become, as we say, matured, or, in other words, capable of
child-bearing. After the system has become thus matured, it is evidently
more natural, and consequently more healthful to bear children than not
to do so. We are to suppose, then, that if a woman follows the order of
nature, it will be better for her, in regard to the easiness of
childbirth, than if she becomes old before this function is brought into
action. Nature, however, is not so closely bound down to arbitrary rules
as we might at first conclude. Indeed, we could not reasonably suppose
that the Creator would form woman’s system in such a way that she could
not safely bear children, even if the child-bearing function were not
brought into action until some years after puberty. I knew a lady whose
marriage took place quite late in life, and whose first child was born
when she was forty-two; and although her labor was a severe one, lasting
seventy-two hours and upward, yet she recovered remarkably well, as much
so as almost any one I ever knew. Her child, too, was a fine, healthy
one, and throve well. Another lady, whom I attended about one year
since, who was thirty-eight years old at the time, it being her first
labor, felt some pains for two days and nights previously to the one on
which I was called to visit her. It could hardly be said, however, that
labor had fully set in before ten o’clock of the day on which the child
was born at four in the afternoon, making the real labor only about six
hours. Thus we see that, although the _age_ of the individual has
generally more or less influence in regard to the painfulness and length
of labor, yet a woman who is far advanced in the child-bearing part of
her life, when she bears her first child, has apparently as good a
chance for a speedy and favorable recovery as a younger one has. In this
circumstance, too, we have still another among the many proofs of the
benevolence of the Creator of all things. He, in His wisdom, foreknew
that it would not be proper for every woman to marry precisely at that
age in which it is most natural for her to become pregnant, and
consequently her system was formed with a reference to that
circumstance, although it is admitted that labor is somewhat more
difficult and protracted if it occur for the first time late in the
fruitful period.
It is an unwise procedure to tell a woman, as has been sometimes done,
that because she is somewhat advanced in years, and must consequently
expect to have a difficult labor, she should be bled frequently toward
the close of her period, have purgative medicines given her, etc., with
the view of _helping_ nature, as it is said. But it were far better,
more honest, as well as more truly philosophic, to tell her that, in
order to get along the best that may be under the circumstances, she
should do every thing in her power to improve her general health; for
always the more strong and vigorous the patient at the time of labor,
the better is her prospect in every respect. Suppose, too, it were
deemed necessary to reduce her system somewhat toward the close of
pregnancy, how much better are abstinence and fasting for that purpose
than bleeding and cathartics? It is a foolish practice to bleed or drug
the system when we have always at hand so much better means.
LETTER XXVI.
MANAGEMENT OF LABOR.
The Placenta, or After-Birth—The Membranes—Management of the
After-Birth—Rules for Extracting it—Of Flooding after Delivery.
In the preceding letter, I spoke of the first two stages of labor. The
last, which refers to the birth, or expulsion of the placenta and
membranes, I now propose considering.
First, I must say something of the nature and office of what is termed
the after-birth.
[Illustration:
THE PLACENTA AND UMBILICAL CORD.
]
The placenta, or after-birth, is of different forms in different
animals. In the human subject, “it is a flat, circular body, about six
inches in diameter, and about one inch and a half in thickness at the
center, becoming thinner toward the circumference. Usually in the
center, but sometimes at or near the edge, we find the insertion of the
funis, or umbilical cord, the vessels of which immediately ramify in a
divergent manner upon the surface of the organ.”
From Dr. Maunsel, of Dublin, I make the following quotation, in regard
to the office of this viscus:
“The uses of the placenta appear to be in some degree analogous to those
of the lungs and stomach of the breathing animal. The blood passes into
it from the hypogastric arteries, and after a very free circulation
through it, returns by the umbilical vein directly to the heart. The
circulation continues until respiration is established, when it ceases
spontaneously, and any interruption of it, before the latter process has
commenced, is immediately fatal. From these facts we are warranted in
inferring that a change necessary to life (probably oxygenation) is
produced in the placenta, although the nature of that change is obscure,
and the relative properties of the blood in the umbilical arteries and
veins not at all known. That the organ in question not only revivifies
the blood, but also elaborates new vital fluid, thus performing a
function analogous to that of the stomach, can only be inferred from the
absence of any other source from whence the fetus could obtain materials
for growth and support.”
THE MEMBRANES.
