Books: The Prospective Mother
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J. Morris Slemons >> The Prospective Mother
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THE FINAL EXAMINATION.--Looking to complete restoration of the
woman's health, the modern management of obstetrical cases breaks
decisively with tradition at three points. An utter disregard of
precaution has given way to very careful preparations before and at
the time of labor; definite rules for the management of the lying-in
period are carried out under the supervision of the physician; and
finally, prompted by the same impulse, the physician examines his
obstetrical patients before discharging them. Satisfactory conditions
are generally found; if they are, it is a great comfort to be assured
of the fact; and if not, timely treatment of the abnormality may
readily correct it; with delay, on the other hand, treatment often
becomes more formidable.
The end of the fourth week of the lying-in period proves a convenient
time for this examination. As yet the restorative changes in the
reproductive organs have not been completed, but one may definitely
say by this time whether or not they will culminate in a satisfactory
manner. Besides, making the examination while the changes are in
progress sometimes enables the physician to treat approaching
complications before they actually develop. Thus, when the pelvic
floor has not regained its strength sufficiently, the patient will be
advised to forego the liberty in moving about ordinarily granted at
this time. When the womb inclines to an improper position, a
temporary support may be introduced to hold it where it belongs;
later, upon removing the device, the womb usually retains a good
position. Again, there are conditions which a douche will relieve,
and still others benefited by medicinal treatment. If an abnormality
is recognized which cannot at once be treated to the best advantage,
arrangements will be made for such prompt treatment that the woman
will not become an invalid. Instead of placing obstacles in the way,
patients should rather insist upon this examination, for it is
important in guarding their future health.
Now and then patients are kept under observation for a longer period,
but, as a rule, they are discharged as well as examined at the end of
four weeks. They may also discard the abdominal binder about this
time and put on corsets, which, however, should not be tightly worn.
Although thrown upon her own resources from this moment, the patient
will clearly understand that she must continue to exercise sound
discrimination in what she does. And here, of course, we encounter
the greatest difficulty in offering practical advice, for what one
may do easily will overtax another. Generally speaking, going up and
down stairs more than once a day is inadvisable until another two
weeks have passed. Likewise the mother who would adopt a conservative
policy will not take full charge of her baby before it is six weeks
old, though there can be no objection if she wishes to direct its
care. The same advice applies to running the household. Over-
exertion, no matter what the source, delays convalescence from child-
birth to such an extent that the safe plan is always to err on the
side of doing too little, rather than to run the risk of doing too
much.
CHAPTER XII
THE NURSING MOTHER
The Breasts--Human Milk--The Technique of Nursing--Hygiene of the
Mother: Diet; Psychic Influence; Recreation and Rest--The
Supplementary Bottle--Weaning.
When the obstetrician pays his final visit the mother usually has
ready a number of questions, most of which anticipate difficulties in
the care of the baby. At that time, however, minute and far-reaching
directions cannot always be given. Unforeseen peculiarities in the
development of the child may modify such general principles for the
management of infants as could be laid down in advance. With a few
exceptions, therefore, mothers require during the early years of a
baby's life skilled advice as to his upbringing--advice for which
neither instinct nor haphazard counsel is a safe substitute. It is an
excellent plan, and one which is becoming more and more popular, to
have a physician supervise the care of the baby through the period of
most active growth. According to this plan, the mother, even though
her baby is well and developing as it should, consults the physician
at regular intervals, once a month for example, and upon these
occasions secures help in solving problems which are certain to
present themselves. Such an arrangement shows a merited appreciation
of the proverbial "ounce of prevention," and when serious
difficulties do arise materially counteracts the tendency to panic
which is exhibited by so many young mothers.
