Books: The Prospective Mother
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J. Morris Slemons >> The Prospective Mother
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About the end of the second month the nipples become larger and more
erectile, and deepen in color. The pigmented, circular area of skin
which surrounds the nipple, called the areola, also darkens. The
shade that the areola assumes will vary according to the complexion
of the individual, growing darker in brunettes than in blondes.
Ultimately, within this pigmented circle a number of elevated spots
appear about the size of a large shot. These spots betray the
presence of tiny glands always located there which, on account of the
better state of nutrition during pregnancy, grow larger, and
generally become visible.
Usually, after two menstrual periods have been missed the breasts
increase in size and firmness, and often the veins which run just
beneath the skin stand out conspicuously. Before very long it is
possible to squeeze from the breasts a fluid which many persons
believe to be milk, though it is really colostrum, a substance that
resembles milk but very slightly. At first colostrum is a clear,
white fluid, but in the later months of pregnancy it becomes yellow
and cloudy.
None of the changes in the breasts are absolutely characteristic of
pregnancy; even the secretion of colostrum has been noted in
association with various other conditions. Furthermore, as a sign of
pregnancy the presence of colostrum is totally deprived of value in
the case of a woman who has recently nursed an infant, for a small
quantity of milk or colostrum often remains in the breasts for months
after the infant is weaned. In general, however, women who have not
been pregnant before should assume that they have conceived if, after
missing a menstrual period, they note the characteristic changes in
the breasts.
_Morning Sickness_.--Soon after conception many women suffer
from nausea and vomiting, especially on rising in the morning.
"Morning sickness" usually passes off in a few hours, although it may
be more persistent. Perhaps this manifestation occurs more frequently
in the first than in subsequent pregnancies, but certainly one-half,
and probably two-thirds, of all prospective mothers suffer from it.
Usually the nausea begins just after a menstrual period has been
missed, and ceases about the third month or a little later.
But morning sickness is never counted an indication of pregnancy
unless taken in conjunction with other symptoms, for individuals who
are not pregnant may also suffer from nausea in the morning. On the
other hand, a number of prospective mothers escape morning sickness
altogether, and a few experience nausea at other times of day.
_Disturbances in Urination_.--It is not an uncommon belief that
some characteristic change occurs in the urine shortly after
conception. But this is not true; at least no change is revealed by
any method of analysis known at present. Yet there are symptoms
associated with the passage of the urine which appear very promptly
and prevail for several weeks. Chief among these is the desire to
empty the bladder frequently; some patients also have difficulty in
urination, and a few experience discomfort with it. All the bladder
symptoms gradually disappear about the fourth month, but become
prominent again toward the end of pregnancy.
Since the inclination to empty the bladder more often than usual may
be due merely to nervousness or to many other conditions, this
symptom taken alone cannot be regarded as a definite sign of
pregnancy. Indeed, it is mentioned, not because of its importance,
but to point out that it is in no way connected with the kidneys, as
patients are sometimes led to believe. It is a direct and natural
result of pregnancy. Since the womb enlarges and tilts forward at a
more acute angle than formerly, it presses against the bladder,
giving the same sensation as when the bladder is distended with
urine.
Although the presumptive signs which we have considered by no means
exhaust the list, all the others are totally untrustworthy. Each of
the more reliable symptoms, as we have seen, must be accepted
cautiously; but taken altogether, except in very unusual cases, they
may be relied upon. _If, for example, menstruation has previously
been regular and then a period is missed, the patient has good reason
to suspect she is pregnant; if the next period is also missed and
meanwhile the breasts have enlarged, the nipples darkened, and the
secretion of colostrum has begun, it is nearly certain that she is
pregnant; whether morning sickness and the desire to pass the urine
frequently are present is of no importance._ But the most
characteristic evidence, we must remember, is not available until the
eighteenth or twentieth week; then the signs of pregnancy are
unmistakable.
