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.]
The introduction of chloroform met with violent opposition, not upon
medical grounds alone, but also for moral and religious reasons. "To
check the sensation of pain in connection with the visitations of
God," zealous theologians announced, "was to contravene the decrees
of an all-wise Creator." Simpson reminded them "that the Creator,
during the process of extracting the rib from Adam, must necessarily
have adopted a somewhat similar artifice--for did not God throw Adam
in a deep sleep?" Nevertheless, a number of years passed before the
prejudice against artificial sleep was overcome. Chloroform only
became popular after Queen Victoria consented to its use at the birth
of her seventh child, Prince Leopold, in 1853.
There is still some difference of opinion regarding the routine
employment of chloroform in obstetrical practice, though the weight
of authority favors its use during the contractions at the end of the
second stage, providing always that no preexisting organic
derangement renders the drug dangerous. Under no circumstances,
however, should chloroform be given in the first stage, and seldom at
the beginning of the second. Prolonged administration will exert an
injurious influence upon both mother and child; under these
conditions it ultimately weakens the uterine contractions and delays
the delivery. Such an effect must be avoided, since it would endanger
the life of the child by asphyxiation as well as exhaust the mother.
On the other hand, a few drops of chloroform inhaled with each pain
toward the end of the second stage will dull sensibility, although
consciousness remains unaffected. When the drug is thus administered,
the uterine contractions are scarcely, if at all, altered, and the
assistance which the patient is willing to give herself generally
becomes more powerful. Should the anesthetic have the opposite
effect, it must be withheld; but that is seldom necessary. As the
head advances the anesthesia is deepened, and the mother sleeps
soundly while the child is being born.
As long as dilatation is in progress, the patient may sit up or walk
about; but with the advent of the second stage she should go to bed,
for there she will be able to make the best use of the expulsive
pains. The appropriate posture for delivery is still the subject of
dispute, though modern views in no instance advocate the unnatural
absurdities formerly supported by custom or superstition. Students of
ethnology relate that among savage tribes almost every conceivable
position was advocated for women in labor. Subsequently it became
customary to have delivery take place in specially constructed chairs
which are still used in semi-enlightened countries. With civilized
nations at present women are always delivered in bed; yet national
peculiarities still prevail. Some physicians favor what is known as
the English position, in which the patient lies on her left side with
her face inclined toward the chest, the trunk bent toward the knees,
and the legs drawn up toward the abdomen. The majority of
obstetricians, however, prefer that the patient should lie flat on
her back. With the average case, and from the standpoint of facility
in delivery, which of these postures happens to be chosen is a matter
of indifference. But it is so much less awkward for the physician
when the patient is on her back that this position has been widely
adopted in America.
During the expulsion of the child the mother intuitively desires to
help herself; generally she cannot resist straining, and rarely needs
encouragement. Assisting the uterine contractions with voluntary
muscular effort, the act commonly described as "bearing down," may be
performed most effectively when the patient is lying on her back. The
knees are drawn up and spread apart; the feet are braced against some
firm object; the hands grasp straps fastened at the foot of the bed;
and the head is slightly raised so as to bring the chin near the
chest. When the contraction begins the patient takes a deep breath
and holds it while she strains vigorously, as if to make her bowels
move. All voluntary effort should cease as the contraction wears
away, for straining between the contractions can accomplish nothing.
Her own inclination to "bear down" will clearly indicate to the
patient when she ought to act.
In the second stage patients regularly experience a feeling of
pressure against the rectum, and this sensation, since it depends
upon a low position of the child's head, is a welcome sign. Cramps in
the legs also indicate progress, for they result from similar
pressure against nerves adjacent to the lower part of the birth-
canal. The cramps disappear immediately after the child is born, and
are consequently never dangerous. Straightening out the legs or
rubbing them usually gives relief. Most women, however, complain
during the expulsive period only of pain in the back, and find
nothing so grateful as firm pressure over this region.