These are expanded from the edge of the placenta, in connection with
which they form a complete _involucrum_ of the fetus and waters, and at
the same time a lining for the uterus. The membranes grow and expand in
the same proportion as the fetus, and when expelled after the birth has
taken place, are, in connection with the placenta, termed the
_secundines_.
There are three of these membranes, which are found surrounding the
fetus. “There is first the outer, or connecting membrane, which is
flocculent, spongy, and extremely vascular, completely investing the
whole ovum, and lining the uterus; secondly, the middle membrane, which
is nearly pellucid, with a very few small blood-vessels scattered over
it, and which form a covering to the placenta and funis, but does not
pass between the placenta and uterus; thirdly, the inner membrane, which
is transparent, of a firmer texture than the others, and lines the whole
ovum, making, like the middle membrane, a covering for the placenta and
funis. With the two last the ovum is clothed when it passes from the
ovarium into the uterus, where the first is provided for its reception.
These membranes, in the advanced state of pregnancy, cohere slightly to
each other, though in some ova there is a considerable quantity of fluid
collected between them, which being discharged when one of the outer
membranes is broken, forms one of the circumstances which has been
distinguished by the name of _by_, or false waters.”
It seemed necessary that I should make these preliminary remarks
concerning the physiology of the placenta and the membranes, in order
that you might the better understand the third process of labor, or that
which consists in the expulsion of these growths, the secundines, as
they are called.
I have now some practical remarks to make, which I hope you will study
faithfully, for it not unfrequently happens that a child is born before
you can obtain the assistance of a physician; and after the child has
been expelled, what to do in reference to the after-birth; that is a
question which, under such circumstances, puzzles your sex more a great
deal than it need or ought to do.
Suppose, then, that a child is born suddenly, or at least before the
medical man or woman whom you would employ, comes to your aid, and the
placenta remains undelivered.
I shall tell you, in another place, not to be in such a flurry, as women
too often are, in regard to separating the umbilical cord. So, too, I
say in regard to the after-birth; _be in no hurry_.
Have you not often heard people say that the after-birth has grown fast
and _sticks_? Women sometimes say this, and so do the doctors, some of
them; such, for example, as are not honest enough to tell the truth, if
they know it, and would make you believe that they are doing a great
thing when they get away the after-birth, if it sticks.
Now please remember that it is right that the placenta should grow fast
to the womb; that is, to its inner surface. It is always grown fast, and
should be; but it is possible for it to adhere more firmly in some cases
than in others; and in some cases, too, the uterus seems to be so weak
that it has not power sufficient to expel it.
In cases when the womb is very active after the birth of the child, the
placenta may be expelled very quickly.
But it is more commonly the case that after the uterine contractions
have forced the child into the world, the womb reposes itself for a half
hour, less or more. After this, periodical pains begin to occur, so that
the after-birth may be completely thrown forth into the world; but far
oftener it is either wholly, or in part only, into the vagina, where it
remains for a time at least.
At what time, and under what rules, should manual aid be administered in
helping away the after-birth? By different practitioners different rules
have been instituted. A rule of Dr. Hunter’s was to wait till four hours
after the birth of the child. If the placenta come away of itself,
before this time have elapsed, it is well; but if, on the other hand, it
still remain in the cavity of the uterus, manual aid may become
necessary.
Another rule is, to judge by the pains, without any regard to the length
of time that has elapsed since the delivery of the child; pains, it is
said, accompany the contractions; the contractions expel the placenta;
the pains, therefore, indicate the time at which artificial assistance
should be interposed.
Another rule is, first to determine the situation of the womb before any
manual attempt is made for helping away the after-birth. If, on
examination, the placenta is found lying in the upper part of the
vagina, and through the os uteri, and more especially if the union of
the umbilical cord with the placenta can be felt, it is considered
proper to remove it. But if the umbilical cord ascend high into the
womb, and no part of the placenta can be felt, it is considered best to
wait.
Still another rule is, to act according to the feeling and condition of
the uterus, without any regard to the length of time after the birth,
the pains, or the situation of the placenta. If, on examination
externally, it is found that the womb is yet large, uncontracted, and
pulpy, the placenta should not, according to this rule, be interfered
with. But if, on the other hand, there is an opposite state of
things—that is, if the uterus is found hard and contracted, feeling like
a child’s head in the abdomen, and if it remain so for some time
permanently, it is considered safe and best at once, in a proper manner,
to remove the viscus. A skillful practitioner will bear in mind all
these circumstances, and form a rule out of all of them, as it were, to
guide him in each individual case; and I wish you to remember, that
although you may consider the principal part of delivery is accomplished
at the time when the child comes into the world, it is to be remembered
that its real danger has not yet commenced, and that the birth of the
placenta is a most important part of the process.