Among the problems which the mother must solve, that of nutrition
outranks all others in importance; and unless the infant is nourished
with human milk, it also exceeds them in perplexity. For, although
great advances have been made in artificial feeding, science has not
yet removed all the intricacies and dangers involved in the use of
the bottle. On the other hand, mothers who nurse their babies rarely
meet with difficulty. Human milk is perfectly adapted to the wants of
the infant; and all substitutes, though carefully designed to
duplicate it, are only partially successful. We have learned how to
modify cow's milk so that in chemical constituents, at least, it is a
very close imitation of human milk; but human milk possesses, in
addition to its chemical properties, other desirable qualities which
cannot be instilled into an artificial food. We must agree,
therefore, that attempts to disseminate a wider knowledge of the
correct principles of bottle-feeding do not have the highest aim. Our
real need is a vastly greater proportion of women who nurse their
children.
THE BREASTS.--For success in nursing the first essential is healthful
breasts. With this the largeness or smallness of a breast has nothing
to do, for size is no more an index of its capacity for producing
milk than is the weight of a woman an index of her energy. The breast
is not a warehouse, but a factory, with very limited storage capacity
for its product. Differences of size are generally to be explained by
the variable amount of fatty-tissue the breast contains. And so far
as the secretion of milk is concerned the fat is entirely passive; it
fills in the space between the glandular elements; and a layer of fat
just beneath the skin protects the glands against external influences
that otherwise might disturb their activity. Stripped of their fatty
envelope the structures which actually secrete the milk and convey it
to the nipple resemble a miniature cluster of grapes. Each tiny,
spherical gland corresponds to one of the grapes and contains a
cavity lined with cells which manufacture the milk. From this cavity
the milk flows through a microscopic tube which unites with similar
tubes to form a larger one; this in turn joins others of its kind;
and so on, until ultimately the milk enters a relatively large duct--
the figurative stem of the cluster--which conducts the milk to its
destination. There are from ten to fifteen of these terminal ducts;
each drains a separate group of glands, but all end in the nipple.
Shortly after conception the breasts become congested; in consequence
they enlarge, become tender, and begin to show swollen veins beneath
the skin. The most significant alteration, however, occurs in the
cells which line the glands; these increase in size at first; and
then, by a process of cell division, their number multiplies. After
pregnancy has advanced six to eight weeks these cells begin to
elaborate the thin, watery fluid called colostrum. Contrary to
popular belief, the quantity of colostrum is not prophetic of the
character of the milk; there is no ill-omen, to be sure, in a
plentiful secretion, but a meager one is quite as likely to be
followed by successful lactation. At present we are unable to predict
by any means either the quantity or the quality of the milk which a
prospective mother will produce.
Some writers contend that influences which come into play during
girlhood ultimately affect the capacity of the breast for making
milk; for example, irregular habits in youth and the wearing of
improper styles of clothing are said to be particularly detrimental
influences. Of course, a healthful mode of life at the time when a
girl is approaching maturity reacts favorably upon her development in
every way, and naturally enough the breasts share this benefit; but
the relation between unhygienic habits at about the time of puberty
and a subsequent deficiency in lactation has been exaggerated by many
writers. It is impracticable, certainly, to institute special
measures to prepare the breasts for their function until the need of
such measures is clearly evident. Throughout pregnancy clothing about
the breasts should be loosely worn. If the nipples are not already
prominent they should be drawn out; and about six or eight weeks
before confinement is expected they should be given the treatment
described in Chapter V.
For the first day or so after the infant begins to nurse its efforts
have a tendency to injure the skin which covers the nipple; and
unless measures to render the nipple resistant have been previously
adopted, nursing may cause the mother considerable discomfort.
Moreover, it is extremely important throughout lactation to keep the
skin covering the nipple free from abrasions, for if it cracks
bacteria have thus an opportunity to enter the glands and set up an
acute inflammation which may result in the formation of an abscess.
This complication is to be avoided, not only because of the
unpleasant symptoms which attend it, but also because for the time it
brings the usefulness of the breast to an end. Fortunately an abscess
seldom impairs the breast permanently.
At any period of lactation there may be an overproduction of milk. In
this event the breasts are likely to become distended, hard, and very
tender. Most frequently "caked breasts," as this condition is called,
develop a few days after delivery, when the secretion of milk is just
beginning, for at first the secretion is more plentiful than need be.