Energetic efforts quickly bring the head to the outlet of the birth-
canal, where it may be seen, at first only during the contractions,
but later during the pauses as well. The crown of the child's head is
generally directed upward and becomes fixed against the pubic bones
of the mother, which lie just in front of the bladder. Around this
firm pivot the child's head rotates upward, and, as a result of the
movement, forehead, eyes, nose, mouth, and chin successively emerge
from the birth-canal. Following the birth of the head, natural forces
turn the body upon one side, the better to accommodate the shoulders
to the passageway. After these are born, the rest of the body slips
easily into the world, and the second stage ends.
THE PLACENTAL STAGE.--Although the third stage is chiefly concerned
with the separation and the delivery of the after-birth, on which
account it is known as the placental period, the description of other
no less remarkable events belongs here. Even after the infant is born
the umbilical cord extends from its navel to the placenta, just as it
has done throughout pregnancy. Among larger mammals separation of the
new-born from the mother is brought about in one of two ways;
sometimes the activity of the young breaks the navel-string, though
more frequently the mother bites it in two. Both these methods, we
are told, have been employed by savages; but at the beginning of
civilization it became customary to sever the cord with a cutting
tool, and the tie thrown round it represents the first attempt of man
to ligate blood-vessels. Ordinarily there is no need for haste in
this operation. On the contrary, some delay is often of advantage,
since an appreciable quantity of blood that otherwise would remain in
the placenta is thus given opportunity to enter the infant's body.
According to present ideas, as long as the heart-beat can be felt in
the cord it should not be tied.
The sleep induced toward the close of the previous stage lasts for a
few minutes, so that most patients are unconscious through the
greater part of the brief placental stage. Before the influence of
the anesthetic has worn off, the physician has an excellent
opportunity to sew up any laceration which may have occurred in the
course of delivery. Slight injuries are not uncommon, especially if
the confinement be the first, for the most skillful treatment often
fails to prevent them. Since superficial tears are never serious if
promptly closed, it is not their occurrence, but the failure to
recognize them, or to sew them up when they are recognized, that
deserves condemnation.
After the birth of the child the womb becomes smaller, its walls grow
thicker, and the cavity within is narrowed. This series of changes
partly detaches the placenta, but the separation depends chiefly upon
the uterine contractions. These contractions also force the after-
birth into the vagina, whence it may ultimately be dislodged by the
patient if she bears down again. Usually, however, it is preferable
to save her further efforts of this kind, and, as a routine, the
physician places one hand upon the abdominal wall, grasps the womb,
and, during the contraction, makes firm pressure downward. The
maneuver expels the after-birth, which consists of the placenta, the
membranes, and the umbilical cord. Then the empty womb will form a
hard, spherical mass about the size of the child's head, lying just
above or to one side of the bladder.
Slight bleeding also occurs during the third stage, and further loss
of blood follows the removal of the after-birth. The total loss
varies between a half pint and a pint, though larger amounts may be
noted occasionally without appreciable effect upon the mother.
Naturally, large, robust women can spare much more blood than those
who are anemic. And yet pregnancy invariably prepares the mother for
a loss of blood that would alarm anyone unfamiliar with obstetrical
practice. Often the woman just delivered is not harmed by a
hemorrhage that would endanger the life of a healthy man. This may
seem paradoxical, but it is not; for the surplus blood, which
formerly performed important duties in connection with the nutrition
of the fetus, must now be removed to readjust the mother's
circulation.
In a very small number of cases an unduly large loss of blood follows
the expulsion of the placenta. Fortunately, by treatment which
consists usually in spurring Nature to more vigorous action we are
well equipped to deal with this emergency. A wonderful mechanism has
been provided by Nature to control excessive bleeding after delivery.