Into all the niceties and difficulties of this part of the accoucheur’s
art, I do not, you will remember, attempt to induct you. It is my object
to give you some general ideas of the matter, such as may be of use to
you in an emergency, and prevent a great deal of unnecessary anxiety and
alarm in some cases. My remarks will also, I trust, go to impress upon
your minds how very necessary it is, under such circumstances, to have
the aid of a physician—a man or woman, I care not which—who understands
well the art. You may say that nature is sufficient in most cases to
perform her own tasks unaided and alone. That, I admit, may all be true,
especially with those who have good constitutions, and who observe well
the laws of life. But remember that these circumstances do not always
exist. Any one of you would rather incur the expense of having a
physician a thousand times, when he is not needed, than to suffer danger
for his want in a single instance.
OF FLOODING AFTER DELIVERY.
Hemorrhage is one of the most dangerous of all circumstances connected
with labor. Fortunately, however, this does not often happen; and in
those cases when it does occur, it may generally be very soon arrested,
provided the proper means are adopted.
This form of uterine hemorrhage not unfrequently occurs when the
physician is absent. For this reason, it is necessary that I should make
some remarks on the subject.
Flooding may be either external or internal. When the blood passes from
the vagina, we call it external; when it does not thus pass off, but
remains within the cavity of the uterus, causing the abdomen to swell
and the patient to faint, we call it internal.
Here is a remarkable fact in nature. Women, in consequence of possessing
the menstrual function, and being exposed to the accidents of
childbirth, are more subject to hemorrhage than men. In striking
accordance with this fact, it appears to have been a benevolent
intention of the Creator to form the female system in such a manner that
it more readily recovers from profuse loss of blood than that of the
opposite sex. Under the effects of severe loss of blood, the system of a
man remains pale and enfeebled for months, perhaps, while that of a
woman regains its strength and color in half the time. Many a time,
before I was aware of these facts, I have been fearful, and sometimes
greatly alarmed at the amount of blood lost at the birth of a child, and
when, to my great surprise, in a day or two the patient was up, and
apparently almost as well as ever. This, then, is an important practical
fact, and one well worth remembering.
In regard to the _treatment_ of flooding after delivery, I refer you to
what I have already said under the head of uterine hemorrhage. Cold,
remember, is the great agent here, as all acknowledge.
If the woman faints from loss of blood—and she may also faint from mere
debility—you should not be alarmed at the circumstance. People generally
make a great deal too much ado when a patient faints. It should be
remembered that the object nature has in causing a person to faint from
loss of blood, is to arrest the heart’s action, for the most part, so
that the blood may, as it were, cease its movement in the uterus, and a
coagulum or plug be formed in the orifice of the bleeding vessel or
vessels. This is nature’s method of arresting an hemorrhage. This being
so, it is no doubt often the case that bringing a person _to_, is the
cause of more harm than good. There should be no hurry; give the patient
good air to breathe, and nature will, as a general thing, do her own
work better than we can do it for her in these cases.
LETTER XXVII.
ADVICE CONCERNING LABOR.
The Medical Attendant—State of Mind—The Room—State of the Bowels—The
Dress—The Bed—The Position, Exercise, Food, and Drink.
It will be inferred, from what I have already said in these letters,
that I am in favor of employing a physician, male or female, in all
cases of parturition. Most cases, I admit, will get along well without
any medical aid whatever; but, as you are well aware, there are
exceptions to all rules; and it is for these exceptions that a physician
is needed.
In the first place, then, it is always advisable in labor that you call
your medical attendant early. If it is worth your while to have aid at
all, it is best to have it in good season. The physician himself always
prefers to be called early.
Once you have fixed upon your medical attendant, resolve to be guided by
him in every particular, and follow his directions faithfully. If you
have, from necessity or otherwise, chosen a _man_-midwife, you need have
none of those foolish whims which some among the so-called reformers of
the present day would have you to believe.
