THE LYING-IN PERIOD
The Changes in the Uterus--The Lochia--The Return of Menstruation--
Other Restorative Changes: The Loss in Weight; The Abdominal Wall;
The Pelvic Floor--The Care of the Patient: The Elimination of Waste
Material; Cleanliness; The Diet; The Environment; The Time for
Getting up--The Final Examination.
A generation ago physicians were accustomed to see their obstetrical
patients only at the time of labor. No preliminary examination was
thought necessary, and after the delivery visits were not made unless
the family became alarmed and requested them. When thus asked to come
back the physician sometimes found that an infection had developed;
occasionally the breasts were giving trouble, or some other
difficulty in the care of the mother or of the infant was baffling
the nurse. It is now recognized that the medical attendant should not
wait for the appearance of untoward symptoms. Although the strict
observance of the various precautions which I have already emphasized
should lead and usually do lead to an uneventful convalescence, it is
none the less true that the danger of infection and of other
immediate complication has not passed until several weeks after
delivery. For this reason and also because skillful guidance of the
mother at this time will prevent unwelcome sequels in the later years
of life, physicians now extend their watchfulness beyond the hour of
birth. The number of visits ordinarily required is not large. In each
case, to be sure, the circumstances will determine the number; but,
as a rule, ten visits, if properly distributed, will be sufficient.
During the month succeeding delivery these visits should be made in
about this order: a daily visit for the first five days, subsequently
one upon the seventh, the tenth, the fourteenth, the twenty-first,
and the twenty-eighth day.
At the conclusion of labor there begins a series of changes which are
the reverse of those incident to pregnancy, and which restore the
body to its original condition. Six weeks are generally required for
these alterations. They should leave the mother in _perfect_
health, but traces of pregnancy are not entirely effaced; even in the
absence of outward evidence, if a woman has ever given birth to a
child a thorough internal examination will disclose the fact.
The initial steps in these restorative processes are taken most
promptly and effectively when patients remain in bed. The traditional
custom of doing so has given to the first few weeks following
delivery the popular name, "the Lying-in Period." To these weeks
physicians usually apply the technical term _puerperium_, the
child's period, a designation which brings to mind the secretion of
milk which, though not a retrogressive change, is, nevertheless, one
of the most distinctive results of childbirth.
Radical as the bodily changes in progress at this time are, the
lying-in period is not a period of illness. But there is, perhaps, no
other time in a woman's life when she may cross the boundary between
sickness and health so easily; for here nature tolerates no trifling.
Not infrequently puerperal patients who are feeling well attempt too
much, and suffer a more or less serious set-back; it is an all-
important duty of the obstetrician, therefore, to restrain them from
harmful activity. In my experience patients yield to restraint most
readily, and secure the best results, if I explain to them the
anatomical facts which should guide the management of the lying-in
period.
THE CHANGES IN THE UTERUS.--Since of all the organs the uterus
undergoes during pregnancy the most extensive development, it also
holds the place of prominence during the lying-in period. Immediately
after delivery the womb weighs two pounds and measures some eight
inches in height, five in breadth, and four in thickness. In the
course of a few days it begins to dwindle in size, gradually sinking
in the abdomen until it lies entirely within the pelvic cavity.
Toward the end of five or six weeks it resumes the position occupied
before conception, regains approximately its original dimensions, and
weighs two ounces. We speak of the process which leads to these
results as the _involution_ of the uterus. Since a great deal
depends upon the rapidity with which involution progresses, we must
understand just what it is and how it may be influenced.
The muscle of the womb, to which this property of involution belongs,
is an aggregation of thousands of individual fibers. In response to
excellent nutrition during pregnancy, these fibers have grown thick
and strong, in order that they may furnish the power needed at the
time of labor. When this purpose has been fulfilled each fiber
becomes smaller and gradually passes into a resting stage the better
to preserve its vigor. It is the shrivelling of the individual
fibers, therefore, which accounts for the total reduction in the size
of the womb.