Generally twenty-four hours later there is an adjustment between the
supply of nourishment and the natural demands of the infant.
Occasionally a longer interval elapses before the breast is
completely emptied at each nursing.
Formerly it was customary, whenever the breasts became tense and
uncomfortable, to express an excess of milk by means of massage; but
this mode of treatment lost favor as soon as physicians realized that
massage stimulated the glands to greater activity. Drawing the milk
with a breast-pump has a somewhat similar though less potent
influence, and, because pumping often affords relief when the breasts
are distended, there is rarely any objection to it. In the light of
modern experience, however, most physicians prefer to avoid
manipulation of the breast so far as possible, and generally resort
to other measures to relieve the mother's discomfort. Thus most
patients are made comfortable if an appropriate bandage is used to
transfer the weight of the breasts from the arm-pits and the front of
the chest to the bones of the shoulder-girdle. It may be necessary
also in some cases to swathe the breasts in warm cloths; in others
cold applications are more acceptable; the choice between these
methods will vary with the time of year, and usually may be left to
the patient herself. Now and then medicine will be employed to
relieve the pain, but the administration of drugs to diminish the
production of milk is inadvisable. It is never very long before the
amount of milk becomes adjusted to the infant's wants, and then
distention disappears spontaneously. No artifice can bring about the
adjustment as ideally as nature does.
During the later months of lactation the liability of the breasts to
over-filling is slight, provided the infant empties them regularly
and completely. Nevertheless, so long as a mother is nursing her
child she must be careful to keep the breasts in a healthful
condition. They require support, yet must not be compressed. And they
should be covered with clothing which will adequately protect them
from sudden changes of temperature. This latter precaution, perhaps,
requires more emphasis than formerly, on account of the present
popularity of motoring; for the chill which one experiences when
driving fast may have a very unpleasant effect upon a nursing mother
unless her breasts are carefully protected. Occasionally fever and
neuralgic pains in the breasts are caused by motoring, or by exposure
to the air-current from an electric fan playing directly upon them.
But even under these circumstances an abscess need not be feared
unless the nipples are sore.
_Human Milk_.--Between the time of birth and the beginning of
lactation there is always an interval during which the breasts
secrete colostrum, just as they do throughout pregnancy. Although the
nutritional value of this fluid is not great, it is doubtful if
colostrum serves any other essential purpose than as nourishment.
Possibly it also stimulates the intestines to expel the material
which has collected within, them during fetal development, yet we
know the bowels will move without a purgative; and often do so long
before the infant is placed at the breast. Typically, the secretion
of milk begins the third day after delivery; yet in perfectly normal
patients it may appear as early as the second or as late as the
fifth, and occasionally lactation does not begin until the baby is
more than a week old.
As to what starts the secretion of milk we have only a vague idea;
but we know that when the flow is once established its continuation
depends primarily upon the sucking efforts of the infant. If nursing
is discontinued the secretion dwindles and the breasts dry up. On the
other hand, the strong, persistent stimulus of the infant's suckling
gradually brings the secretion to a high degree of efficiency. Within
the first two weeks, therefore, the daily secretion increases from a
few ounces to a pint or more. Subsequently the output fluctuates
between one and two quarts daily, according to the demands made upon
the breasts; the secretion is larger, consequently, if there are
twins. Astounding yields of milk have been recorded, as in the case
of a wet-nurse in a German institution who nursed a number of infants
and became capable of supplying three to four quarts daily.
That newborn infants thrive better on human milk than on any other
nourishment is a conviction that must come home to every one who has
had even a limited experience. It keeps the babies in health, serves
to make them grow, and promotes the development of all their organs
as nothing else will. Because there are present in this fluid all the
elements necessary for nutrition, physiologists have called it a
perfect food. Quantitatively its most important ingredient is water,
which constitutes about 86 per cent. of its weight. It also contains
about 7 per cent. of milk-sugar, 4 per cent. of butter fat, 2 per
cent. of protein, and 0.2 per cent. of mineral matter.