If the forces upon which this mechanism depends are sluggish, the
physician stimulates them. As in the preceding stages, the muscle
fibers of the uterus supply the power in question, and because of
this role an observant obstetrician once called them, "living
ligatures." Certain of these fibers encircle the mouths of the blood-
vessels which have been left open through the detachment of the
placenta. When they contract the vessels are squeezed, impeding the
escape of blood. The necessity of this action explains the
contractions which continue even after the placenta has been
expelled, when they are vigorous enough to cause discomfort they are
spoken of as "after-pains." After-pains seldom follow the birth of
the first child, but they regularly follow later confinements. In any
case, such contractions do not persist very long, for tiny clots form
within the blood vessels and effectually close them. As soon as the
lining of the womb has been restored the clots are absorbed, leaving
the organ in much the same condition as before conception took place.
THE EFFECT OF LABOR UPON THE CHILD.--Unless the experience of
countless generations had taught us otherwise, we should fear the
child would be injured by its passage through the birth-canal.
Immediately after the birth evidence of the journey is seldom
wanting, but it quickly disappears.
The unusual size of the infant's brain requires the head to be large,
and bestows upon it a contour which differs from that of the mother's
pelvic cavity. Since the bones of the pelvis are rigid, while those
of the fetal skull are malleable, the head is molded as it descends
into the pelvic cavity, so that its passage may be made the easier.
As the result of this process of accommodation the skull becomes
relatively longer from crown to chin than in adults. Within a few
weeks, however, the modification vanishes. If an infant is born with
the buttocks first, the head does not linger in the birth-canal, a
fact which in such cases explains the pleasing shape of the skull,
which emerges with the contour determined by fetal growth.
Whenever a soft swelling appears over that portion of the scalp which
was foremost during the birth, the curiosity of the family is
aroused; but the swelling is harmless and subsides quickly. It
originates for the same reason that a finger swells if too tight a
ring is worn, which, as everyone knows, is because of interference
with the circulation. Just as the swelling of the finger disappears
when the constriction is removed, so the swelling of the scalp
subsides shortly after the child is born. Usually no trace of it can
be found the next day; but even when more persistent it will always
vanish after a short time.
For the child the most notable result of labor relates to the
revolutionary changes in its mode of existence. Up to the time of
birth the fetus received nourishment by way of the placenta, but
after separation from the mother another source of food must be
found. The health of the tissues, perpetually in need of oxygen,
requires that the lungs act very promptly. Contact with the air,
which is cooler than the previous environment of the child, irritates
the nerve-endings in the skin; in response to the sensation thus
produced breathing is established automatically. Whenever the
temperature stimulus proves insufficient, physicians employ a
stronger one, spanking the child until it cries lustily. Crying not
only expands the lungs, but also has a favorable influence upon
needful alterations in the fetal circulation.
The lungs, since they must from this time on provide oxygen for the
infant, need to receive more blood than formerly. The vessels leading
toward them must be widely opened, and structures which previously
diverted the blood-stream to the navel must be closed. The intricate
shifting of forces which produces the change cannot be understood
without a knowledge of anatomy; it will suffice for us to know that
the blood is drawn into the vessels of the lungs with each
inspiration. Other changes also occur. On account of some of these,
namely, certain alterations in the blood current through the heart,
physicians once taught that newly born infants should always be laid
upon the right side. Except in very unusual cases, that precaution is
now regarded as unnecessary.
Of all the elements essential to nutrition, oxygen is the only one
required immediately after birth; as the child enters the world well
stocked with all the others. Babies are not born hungry, as many
people seem to think. Neither is their crying a proof of it, for, as
we have observed, they have other very good reasons for crying; nor
is their readiness to suck anything that comes in contact with the
mouth, for they will behave in the same way while they are receiving
an abundance of nourishment through the umbilical cord. Many hours
pass before a newly born infant can possibly need food. Indeed, it
could survive a week or longer without taking anything, by mouth,
except water. The ability to suckle at birth merely indicates that
the infant is prepared to utilize the mechanism which nature will now
employ to sustain it.