Although the source of the stimulus which causes the muscle-fibers to
atrophy is not so clear as we should like it, we are acquainted with
certain influences to which involution is susceptible. Of these none
merits so much attention as the influence of the breasts. The
intimate relation between the breasts and the uterus manifests itself
in such a variety of ways and with such force that no one doubts its
existence. Thus, if a nursing mother becomes pregnant her infant is
usually deprived of sufficient nourishment or suffers some digestive
disturbance; if not, and the mother, ignorant of her condition,
continues with the breast feeding, she may jeopardize the newly begun
pregnancy. Very likely she will be warned of the fact by the signs of
threatened miscarriage. More frequently, but in quite the same way,
we find that nursing causes uterine contractions in the early part of
the lying-in period, when they are called after-pains. Women who
experience them tell us they are more severe while the infant nurses;
and they also say that the discomfort disappears after several days,
a fact which indicates that involution has made notable headway. The
physician is not dependent on such evidence, however; for a simple
examination reveals at any time how far involution has progressed. By
this means we have learned that nursing facilitates the involution
process. On the other hand, it is found to be true, as we should
naturally expect, that women who decline to suckle the infant recover
from childbirth somewhat less rapidly than those who follow nature's
plan. In this fact, therefore, is found a selfish motive, yet a very
good one, which should impel mothers to perform this exceedingly
important duty.
Aside from the change in the mass of the uterus, notable results of
involution relate to its mouth and to its ligaments, for these
structures are also chiefly muscle. The mouth of the womb, lately
stretched to permit the exit of the child, gapes widely for a time;
but ultimately its lips are drawn together, the tissues which compose
them stiffen, and the canal which they enclose is narrowed to almost
microscopical dimensions. When involution is complete, the uterus has
so far regained its virginal character that no trace of childbirth
remains other than a few small fissures in the margin of its mouth.
It is the office of the ligaments to hold the uterus in proper
position. In consequence of pregnancy they have been stretched, and,
as we might anticipate, after the contents of the womb are expelled
the ligaments hang loosely from its sides, very much as sails hang
when a breeze dies down. Immediately after delivery, therefore, the
ligaments give the womb little or no support; eventually they shorten
and tighten, readily accommodating themselves to the existing
conditions. Until the accommodation is perfected, it is especially
desirable to permit no pressure which might push the womb backward.
It is for this reason that many obstetricians object to the time-
honored custom of applying a tight bandage about the abdomen at the
conclusion of labor; for, though bandaging is not always harmful, it
has a distinct tendency to misplace the womb. A friend who has served
as an assistant in one clinic where patients were bandaged regularly
and in another where they were not, tells me that displacements of
the womb were much more common among women treated by the former
method.
While the process of involution is altering the shape and size of the
womb, other forces are at work within the organ to provide its cavity
with a new mucous membrane. In character and in extent the inner
surface of the womb, left raw and bleeding at the conclusion of
labor, is comparable to the wound which would result if some accident
removed the skin from the palms of both hands. No one would question
the wisdom of guarding such an injury to the hands; but cleanliness
is even more necessary to the prompt and healthful restoration of the
uterine mucous membrane. However, the wound within the uterus is so
far from the surface of the body that it need not be directly covered
with a surgical dressing; sterile pads are kept over the vulva to
exclude contaminating material until the healing is completed. Since
bleeding ceases after that point is reached, we have no difficulty in
knowing when the mucous membrane has been restored.
THE LOCHIA.--The vaginal discharge which regularly follows the
termination of pregnancy gets its name from the Greek word
_lochia_. At first the discharge is pure blood, because it
issues exclusively from the vessels left open by the removal of the
after-birth. The greater part of the blood flows out of the birth
canal, but frequently some of it collects in the cavity of the uterus
or of the vagina; there it coagulates, and the clots may not be
expelled until several days later. In that event, as whatever effect
the bleeding may have had has long since passed, the appearance of
the clots is usually no occasion for alarm.
The amount of lochia varies, and will likely fall below the average
in small or anemic women and rise above it in those who are large or
robust. Then again, the discharge is less profuse if considerable
blood has been lost immediately after the labor. For the first ten
days the total quantity seldom exceeds eight or ten ounces; after
that time it is so small that it cannot be accurately estimated.
