properly performed it secures a flow of
air to and from the lungs with the same rapidity as in the normal
respiration of an infant. Efforts to revive the child must not be
quickly given up, as a successful outcome occasionally requires half
an hour of work or even longer. One method after another should be
tried in the order which I have indicated. A physician always
perseveres so long as the heart-sounds can be heard; but, since an
inexperienced person might be unable to decide upon this point, the
most reliable course for the layman is to persist in the
resuscitation until the physician arrives.




CHAPTER XI


THE LYING-IN PERIOD

The Changes in the Uterus--The Lochia--The Return of Menstruation--
Other Restorative Changes: The Loss in Weight; The Abdominal Wall;
The Pelvic Floor--The Care of the Patient: The Elimination of Waste
Material; Cleanliness; The Diet; The Environment; The Time for
Getting up--The Final Examination.

A generation ago physicians were accustomed to see their obstetrical
patients only at the time of labor. No preliminary examination was
thought necessary, and after the delivery visits were not made unless
the family became alarmed and requested them. When thus asked to come
back the physician sometimes found that an infection had developed;
occasionally the breasts were giving trouble, or some other
difficulty in the care of the mother or of the infant was baffling
the nurse. It is now recognized that the medical attendant should not
wait for the appearance of untoward symptoms. Although the strict
observance of the various precautions which I have already emphasized
should lead and usually do lead to an uneventful convalescence, it is
none the less true that the danger of infection and of other
immediate complication has not passed until several weeks after
delivery. For this reason and also because skillful guidance of the
mother at this time will prevent unwelcome sequels in the later years
of life, physicians now extend their watchfulness beyond the hour of
birth. The number of visits ordinarily required is not large. In each
case, to be sure, the circumstances will determine the number; but,
as a rule, ten visits, if properly distributed, will be sufficient.
During the month succeeding delivery these visits should be made in
about this order: a daily visit for the first five days, subsequently
one upon the seventh, the tenth, the fourteenth, the twenty-first,
and the twenty-eighth day.

At the conclusion of labor there begins a series of changes which are
the reverse of those incident to pregnancy, and which restore the
body to its original condition. Six weeks are generally required for
these alterations. They should leave the mother in _perfect_
health, but traces of pregnancy are not entirely effaced; even in the
absence of outward evidence, if a woman has ever given birth to a
child a thorough internal examination will disclose the fact.

The initial steps in these restorative processes are taken most
promptly and effectively when patients remain in bed. The traditional
custom of doing so has given to the first few weeks following
delivery the popular name, "the Lying-in Period." To these weeks
physicians usually apply the technical term _puerperium_, the
child's period, a designation which brings to mind the secretion of
milk which, though not a retrogressive change, is, nevertheless, one
of the most distinctive results of childbirth.

Radical as the bodily changes in progress at this time are, the
lying-in period is not a period of illness. But there is, perhaps, no
other time in a woman's life when she may cross the boundary between
sickness and health so easily; for here nature tolerates no trifling.
Not infrequently puerperal patients who are feeling well attempt too
much, and suffer a more or less serious set-back; it is an all-
important duty of the obstetrician, therefore, to restrain them from
harmful activity. In my experience patients yield to restraint most
readily, and secure the best results, if I explain to them the
anatomical facts which should guide the management of the lying-in
period.

THE CHANGES IN THE UTERUS.--Since of all the organs the uterus
undergoes during pregnancy the most extensive development, it also
holds the place of prominence during the lying-in period. Immediately
after delivery the womb weighs two pounds and measures some eight
inches in height, five in breadth, and four in thickness. In the
course of a few days it begins to dwindle in size, gradually sinking
in the abdomen until it lies entirely within the pelvic cavity.
Toward the end of five or six weeks it resumes the position occupied
before conception, regains approximately its original dimensions, and
weighs two ounces. We speak of the process which leads to these
results as the _involution_ of the uterus. Since a great deal
depends upon the rapidity with which involution progresses, we must
understand just what it is and how it may be influenced.

The muscle of the womb, to which this property of involution belongs,
is an aggregation of thousands of individual fibers. In response to
excellent nutrition during pregnancy, these fibers have grown thick
and strong, in order that they may furnish the power needed at the
time of labor. When this purpose has been fulfilled each fiber
becomes smaller and gradually passes into a resting stage the better
to preserve its vigor. It is the shrivelling of the individual
fibers, therefore, which accounts for the total reduction in the size
of the womb.