The milk of all animals contains a relatively small quantity of
mineral matter; judged from this standpoint, the mineral matter would
seem of minor importance, but it is actually as vital as any other
constituent. Without it the bones would hot harden properly; and
other services which it performs are absolutely essential to life. As
we should expect, human milk contains all the mineral ingredients
necessary for the development of the infant; indeed, with the single
exception of iron, they are present in the precise amounts in which
they are needed. In this omission, however, nature is guilty of no
oversight, since the infant has already been provided by the time of
birth with a rich supply of iron.
THE TECHNIQUE OF NURSING.--Since the mother should have opportunity
to recuperate from the fatigue of labor, physicians generally
recommend that an interval of at least twelve hours elapse between
the birth of the infant and the time it is first put to the breast.
Moreover, the best interests of the infant demand that it be kept
warm and left undisturbed while becoming accustomed to its new
environment. There is no immediate need of food; and if there were,
nature does not fit the mother to supply it, for at this time the
breasts contain merely small quantities of colostrum.
Some babies nurse vigorously at the outset, but later, discouraged
because they get so little, become indifferent and restless, or even
decline to take the breast. And the mother, who is handicapped by
inexperience and by the awkwardness of nursing in a recumbent
position, often feels desperate. Fortunately technical difficulties
are confined to the first few days, and, trying as they sometimes
are, no one should be discouraged or imagine that she is incapable of
nursing; for practically every woman who persists will succeed.
For a week or ten days the mother will nurse in the recumbent
posture. She turns to one side or the other, according as the right
or left breast is used, and holds the corresponding arm to receive
and support the baby, which will lie beside her. Then with the
opposite hand she holds the breast, placing her thumb above and her
fingers below so as to keep it from the baby's face, for only in this
way can the infant breathe freely. One must also remember that the
infant draws the milk into the terminal ducts chiefly with the back
of its mouth, and drains the ducts by compressing the base of the
nipple with its jaws; the infant therefore should take into its mouth
not only the nipple, but also the areola, the area of deeply colored
skin round about it. Mothers frequently disregard these directions,
and the failure of their infants to nurse properly may be thus
explained, for it is impossible to secure undisturbed nursing unless
they are obeyed.
Generally the breasts are employed alternately, but both may be used
at each nursing if one is insufficient. To fix the duration of the
nursings arbitrarily is impossible; from ten to fifteen minutes
generally proves satisfactory, but in each case systematic
observations of the change in the baby's weight, of the character of
its stools, and of its general condition must determine how long to
leave it at the breast. The common error, unfortunately, is to be
over-indulgent, and, as a result, infants are more frequently ill
because the nursings are too long, than too short. Furthermore, the
duration of the feedings can never be gauged accurately if the infant
is allowed to nap while nursing.
The successful training of a baby begins with the development of
regular habits of nursing. The old-fashioned custom of allowing the
baby to nurse whenever it cried, tacitly--and incorrectly--assumed
that it could have no other sensation than hunger. As a matter of
fact an infant may have pain from overfeeding. Again, it may be
thirsty, or uncomfortable from the pricking of a pin, from the
monotony of one position, from a soiled napkin, or from neglect of
many simple details in its care. Any of these things make a baby cry,
for it has no other means by which it can express disapproval.
So long as the breasts contain colostrum the nursings should be at
least three hours apart during the day; at night it is preferable not
to disturb the mother at all. As soon as milk appears the interval is
usually shortened to two hours during the day. In many cases,
however, the three-hour interval will be retained even after the milk
appears, for otherwise the infant may not become hungry and will fail
to nurse as strongly as it should. The following schedule is adapted
to the average infant:
Age Interval During Total Number
the Day of Feedings
From 1st to 4th week 2 hours 9
" 4th " 8th " 2-1/2 " 8
" 2nd " 4th month 3 " 7
" 4th " 10th " 3 " 6
" 10th " 12th " 4 " 5
After the first few days most young infants require one feeding in
the middle of the night, which is usually given about 2 A.M. The day
feedings then begin at 6 A.M., and are repeated at regular intervals
until 9 or 10 P.M. The daily bath should be scheduled so that a
feeding will be due just after the bath has been completed. If asleep
when the next succeeding feeding falls due, the infant should not be
waked, but at other times nothing should interfere with the
regularity of the schedule. Occasionally there may be difficulty in
getting the child to nurse during the day, but it must be taught to
do so; otherwise it will want to nurse throughout the night.