Formerly much larger amounts were considered normal, and, therefore,
it is probable that modern aseptic treatment of child-birth has
lessened the subsequent loss of blood. Toward the end of a week the
lochia changes from a bright red to a brownish color, because the
discharge now includes certain products of disintegration. Somewhat
later the lochia consists almost entirely of mucus, being only
streaked with blood; but there will be an increase in the bleeding
when the patient gets up; and injudicious activity may cause
flooding. A slight bloody discharge may be expected to continue until
five or six weeks after the child was born.
A faint but characteristic odor to the lochia proves very
disagreeable to some patients, and on that account it was formerly
customary to give them a daily douche throughout the lying-in period.
This was before the characteristics of the puerperal uterus and the
nature of infection were thoroughly understood. Most physicians are
now convinced that the early use of douches is rarely beneficial; and
since there is danger of washing infectious material from the lower
part of the vagina into the uterus, they may, if given prior to the
second week after delivery, actually do harm. Consequently douches
are not now used in a routine way. Whenever irrigations are indicated
the doctor will prescribe them. Late in the puerperium vaginal
douches are unobjectionable, and patients may take them unassisted,
for then the fluid will not penetrate the womb so long as it has a
free escape from the outlet of the vagina. Moreover, it is immaterial
if some of the fluid should pass into the womb, for its lining will
have been largely restored by this time, and at points where
restoration is incomplete defenses have been thrown up against
infection.
THE RETURN OF MENSTRUATION.--On account of the dilatation at the time
of labor women who have previously suffered with menstruation may
look forward to relief after child-birth. Menstruation generally
becomes as painless as the flow of the lochia; and so far as a
patient can tell the two phenomena are identical. Actually, however,
they bear no relation to each other. The fact that the cavity of the
uterus has been deprived of its lining is responsible for the lochia,
whereas the menstrual discharge occurs in spite of the lining,
through which it breaks at regular intervals in response to a
stimulus that is absent for a longer or shorter period after the
birth of a child.
In the latter part of the puerperium there may be doubt as to whether
a discharge is menstrual or lochial; though, if necessary, an
examination of the interior of the womb would always settle the
question, for structural changes in the uterine mucous membrane form
the most characteristic feature of menstruation. If, therefore, small
bits of this tissue are removed and studied under the microscope, a
definite conclusion can be reached. Physicians may resort to such an
examination when the significance of a discharge is not clear without
it; but other evidence usually enables them to decide the matter.
The secretion of milk often exerts an influence upon the
reestablishment of menstruation. Under ideal circumstances the mother
does not menstruate while she nurses her infant; whereas, if the
breasts are not in use, the menstrual function returns six to eight
weeks after delivery. Other pertinent clinical facts also lend weight
to the opinion that the activity of the breasts, more technically
called lactation, should not only prevent menstruation but also
hinder the ripening of egg-cells in the ovary. Thus, the nursing
infant has a potent influence upon the reproductive function of its
mother, enabling it to preserve its food supply; for in the event of
conception the milk usually decreases in amount or becomes of an
inferior quality. To secure this protective influence should prove a
strong incentive for the mother to nurse her child; in barely half
the cases, however, is it effective throughout a year. One-third of
nursing mothers, statistics indicate, begin to menstruate about two
months after delivery, and month by month the proportion gradually
increases.
Since menstruation appears so frequently during lactation, it cannot
be considered abnormal. It does not follow that the function will
become permanently reestablished after a patient has menstruated
once; in many instances several months elapse before there is another
period, and in a few cases there will be only one period during the
year the child suckles. Nevertheless, when the function has once made
its appearance extraordinary precaution should be exercised to avert
a return, and about the time its reappearance would be expected the
woman should go to bed for several days. Although this measure may
prove futile, we know of no other so likely to prove successful.
Menstruation is more apt to return prematurely after the birth of the
first child than of later ones. This may be due in part to a kind of
accommodation of the maternal organism to the reproductive process as
one pregnancy follows another; but I am convinced that it is also due
in part to the greater physical and mental composure of experienced
mothers. Until a woman has learned the unwelcome consequences she is
apt to take over household duties before she is equal to the task, or
she may engage in too strenuous amusements; and most mothers err in a
too energetic care of the baby.