THE DURATION OF PREGNANCY.--After the existence of pregnancy has
become assured, perhaps the greatest interest centers about the date
upon which the birth may be expected. Even to approach accuracy in
this prediction the prospective mother must be familiar with certain
facts which she will always observe, but which, unless she
appreciates their importance early in pregnancy, she may fail to
record or to remember. In a few cases, however, such exceptional
information as knowing the date of conception does not lead to an
absolutely accurate prediction. But the deviation from the rule will
be understood only after we understand the rule itself, which is
based upon what we accept as the average duration of human pregnancy,
technically called the period of gestation.
In a broad sense, the period of gestation for each variety of mammal
is determined by the time required for embryonic development to reach
the point where the young may live independently of the mother. This
point is reached more quickly with small animals than with large. The
mouse, for example, generally brings forth its young in three weeks,
whereas the pregnancy of the elephant lasts two years. In human
beings, counting from the time of conception to the time of delivery,
pregnancy continues approximately 273 days. This number is merely an
estimate calculated from hundreds of cases in which there was no
question as to the underlying facts. Individual cases vary notably,
and indicate that two women may become pregnant on the same day and
yet not necessarily be delivered at the same date.
Irregularities in the duration of pregnancy are not limited to man.
Thus, while the mean period of gestation in the rabbit is thirty-one
days, it may be either shorter or longer by as many as eight days.
Similar variations occur in the pregnancies of all animals, and are,
moreover, notably greater among larger animals, since for such
animals the period of gestation is relatively long. For instance, the
accurate observations of veterinarians indicate that the mean period
of pregnancy in the cow is 285 days from the time of conception. This
fact notwithstanding, a competent observer found that, of 160 cows,
67 were delivered before the 280th day; 68 between the 280th and the
290th day; and 25 after the 290th day. Although nothing unnatural was
observed in any instance, the first animal was delivered 67 days
before the last, and in 5 instances gestation continued 308 days.
In ancient times it was believed that the duration of pregnancy was
of even more uncertain length in man than in the lower animals; but
since the eighteenth century thirty-nine weeks have been accepted as
the average duration of the human pregnancy when reckoned from the
day of conception. As this date is seldom known, it is most
convenient to reckon from the first day of the last menstrual period.
Estimated in this way its average duration is 280 days. As this
period corresponds to ten menstrual cycles, physicians prefer to
describe pregnancy as lasting 10 lunar months of four weeks each.
This is equivalent to 9 calendar months, in terms of which its
duration is popularly stated.
THE ESTIMATION OF THE DATE OF CONFINEMENT.--Since pregnancy is not an
absolutely fixed period, we possess no reliable means of predicting
the exact day when it will end. The most satisfactory method of
prediction consists in counting forward 280 days from the beginning
of the last menstruation or, what gives the same result, counting
backward eighty-five days from this date. _To make the calculation
in the simplest way we count back three months and add seven
days_; this addition is made because seven days generally
represents the difference between three months and eighty-five days.
If the last menstruation, for example, began on October 30th, we
count back three months to July 30th and add seven days, which gives
August 6th as the probable date of confinement.
A prospective mother should remember that this prediction is no more
than approximate. The calculation does not give the exact date of
delivery more than four or five times in a hundred cases. It is
accurate within a week in half the cases and within two weeks in
four-fifths. We also know that delivery is somewhat more likely to
occur after the expected date than before it. But perhaps we shall
get the clearest idea of the accuracy of the rule, or better still
of its inaccuracy, if we imagine twenty patients to have the same
predicted date, all of them giving birth to mature infants. The
chances are that only one of these patients will be confined upon the
day predicted; nine will be confined before and ten after it. In all
probability five of those who pass the predicted day will be
delivered within a week and four others within the second week, while
the twentieth patient will not be delivered until three weeks or more
have elapsed.
Such results clearly indicate our inability to make accurate
predictions even though pregnancy is normal in every way. Whenever
patients pass their expected date uneventfully, if they will bear in
mind that the fault lies with the method of prediction and not with
the pregnancy, they will often be saved anxiety. Frequently such
discrepancies are attributable to a false assumption, for our rule
always assumes that the conception took place immediately after a
menstrual period. While this is generally true, the number of cases
in which it occurs just before the period to be missed is by no means
inconsiderable, and in these we should not expect pregnancy to end
until two or three weeks after the day predicted by the rule.