After the umbilical cord has been severed the blood vessels within it
can serve no further purpose. Consequently the remnant of this
structure attached to the child's abdomen begins to shrivel. Formerly
the care of the stump was considered a trivial matter; when
cleanliness was neglected decomposition caused more rapid separation
than takes place under the treatment which it now receives. No
annoyance should be felt because the cord hangs on a long time;
indeed, such an experience means it has been given exceptionally good
care. Separation rarely occurs before the end of a week. It may be
deferred for two weeks, or even longer, if the stump has been kept
perfectly clean. After the shriveled cord drops off, the skin around
the navel contracts, leaving a small raw area which discharges a
yellow fluid for two or three days before the healing is complete.
MEDDLING.--In selecting a physician the patient will almost certainly
have been guided by her confidence in his ability. It may seem
strange, therefore, to insist that he be allowed to conduct the
delivery as he thinks best. Nevertheless, suggestions from outsiders
are so common, especially if the labor be at all prolonged, that it
seems appropriate to warn patients to pay no attention to such
advice. In the heat of excitement well-meaning relatives are
sometimes inclined to interfere, and women who are not members of the
family occasionally wish to discuss their experiences, irrelevant as
they may be.
The patient's intimate friends, quite naturally, have the keenest
personal interest in the event, an interest that of itself
disqualifies them from reasoning calmly at the time. Their influence
may be positively harmful if they persuade the physician to undertake
procedures which his judgment convinces him are inadvisable. Should
he turn a deaf ear, they will think him lacking in sympathy; but
should he adopt their suggestions he would assume the full
responsibility, and would perhaps be censured later by the very
persons whom he sought to please. There can be no question of the
proper course for him to pursue. Any influence which such entreaties
may have will always be in the direction of too early interference,
which is fraught with danger to mother and child alike. The master-
word is patience, and it applies alike to the mother herself, to the
doctor, and to her friends.
Almost always the whole duty of the doctor consists in watching the
progress of labor, so that he may be ready to render assistance
should it be needed. Until the second stage begins there is no real
necessity for him to remain in the room. Indeed, it is better for him
not to do so after he has made sure that satisfactory conditions
prevail, for his judgment will be less biased if the patient is not
continuously under his observation.
JUSTIFIABLE INTERVENTION.--It is quite true that in the progress of
the birth difficulties now and then arise; yet they are far less
common than rumor would lead us to believe. The unusual always
attracts attention, often receiving greater emphasis than it merits.
The particulars of confinement provide no exception to this rule; a
delivery which requires artificial aid will be talked about, while
hundreds that terminate naturally pass without comment. In this way
the public gets an exaggerated notion of the frequency of difficult
labors. Moreover, the nature of the trouble is usually distorted, for
reports of medical events are apt to be incorrect, and errors
multiply with each rehearsal. Obstetrical patients who wish, so far
as possible, to escape the depressing influence of such inaccurate
reports will be most likely to succeed if they follow the advice to
select a physician at the beginning of pregnancy. When this is done
the physician will have opportunity to explain or discredit alarming
rumors, a task which it is usually necessary for him to perform, for
there are always some persons who feel that a prospective mother
should listen to everything that they have heard of childbirth.
The most frequent cause for intervention during labor is
insufficiency of the muscular contractions to overcome the resistance
of the birth-canal. Unusual resistance of this kind explains the
longer labors of women who have passed middle life before becoming
pregnant. They may need to exercise more patience than younger women,
though they have no greater reason to apprehend serious difficulties.
Whenever rigidity of the muscles adjacent to the birth-canal arrests
delivery the physician may employ the obstetrical forceps, which have
been in use since the seventeenth century.