OTHER RESTORATIVE CHANGES.--Many of the restorative changes in the
mother's body are either so intricate or so devoid of practical
significance that we may pass them by; though all of them have great
interest for the specialist, and some have occasioned bitter
controversy. The alterations in the heart, for instance, have been
the subject of a prolonged dispute between French and German
scientists. The former still assert that this organ regularly
enlarges during pregnancy and subsequently returns to its normal
size. The Germans deny both these contentions. Certainly the
alterations are insignificant from a practical standpoint; otherwise
competent observers would not disagree.
The really important changes in the body, other than those pertaining
to the uterus, are familiar to women who have passed through
pregnancy; but other prospective mothers may not understand that they
will regain the bodily condition which existed before conception.
_Loss in Weight_.--While the weight lost during the lying-in
period is not so vital as some other alterations, many have a keen
interest in it. In addition to the loss of ten to fifteen pounds at
the time of birth, a further loss occurs in the course of a few
weeks. Diminution in the size of the uterus is responsible for the
loss of nearly two pounds, and the lochial discharge for at least
another; but the chief factor concerned is the removal of water from
the tissues, many of which have become dropsical toward the end of
pregnancy. Altogether patients do not lose less than ten pounds
during the lying-in period, and often lose a great deal more. The
average loss for the first week alone is said to equal one-twelfth of
the patient's weight at the conclusion of labor; the total loss for
the whole of the puerperium corresponds to one-tenth of her weight at
the beginning of it. Variations from the rule are attributed to
individual peculiarities of nutrition. In general, stout women lose
more than slender ones, but with all types the loss is greater if the
mother nurses her infant. On the other hand, a generous diet tends to
counteract any loss in weight whatever.
_The Abdominal Wall_.--Much more important than the question of
weight is the recovery of the abdominal wall from the strain imposed
by the enlargement of the womb. In normal cases, to be sure, there is
very slight disproportion between the size of the pregnant uterus at
term and the capacity of the abdomen, yet the abdominal wall
invariably suffers a little stretching and unless it retains its
elasticity, the viscera are deprived of essential support, and cause
more or less discomfort.
The restorative changes in the abdominal wall involve the skin, the
fatty tissues, and the muscles. As soon as the distention has been
relieved the skin falls into folds, less noticeable if the pregnancy
was the first; and the muscles become so flabby that one has no
difficulty in pushing the wall backward until it touches the tissues
which cover the spinal column. Within a few weeks, if all goes well,
the muscles regain their "tone." Coincidently, the excessive fat over
the abdomen is absorbed. The skin becomes smooth, and its
pigmentation fades completely; but the pregnancy streaks rarely
vanish entirely, although they always become very much less
noticeable.
Whether or not the abdominal wall will recover from the distention of
pregnancy depends entirely upon the muscles. As the lying-in period
advances each fiber should gradually shorten until the whole muscular
structure becomes as firm and tight as it ever was. But this takes
time, and no artifice can hasten the repair. Perfect recovery is most
likely with the body in a recumbent position, which relieves the
muscles from any strain. These facts are better appreciated than
formerly, hence most physicians encourage their obstetrical patients
to remain in bed somewhat longer than their mothers did. Generally
nothing else will be required, and only under extraordinary
circumstances will nature need assistance. Thus, if there has been
unusual distention, as, for example, that due to twins, the muscular
impairment may be extreme; or if pregnancies follow one another in
quick succession the strain becomes so nearly continuous that there
is not sufficient time for adequate repair. Whenever nature does need
encouragement calisthenics of some kind are advisable. These
systematic exercises, which the patient practices in bed and flat on
her back, are usually begun about a week after delivery, though there
may be some reason for beginning them earlier or later than this.