Occasionally patients know the precise day upon which conception took
place, and prefer to estimate the day of confinement from that rather
than from the beginning of the last menstruation. They may do so by
counting back thirteen weeks from the day of conception; but this
method also is subject to error for, as we have noted, the duration
of pregnancy reckoned in this more exact manner is not constant. Such
a calculation rarely offers any advantage over that made from the
menstrual record.
Another method of estimating the date of confinement is based upon
the assumption that fetal movements are first perceived by the mother
toward the eighteenth week of pregnancy; and in consequence twenty-
two weeks generally elapse between quickening and the day of
delivery. Although such a calculation is far from certain in its
prediction, there are instances in which no other calculation can be
made. A nursing mother, for example, may become pregnant before
menstruation has been reestablished. Under these circumstances,
obviously, the date of confinement cannot be estimated in the
ordinary way, and it is then especially important to know the first
day on which the fetal movements were felt. Furthermore, it is
helpful to note this date in every case, since it serves, if for
nothing more, to confirm the prediction made from the menstrual
record. Besides the two methods just described, which are alike in
that they require the patient herself to make the necessary
observations, there is a third method of estimating how far pregnancy
has advanced, by which the physician is enabled to draw his own
conclusions. This method is based upon the fact that the womb
enlarges from month to month during pregnancy at a constant rate. Up
to the end of the third lunar month it cannot be felt through the
abdominal wall; but in the course of the fourth month, on account of
its size, it must rise into the abdominal cavity. At the beginning of
the sixth month the top of the womb is at the level of the navel, and
at the ninth reaches the ribs. The diaphragm then prevents the womb
from going higher; and two or three weeks before the end of pregnancy
it drops several inches, causing a change in the figure which is
noticeable to the patient, since her skirts hang somewhat lower than
before. From this time on she is more comfortable, because the lungs
are not crowded, and there is less interference with breathing.
These alterations in the position of the womb indicate very
satisfactorily the month to which pregnancy has advanced, but not the
week and much less the day. They do not afford a more accurate means
of predicting the date of confinement than does quickening. The
evidence gained from the position of the womb, like that afforded by
the beginning of quickening, generally confirms the prediction made
from the menstrual history; it serves only occasionally to correct
it.
PROLONGED PREGNANCY.--Since birth does not occur in many cases until
the predicted date has been passed, it will be helpful even at the
cost of repetition to sum up what we know in explanation of such
unfulfilled predictions. They are to be explained sometimes by
uncertainty as to the beginning of pregnancy, as for example by the
supposition that conception took place shortly after the last
menstrual period, whereas it actually occurred two or three weeks
later. In a few instances, however, errors of observation or of
calculation will not account for false predictions.
It is generally admitted that second pregnancies average somewhat
longer than first pregnancies; one series of statistics indicates
that the duration increases slightly with each pregnancy up to the
ninth and decreases after that. Pregnancy is protracted more
frequently in healthy women than in those who are not, and again more
frequently in those who are inactive than in those who work. With
twins, contrary to the popular belief, pregnancy is apt to end
before, not after, the expected date. The sex of the child, in all
probability, has no influence upon the duration of pregnancy.
As we might expect, individuality is also a factor in this problem.
Thus, the period of gestation with some women is regularly longer,
with others habitually shorter than the accepted average. Until
experience has demonstrated their existence, generally, such
peculiarities are overlooked. But occasionally they may be detected
from knowledge of the interval between the menstrual periods; an
unusually long interval between them, for example, would lead us to
anticipate a protracted pregnancy.
Any delay after the expected date of birth has arrived taxes the
patience of the prospective mother. The fact, however, that more than
280 days have passed since the last menstruation, does not
necessarily mean that a patient has gone "over time." Such a question
can be decided solely from the weight and length of the child. Judged
in this way, comprehensive statistics indicate that once in several
hundred cases pregnancy may be fairly called prolonged. Even in these
rare instances an examination about the time of the predicted date
makes it clear whether pregnancy should be artificially ended or be
allowed to proceed to its natural conclusion.