At no time should an infant remain in the bed with its mother after
it has finished nursing; at night this rule must be rigidly enforced,
for mothers have been known to fall asleep and smother the baby, an
accident known as over-lying. Infants can frequently be trained to go
without feeding in the middle of the night even when a month old; and
such training is always advisable, since it affords the mother
opportunity for six or eight hours' continuous sleep.
Before and after each nursing the mothers' nipple should be cleansed
with a solution of boric acid made by placing a tablespoonful of the
powder in a tumbler which is then filled with water. Such cleansing
protects the breasts against infection, a complication which the
nursing mother must spare no pains to prevent. Now and then, in spite
of conscientious efforts to harden them, the nipples become sore. If
they crack, the baby's mouth must not come in direct contact with
them, since nursing with a cracked nipple is a common source of a
gathered breast. Fortunately when a nipple cracks we may employ a
shield, obtainable at any drug-store, which enables the infant to
nurse without any danger to the mother. Most babies will take the
shield as well as the breast itself; nevertheless, its use should be
discontinued as soon as the nipple heals, for while the shield is
used the secretion of milk is not stimulated as vigorously as when
the infant nurses directly from the breast. In the rare cases in
which the shield cannot be used satisfactorily the infant must be
taken from the breast temporarily and given a bottle. Radical as this
advice may appear, the mother must consent to follow it, for, as I
have pointed out, to permit an infant to nurse a cracked nipple is
extremely hazardous. When treatment is begun promptly the cracks will
generally heal within twenty-four hours.
HYGIENE OF THE MOTHER.--Since the mammary glands manufacture their
product from the constituents of the mother's blood and their
activity is controlled by her nerves, it is clear that her physical
condition and her state of mind will influence the secretion of milk.
Intelligent women who understand this desire to know how they should
live that they may best insure an ample supply of good milk.
Fortunately the first important step toward success has been taken
when a mother wishes to nurse her baby; but there are also necessary
wholesome food, habits conducive to health, and a mind free from
worry.
It is unfortunate that current beliefs throw many restrictions about
nursing-mothers which are unreasonable and unsupported by scientific
investigation. There was a time when mothers did not question their
ability to nurse, they assumed this duty as a matter of course.
Indeed, they were compelled to do so, since refined methods of
artificial feeding had not as yet been devised. Among the
agricultural class, even to-day, it is exceptional for mothers to
fail to nurse their children, if they are provided with the ordinary
comforts of life. But women who live at the higher tension of city
life are frequently unsuccessful, because they are more inclined to
be nervous or because they disregard, among other things, the need of
fresh air, plain food, or regular habits. It is wrong to suppose that
elaborate rules of conduct are necessary for nursing mothers; the
instruction they require is simple and scarcely different from that
to be given anyone who desires good health. If she lead a wholesome
existence a woman will not only nurse her child successfully but will
gain in strength.
_Diet_.--In manufacturing centers, where a large proportion of
the women are employed in confining work, the percentage of mothers
who are able to nurse their children is exceedingly small;
consequently the infant mortality is very high. Better nourishment
for the mother, it has seemed, would render her more capable of
successful lactation, and would decrease or even eliminate badly
executed artificial feeding, and would therefore reduce the death
rate among the babies. In a few foreign cities the idea has been put
into practice. Free restaurants have been established for working
mothers, and they have thus been enabled to perform their maternal
duties much more successfully. Incidentally it has been shown that
nourishment may be supplied mother and infant at a smaller cost than
proper artificial food for the infant alone.
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