The physician will always select the proper calisthenics, but the
following "movements" generally prove satisfactory. To exercise the
muscles at the front of the abdomen one leg after the other is raised
and lowered; as this is being done the knee will be bent (flexed) at
first, but later the leg may be held straight (extended). Other
muscles come into play when the feet are alternately brought together
and separated as widely as possible. A third movement which exercises
the muscles at the side of the abdomen consists in raising the
shoulders from the bed and twisting the trunk so that the weight of
the chest rests now on the right, now on the left elbow. When these
movements can be performed fifteen or twenty minutes without fatigue
more vigorous exercises may be adopted. For example, the buttocks,
together with the lower part of the back, are raised off the bed,
while the shoulders, elbows, and the heels remain stationary. A day
or so before getting up the patient should practice alternately
raising herself from the recumbent to the sitting posture and
returning to the above position without assistance from the arms.
The value of bandaging the abdomen immediately after delivery as a
means of strengthening the abdominal muscles is questionable; though
physicians agree to the advantages of a supporter after patients are
out of bed. We constantly see perfect restoration of these muscles
without the early use of a binder; in fact, women who have employed
it throughout the lying-in period do not secure an efficient
abdominal wall more frequently than others who began its use two
weeks after they were delivered. Even those physicians who advocate
an early application of the binder concede that it works harm in
certain cases and do not recommend it indiscriminately.
Those who postpone for a fortnight the use of the binder will escape
the tendency it has to cause displacements. By this time the
involution will have advanced so far that the womb lies within the
pelvic cavity, where it is surrounded by the hip bones, which protect
it from external forces that otherwise would influence its position.
When permitted to get up patients ought to use a binder, because it
counteracts the feeling of "falling to pieces" of which some complain
when the abdominal walls are not comfortably supported. But there is
no evidence to show that a binder plays any part in restoring the
figure. When, in spite of ample rest, the abdominal muscles fail to
recover completely, we have no better way of strengthening them than
by use of calisthenics or massage.
_The Pelvic Floor_.--Second only in importance to having the
womb restored to its original position is the necessity of
restoration of the pelvic floor. This structure, also called the
_perineum_, we should know, lies between the thighs, shuts in
the bottom of the abdomen, and prevents prolapse of the viscera. In
women it forms the lower portion of the birth-canal, enclosing the
aperture through which the child enters the world. Although
intelligent management of labor is of the greatest value for the
protection of the pelvic floor, under certain circumstances it may be
impossible to preserve it intact; injury to it is the rule when the
first child is born, and not unusual in later births. There can be no
doubt regarding the advisability of uniting the edges of a tear;
indeed, to do so immediately is the very first essential toward
restoring the pelvic floor to its wonted integrity. But even though
tears are sewn up successfully, there is invariably some relaxation
of the perineum until the restorative process, which here again
chiefly concerns the muscles, has been given opportunity to become
effective.
As with all the restorative changes in the lying-in period, to rest
calmly in bed favors the perfect recovery of the pelvic floor more
than anything else. Keeping the thighs together during the first few
days undoubtedly assists tears in healing, but that precaution is not
always necessary, and when it is the physician will call attention to
the fact. The really important matter, as I have said, is that the
upright position should not be resumed until the pelvic floor has
become firm.
THE CARE OF THE PATIENT.--Now we have learned enough of the manifold
changes in the lying-in period to appreciate the fact that patients
require medical direction even though they are feeling perfectly
well. The view held by former generations that women can get along
without a doctor and with any sort of nursing is partly responsible
for the existence of gynecology, the branch of medicine which deals
with the diseases of women. Recently delivered women should be
treated as surgical patients, not because they are ill, but to keep
them from becoming so.
If the patient desires the highest degree of protection an
experienced nurse is indispensable, for she will make systematic
observations which would consume too much of the doctor's time for
his personal attention, yet without which he would not be
sufficiently conversant with his patient's condition to guide her
properly. The temperature, the rate of the pulse, and of the
respiration should be recorded at regular intervals during the day
and night. An elevation of temperature at the conclusion of labor
need give no uneasiness, for experience has shown that it generally
subsides within a few hours. Moreover, slight elevations in the
course of the following week are so frequent that obstetricians have
agreed to regard as a normal temperature for this period 100.4
degrees instead of the usual normal of 98.4 degrees. The pulse-rate
most frequently does not depart from what is characteristic for the
individual, though about one-fifth of puerperal women have a slowing
of the pulse, a phenomenon of favorable significance. Any difficulty
in breathing that may have existed in the latter part of pregnancy
disappears when the abdominal distention is relieved, and the
respiratory rate becomes normal. So long as the body is getting rid
of the tissue-substance essential to pregnancy, but now without any
purpose, more than the usual amount of waste material is present in
the expired air.