CHAPTER II
THE DEVELOPMENT OF THE OVUM
The Germinal Cells--Fertilization--The First Steps in Development--
The Reaction of the Uterus--The Amniotic Fluid--The Placenta--The
Umbilical Cord.
Pregnancy, besides changing the external form of the body, causes
sensations--as for example those due to fetal movements--which are so
distinctive that they cannot escape notice. These obvious evidences
of approaching motherhood naturally lead thoughtful women to wonder
about the hidden mechanism of development, a mechanism which, of
itself, causes no sensation whatever. It is for this reason, perhaps,
that a prospective mother's imagination is so apt to be unusually
active, often picturing absurd conditions as responsible for one
symptom or another. Those who give free play to the imagination in
regard to the formation and progress of the embryo are pretty certain
to arrive at erroneous if not grotesque conclusions; for example,
they may attribute a protracted pregnancy to the child's having grown
fast to the mother, a situation that cannot arise.
Of course it is not essential that a prospective mother should
understand what is happening within the womb. And upon those who
prefer to be ignorant of the mechanism of development I would not
urge another point of view, for not ignorance but the unchallenged
acceptance of "half-truths" and of totally incorrect explanations is
the chief source of harm. On the other hand, my own experience has
taught me that women who wish to know about development should be
told the truth. In accord with this is the fact that I never have
more satisfactory patients than those who have previously been
trained nurses and who, in preparing for that profession, received
instruction concerning the reproductive function of human beings.
A description of development, in order to be perfectly clear, must
begin with a word about the fundamental structure of the adult body.
Everyone knows that the various parts of the body perform different
functions; but not everyone, perhaps, realizes that, in spite of
their different functions, all the organs of the body are composed of
similar structural units, known as cells. Of course, cells are
definitely arranged according to the use for which the tissue that
they chance to compose may be designed; they have, moreover,
distinctive individual peculiarities which can be easily recognized
under the microscope; but the essential features of the cells remain
the same, wherever they may be located. That is to say, each cell is
a minute portion of living matter, or protoplasm, separated from its
neighbors by a partition, the cell-membrane; each has its own seat of
government, the nucleus, located near its center; and each, to all
intents and purposes, leads an individual existence.
THE GERMINAL CELLS.--Many of the cells in the human body are able to
produce others of their kind. This they do virtually by growing and
splitting in half; cell-division, as this splitting is called, really
represents reproduction reduced to the simplest terms. Most cells can
do no more than produce units like themselves. The bodies of women
contain, however, a type of cell which possesses a far more wonderful
power. Provided the requisite conditions for such development are
met, these cells are capable of developing into human beings. Each of
these remarkable units is called an Ovum, or egg-cell, and represents
one variety of the germinal cells. But the other variety, represented
by the Spermatozoon and developed only in the male sex, is also
required for the production of a human being.
Every ovum originates in the ovaries. These are organs peculiar to
women, having the size and shape of large almonds, and placed in the
lower part of the abdominal cavity. Though the ovaries are two in
number, one alone is sufficient for every requirement of health. It
has been estimated that the ovaries together contain at the time of
birth about 40,000 ova, distributed equally between them. Since less
than 500 ova are required to insure regularity in the menstrual
function, it is clear that, if the surgeon finds it necessary to
remove one of the ovaries, the other will provide abundantly for
menstruation and for the bearing of children. Although every ovum
that will be produced as long as a woman lives has already sprung
into existence by the time she is born, not a single one ripens for
from twelve to fifteen years. The ripening process begins about the
time of puberty, and, unless suspended through the occurrence of
pregnancy, continues until the menopause. During this period, which
is also characterized by the periodical appearance of menstruation,
one ovum ripens each month; sometimes, though rarely, several ripen
at once, and this tendency is partly responsible for twins.