Although the source of the stimulus which causes the muscle-fibers to
atrophy is not so clear as we should like it, we are acquainted with
certain influences to which involution is susceptible. Of these none
merits so much attention as the influence of the breasts. The
intimate relation between the breasts and the uterus manifests itself
in such a variety of ways and with such force that no one doubts its
existence. Thus, if a nursing mother becomes pregnant her infant is
usually deprived of sufficient nourishment or suffers some digestive
disturbance; if not, and the mother, ignorant of her condition,
continues with the breast feeding, she may jeopardize the newly begun
pregnancy. Very likely she will be warned of the fact by the signs of
threatened miscarriage. More frequently, but in quite the same way,
we find that nursing causes uterine contractions in the early part of
the lying-in period, when they are called after-pains. Women who
experience them tell us they are more severe while the infant nurses;
and they also say that the discomfort disappears after several days,
a fact which indicates that involution has made notable headway. The
physician is not dependent on such evidence, however; for a simple
examination reveals at any time how far involution has progressed. By
this means we have learned that nursing facilitates the involution
process. On the other hand, it is found to be true, as we should
naturally expect, that women who decline to suckle the infant recover
from childbirth somewhat less rapidly than those who follow nature's
plan. In this fact, therefore, is found a selfish motive, yet a very
good one, which should impel mothers to perform this exceedingly
important duty.

Aside from the change in the mass of the uterus, notable results of
involution relate to its mouth and to its ligaments, for these
structures are also chiefly muscle. The mouth of the womb, lately
stretched to permit the exit of the child, gapes widely for a time;
but ultimately its lips are drawn together, the tissues which compose
them stiffen, and the canal which they enclose is narrowed to almost
microscopical dimensions. When involution is complete, the uterus has
so far regained its virginal character that no trace of childbirth
remains other than a few small fissures in the margin of its mouth.

It is the office of the ligaments to hold the uterus in proper
position. In consequence of pregnancy they have been stretched, and,
as we might anticipate, after the contents of the womb are expelled
the ligaments hang loosely from its sides, very much as sails hang
when a breeze dies down. Immediately after delivery, therefore, the
ligaments give the womb little or no support; eventually they shorten
and tighten, readily accommodating themselves to the existing
conditions. Until the accommodation is perfected, it is especially
desirable to permit no pressure which might push the womb backward.
It is for this reason that many obstetricians object to the time-
honored custom of applying a tight bandage about the abdomen at the
conclusion of labor; for, though bandaging is not always harmful, it
has a distinct tendency to misplace the womb. A friend who has served
as an assistant in one clinic where patients were bandaged regularly
and in another where they were not, tells me that displacements of
the womb were much more common among women treated by the former
method.

While the process of involution is altering the shape and size of the
womb, other forces are at work within the organ to provide its cavity
with a new mucous membrane. In character and in extent the inner
surface of the womb, left raw and bleeding at the conclusion of
labor, is comparable to the wound which would result if some accident
removed the skin from the palms of both hands. No one would question
the wisdom of guarding such an injury to the hands; but cleanliness
is even more necessary to the prompt and healthful restoration of the
uterine mucous membrane. However, the wound within the uterus is so
far from the surface of the body that it need not be directly covered
with a surgical dressing; sterile pads are kept over the vulva to
exclude contaminating material until the healing is completed. Since
bleeding ceases after that point is reached, we have no difficulty in
knowing when the mucous membrane has been restored.

THE LOCHIA.--The vaginal discharge which regularly follows the
termination of pregnancy gets its name from the Greek word
_lochia_. At first the discharge is pure blood, because it
issues exclusively from the vessels left open by the removal of the
after-birth. The greater part of the blood flows out of the birth
canal, but frequently some of it collects in the cavity of the uterus
or of the vagina; there it coagulates, and the clots may not be
expelled until several days later. In that event, as whatever effect
the bleeding may have had has long since passed, the appearance of
the clots is usually no occasion for alarm.

The amount of lochia varies, and will likely fall below the average
in small or anemic women and rise above it in those who are large or
robust. Then again, the discharge is less profuse if considerable
blood has been lost immediately after the labor. For the first ten
days the total quantity seldom exceeds eight or ten ounces; after
that time it is so small that it cannot be accurately estimated.
Formerly much larger amounts were considered normal, and, therefore,
it is probable that modern aseptic treatment of child-birth has
lessened the subsequent loss of blood. Toward the end of a week the
lochia changes from a bright red to a brownish color, because the
discharge now includes certain products of disintegration. Somewhat
later the lochia consists almost entirely of mucus, being only
streaked with blood; but there will be an increase in the bleeding
when the patient gets up; and injudicious activity may cause
flooding. A slight bloody discharge may be expected to continue until
five or six weeks after the child was born.