_The Elimination of Waste Material_.--As we might expect from
the loss in body weight, the excretory organs are particularly active
during the lying-in period. In quantity the loss of water exceeds all
the other waste-products together; and pronounced activity of the
kidneys or of the sweat glands may become a source of annoyance.
Since it is undesirable to interfere with these functions, whatever
inconvenience either may cause will be borne with less complaint if
the patient understands that a large loss of water at this time
indicates a healthful condition of the body.
Shortly after delivery there may be difficulty in emptying the
bladder; and, under such circumstances, the doctor or nurse used to
catheterize the patient immediately; this habit once begun, it was
often necessary to repeat the operation day after day, or, for that
matter, several times a day. But as physicians came to know more of
the relations of bacteria to inflammation of the bladder, they grew
more cautious, and preferred to wait a long time before resorting to
the catheter. The reward of this patience was to find that, with
remarkably few exceptions, puerperal women ultimately void of their
own accord. Accordingly catheterization after child-birth is now
postponed, and is never performed until a number of devices to get
the patient to void spontaneously have been tried without success.
Often urination follows putting a hot-water bottle over the bladder;
or pouring warm water over the vulva; or placing the patient upon a
bed-pan from which steam is rising. When these and other devices well
known to every nurse are not effective, catheterization becomes
necessary. With the elaborate precautions taken to avoid infection of
the bladder, catheterization is now performed with very slight risk.
Constipation, for various reasons, becomes a regular feature of the
lying-in period. The confinement in bed, restricted diet, relaxation
of the abdominal wall, and sensitiveness about the region of the
rectum, all have a tendency to prevent spontaneous movements of the
bowels. As one of these influences after another is removed the
bowels begin to act naturally. Childbirth may cause chronic
constipation, but this sequel would occur much less often if a little
care were taken to prevent it.
The routine use of enemas deserves to be condemned. I see no
objection to an occasional enema if purgative medicine has been taken
without effect, but constant use of them, more than likely, will
result in the enema habit. Similarly, long-continued administration
of strong purgatives tends to make them a permanent necessity. While
in bed if medicine is taken every other day the bowels will have
opportunity on the intervening days to move spontaneously, though we
do not really expect them to move naturally until six or eight weeks
after the delivery, when the patient is able to take as much exercise
as she likes. Toward the end of the second week, however, mild
laxatives generally prove effective, and it is important to select
one the dose of which may be gradually decreased. Senna prunes, which
were described in Chapter V, fill the purpose very well. Six or eight
of them may be needed at first, but the number may be gradually
reduced, until finally none are necessary.
_Cleanliness_.--In view of the excessive elimination of waste
products from the body, the maintenance of cleanliness during the
lying-in period may require the use of a large amount of linen.
Occasionally patients perspire so freely that the night clothes have
to be changed several times in twenty-four hours, and the bed linen
only a little less frequently. But at any cost it is imperative not
to hinder but rather to promote this function and to keep the skin in
a healthful condition through bathing and massage. Nurses are taught,
on this account, to give a warm soap and water bed-bath in the
morning and an alcohol rub at night. Patients are usually allowed to
take tub-baths after the third week.
Local cleanliness, which is a matter of the very first importance,
can only be attained through bathing the vulva with an antiseptic
solution and the use of sterile pads. At first the pads are changed
very frequently, but after the discharge becomes less profuse they
are renewed at intervals of four to six hours.
_The Diet_.--For the first week of the lying-in period not all
patients are given the same diet, and the physician always leaves
specific directions regarding it. Generally the diet consists of
liquids, such as milk and broths, for a couple of days; under some
circumstances liquid nourishment is continued longer. As the appetite
increases easily digestible but nutritious food is added, and before
long the patient resumes her ordinary diet.