The human ovum is a tiny structure, measuring about 1/125 of an inch
in diameter. With the naked eye it can barely be seen; magnified by
the microscope it appears as a little round bag made of a transparent
membrane. Briefly described, the ovum is a single cell. That is, it
belongs to the simplest class of anatomical structures, and is one of
the millions upon millions of units that make up the body. It
contains a nucleus surrounded by nutritive material, the yolk. Yet
the quantity of yolk is exceedingly small. In this particular the
human ovum differs notably from the egg of birds, as it does also in
that it lacks a shell. Obviously, a shell would not only be useless
to an embryo developing within the body of its parent, but would shut
off the nourishment, which, since the ovum contains so little, must
necessarily be provided by the mother.
When the ovum has ripened, it becomes detached from the ovary, and
enters a fleshy tube about the size of a lead pencil, known as the
oviduct. There are two of these tubes, one running from the
neighborhood of each ovary; both enter the uterus, but on opposite
sides. The ovum travels down the tube which corresponds to the ovary
where it originated. The journey is fraught with momentous
consequences, for it is during this passage through the oviduct that
the fate of the ovum is determined. If it is to develop into a living
creature, a great many conditions must sooner or later be fulfilled;
but there is one which must be promptly satisfied. Shortly after
leaving the ovary the ovum must receive the stimulus to live and
grow; otherwise it will quickly wither and die. This vital stimulus
can be imparted only by the spermatozoon.
The male germinal cell is like the female cell in the possession of a
nucleus; in other respects it is very different. Longer but much
narrower than the ovum, the tiny arrow-shaped spermatozoon is
particularly distinguished by its active motility, for it has a tail
that propels it. The human male cell must travel some distance to
reach the point where it can meet a ripe and vigorous ovum; and since
the journey is not without danger to its life, Nature has provided
that exceedingly large numbers of the male cells shall be deposited
in the vagina at the time of the marital relation. In this way, it is
made sure that some of them will travel up through the uterus and
oviducts, arriving in the neighborhood of the ovaries.
FERTILIZATION.--Convincing observations upon the lower forms of life,
especially upon fishes, have shown that when the germinal cells come
near to each other, the ovum attracts the spermatozoon. The power of
attraction which the ovum exerts may be likened, most simply, to the
influence of a magnet upon iron-filings. While there has been no
opportunity to observe such attraction between the parent cells of
human beings, its existence is not open to doubt. And it is
practically certain that these cells meet in the oviduct, even in
that portion of it which receives the ovum just as it leaves the
ovary. Thither a number of the male cells have traveled by their own
activity; several come in contact with the ovum and one, but only
one, actually enters it. Almost at the moment when they touch, the
two cells unite so intimately that all trace of the spermatozoon is
lost. Fertilization of the ovum, as this event is scientifically
termed, has as its main purpose the uniting of the nucleus of a male
germinal cell with the nucleus of the female germinal cell. This
detail has been carefully studied; we know that the nuclei quickly
blend into one, and that the particles of living matter contributed
by the male animate the female cell with a new and wonderful
activity.
In our every-day way of speaking, fertilization means conception; it
is the instant in which a living being begins its existence. There is
no longer the slightest excuse for confusion regarding the period at
which the life of the unborn child begins. Before the significance of
fertilization was understood, it was perhaps not unreasonable to
believe that life began with quickening or about the time the fetal
heart-sounds could be heard. But now we must acknowledge that both
these ideas were incorrect. The animation of the ovum at the moment
of conception marks the beginning of growth and development which
constitutes its right to be considered as a human being.
Individuality, hereditary traits, sex--all these, we may be sure--are
unalterably determined from the moment of conception. The germinal
cell forms the total contribution of the male parent to pregnancy;
therefore no other opportunity for him to influence his progeny
presents itself, and the substance which enters the ovum at the time
of fertilization must be the basis of inheritance from the father. It
is equally true, as we shall see in the next chapter, that the
nucleus of the ovum and the nucleus alone transmits maternal
qualities. The material which conveys inheritable characters can be
seen and has been identified in both germinal cells; from each of
them the fertilized ovum derives equal amounts. As the parental
nuclei unite, the material which they contain intermingles and
establishes a new being; to attain full development, it requires
nothing further from the father, and nothing save nourishment from
the mother.
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