Although it is widely known that physicians sometimes terminate labor
in this way, the public estimate of the merits and of the limitations
of the instrument is so inexact that the truth about it should be
understood. Obstetrical forceps were devised by one of the
Chamberlens, a family of French Huguenots who fled to England in
1569. The invention was long kept a secret; therefore its date cannot
be fixed, nor even the inventor clearly identified, though everyone
agrees that he was a member of this family. Clearly the instrument
had been in use for some generations prior to Hugh Chamberlen, who
translated from French into English the foremost obstetrical textbook
of his time. The book, published in 1672, does not contain a
description of the forceps, but in his preface Hugh Chamberlen refers
to delay in delivery, saying, "My father, my brothers, and myself
(though none else in Europe as I know) have by God's blessing and our
own industry attained to and long practiced a way to deliver women
without prejudice to them or their infants in this case." It is not
questioned that the forceps was the secret that his ancestors and he
himself employed so long and so profitably. About a century ago what
are probably the original models of the instrument were discovered in
a country home of Essex which once belonged to the Chamberlens; there
they had been hidden in a trunk in the garret. The box in which they
were concealed contained four pairs of forceps, representing
different stages in their development, besides other instruments and
a number of letters which established their ownership.
After an unsuccessful attempt to sell the family secret in Paris,
Hugh Chamberlen found a purchaser in Amsterdam. The privilege of
using it in Holland was then granted physicians for a monetary
consideration, and that practice continued until two philanthropists
purchased the secret to make it public. It was ultimately learned,
however, that the sale was a swindle, for the device which the
purchasers obtained consisted of only half the genuine instrument.
The real secret was revealed by a son of Hugh Chamberlen, who bore
the same name as his father; but probably the first accurate printed
description of the forceps was made by Samuel Chapman, in his
treatise on obstetrics which appeared in 1733. Subsequently they came
into general use, and, with many modifications, remain the most
important instrument in the obstetrician's equipment. There can be no
exaggeration in the claim that the instrument has done more to save
human life than any other surgical appliance.
The obstetrical forceps have been of such great service in
diminishing the number of still-born infants that they were once
called the child's instrument. The need of its employment in behalf
of the child may be determined by careful observation of the fetal
heart-sounds, which are heard over the mother's abdomen, and by means
of which one may learn the condition of the child. Signs of danger
are extremely uncommon so long as dilatation of the womb is not
complete, for any strain which labor may impose upon the child will
usually occur during its passage through the pelvis. Most often,
therefore, the head has reached the outermost part of the birth canal
before extraction becomes advisable.
The forceps are used also on behalf of the mother, if the
continuation of labor seems likely to throw undue stress upon her. On
this account the physician frequently resorts to them if his patient
is suffering from pneumonia, typhoid fever, or any acute illness at
the time of labor. Other maternal indications for their use include
various chronic derangements, well exemplified by certain diseases of
the heart. Furthermore, even when there are no preexisting
complications forceps are employed on account of exhaustion or other
conditions which may develop during the course of labor. It must be
clearly understood, however, that the physician alone can determine
when intervention is justified, as well as what operative procedure
is most appropriate; for even though good reasons for terminating
labor exist, forceps cannot be properly used unless nature has
already fulfilled very definite requirements. By no chance can the
patient, much less her friends, decide this matter. And besides, none
but a trained observer can detect the symptoms which clearly indicate
Nature's incompetence to effect delivery. Disregard of these truths
by the family with consequent urging that something be done must be
held partly responsible for the reckless use of the instrument. It
will be a step in the right direction, therefore, when the laity
comes to understand that the value of the instrument generally
pertains to the welfare of the child, and that, in any event, its use
will be harmful if employed before the womb has been completely
dilated.
Although forceps can be employed only in cases of head presentation,
intervention may be warranted when some part of the fetus other than
the head will be born first. Two or three times in every hundred
patients we meet with breech presentations, that is, cases in which
the buttocks precede; after their expulsion, the body, the arms, and
the head follow. Breech presentations occur more frequently among
women delivered prematurely, as might be expected since an
examination eight to ten weeks before the calculated date reveals a
larger percentage of breech presentations than a similar examination
about the normal end of pregnancy. In explanation of these results we
accept the view that the size of the fetus at the earlier date does
not require nicety of adaptation to the cavity of the womb, whereas
at term, unless the child is small, the best accommodation is secured
when the head lies downward.
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.