The modern tendency is to give solid food and to give it in
substantial amounts much earlier than was once customary;
restrictions, none the less, are still observed so long as the
patient remains in bed. With the body at rest, its food requirements
are diminished and hearty meals are unnecessary. If convalescence
proceeds satisfactorily such wide latitude in the choice of food is
permissible that the nurse may regulate the diet, consulting the
physician whenever necessary.
_The Environment_.--A large, bright room that can be quickly
heated and easily ventilated adds notably to the comfort of the
lying-in period. The windows may be opened through the greater part
of the day and at night should always be left so. To make thorough
airing of the apartment more feasible and to protect the mother from
annoyance when the baby cries, it is more satisfactory to have the
baby occupy an adjoining room where the nurse sleeps within call.
Under any circumstances some arrangement must be made so that the
mother's rest at night will not be broken needlessly.
No pains should be spared to keep the patient quiet for at least ten
days. Household cares and petty worries materially delay
convalescence. During this period only a limited number of the
immediate members of her family ought to see her, and their visits
should be brief. Unfortunately, if too many relatives and friends
visit her a number of questions will be repeatedly asked which are
decidedly wearing on any patient.
_The Time for Getting Up_.--How long a woman should stay in bed
after the birth of a child is a question which has given rise to
prolonged discussion. The majority of obstetricians adhere to the
traditional ten days; but there are advocates of a longer period and
advocates of a shorter one. The generalizations of many writers upon
this subject are too sweeping, for exceptions may be found to any
rule. Each patient is best counselled when the advice given is based
upon her own condition and particularly upon the progress made in the
involution of the uterus, which does not advance with the same
rapidity in all cases.
More or less in imitation of the custom among savages, Charles White,
in 1776, recommended that women should not remain in bed longer than
a day or two after child-birth. Very likely the inadaptability of the
method to civilized women soon became apparent; at any rate his
suggestion was not widely adopted, and had been completely forgotten
until a few years ago, when the custom was revived in one of the
German clinics. The innovation met with violent opposition in Europe,
and, so far as I know, has found but scant favor in America.
Generally patients are allowed to sit up in bed toward the end of the
first week, but if there are stitches, sitting up is deferred until
ten days or later, when the stitches have been removed. Under the
most favorable circumstances, however, sitting up in bed becomes
wearisome, for the weight of the body does not fall upon the spine,
as it should; and besides the extended position of the legs is
fatiguing. No one should force herself to keep this posture, for at
best it does no more than relieve monotony. The exercises previously
suggested prepare her much more effectually for getting upon her
feet.
Between the tenth and the fifteenth day patients may leave the bed
and sit quietly in a chair. The condition of the uterus, the
character of the lochia, and the firmness of the pelvic floor will
determine the day, but usually it proves wiser to defer it until
fully two weeks have lapsed. As a rule, the patient remains out of
bed an hour the first day, two the second, three the third, and so on
until she is up all day. She should not attempt to walk until the
second or third day. At first she should take only a few steps, but
gradually she may increase the number and finally walk with freedom
and ease. Several reasons make it advisable for patients to remain
four weeks on the floor where they have been confined; going up and
down stairs is especially tiresome, and, of still greater importance,
patients pass from the doctor's control as soon as they go down
stairs. For fear of overtaxing the strength none of the household
cares should be assumed before the fourth week, and not all of them
then, for women are not capable of resuming their accustomed duties
fully until the sixth week; and some are not strong enough to do so
until a somewhat later date.
Since patients generally feel well during the lying-in period they
are apt to object to remaining in bed two weeks. Most of them
acquiesce as soon as they understand the organic changes in progress
and appreciate the lasting benefits of a temporary forbearance, but a
few must be made to realize that very serious penalties may be
attached to undue haste. For the latter it might be better if the
alarming consequences of getting up too early--discomfort,
hemorrhage, and collapse--occurred more frequently than they do. As
it happens, the ill-effects of such indiscretion are not usually felt
immediately; when too late the lesson is learned that many of the
operations upon women in the later years of life are dependent on
imprudent conduct just after the first child was born.
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.