It is always an unpleasant duty for one to attend a woman in childbed;
and be assured that, of all places in the world, a delivery is the last
one in which lascivious or lustful excitement is experienced. I wish
you, then, one and all, to remember that if it is unpleasant for _you_
to be attended by a man under such circumstances, it is equally so to
_him_. If he is a conscientious and benevolent physician, he will
cheerfully do that which he considers his duty to do; but as far as his
own personal self is concerned, he would much rather be at home,
enjoying its quiet and its sleep, if need be.
In regard to your preparation for labor, I will suppose that you have
done all in your power to maintain an equable and healthful state of
both mind and body, and that you are resigned to encounter whatever God
in His mercy may see fit to bring upon you. If you have done all that
you could for yourself, and are still willing and determined to do so,
surely you should feel contented; you can do no more.
_The Room._—As to the apartment in which you are to be confined, you
should take the best one in the house. If possible, you should have one
which is well lighted and aired, and which can be readily warmed, if
there is need of raising the temperature. If it is in a city, a back
room should be preferred in preference to one in front, on account of
the noise of the street.
If the labor is to be a tedious one, it is particularly necessary that
the air of the apartment be kept as pure as possible. Not only should
the strictest attention be paid to ventilation, but all odors and
perfumes should be dispensed with. These do no good, for mere _hiding_
the bad air is not _destroying_ it, and they always do more or less
harm.
There should not be too many persons in the room when the woman is to be
confined. In the country it is by far too much the fashion for a large
company of women to get together on such occasions. This always renders
the air of the apartment more foul than it otherwise would be, and for
other reasons it ought not to be permitted.
I have many a time pitied the condition of women whom I have attended,
who had but one room to live in, cook, wash, iron, and at last to be
confined in; and yet those women have in general got along better than
such as live in a more sumptuous way. Such women are, in fact,
_workers_, and employment, as I have before remarked, is a most blessed
thing in regard to preparing the system for the important function of
labor.
_The Bowels._—If the bowels should be constipated at the time when labor
is about to come on—and such is likely to be the case—the woman should
use clysters freely. This practice is, in fact, advisable in all cases,
inasmuch as it can do no harm. If there is fecal matter in the colon, it
is better that it be removed before the birth is about to take place.
Hardened excrementitious matters in the lower bowel are always a
hindrance to labor.
_The Dress._—Formerly it was considered a matter of importance as to how
a woman was dressed in labor. Different countries and provinces had
their particular forms of gowns, jackets, chemises, and head-dresses.
The great thing, however, to be observed, is simplicity; that is,
nothing should be worn which at all interferes with the body in any of
its functions or parts. If the dress is such as causes no constriction
of the abdomen, the chest, or the neck, such as gives free motion to the
limbs, and is of such material that it makes the body neither too hot
nor too cold, it is all that is required. Generally too much clothing is
worn at the time of labor. It is safer to be on the side of too great
coolness than of the opposite extreme.
_The Bed._—This has been called by different names; the _lying-in bed_,
_bed of labor_, _bed of pain_, _bed of misery_, _little bed_, etc.
Some women will not make use of any sort of couch whatever. I know a
lady in this city who has borne a pretty large family of children, who
affirms that she gets along much better upon her hands and knees on the
floor than in any other way. Some are delivered standing up, the elbows
resting on some object, as the mantle-piece, bureau, the back of a
chair, or some other piece of furniture, or perhaps upon the shoulders
of a friend. “A strong and well-formed woman,” says Velpeau, “may be
delivered in any posture, on a chair, on the floor, a bundle of straw,
on foot, and on all the kinds of beds that have been proposed; so that
it is only in the cases where nothing interferes with the accoucheur’s
doing just what he thinks best, that he ought to attach some value to
the composition of the lying-in bed; further, the only essential matter
is, that the woman should lie as comfortable as possible, that she
should not be incommoded, neither during the pains nor the intervals
between them, and that the perineum may have room to dilate.”
Oftener than otherwise in this country, the woman is delivered on the
same bed on which she sleeps. Sometimes, also, a cot is used, which also
is a very convenient contrivance, since it allows of the free passing of
the physician and others about it. It is, likewise, a healthful plan to
move from one bed to another after labor; but this is by no means
strictly necessary. Cleanliness, comfort, and good air—these are the
great requisites in regard to the bed.
_The Position._—If the patient is to lie upon a bed, which is doubtless
the preferable plan in the majority of cases, what shall be her
position?
This, like many other things, is a matter somewhat of fashion. In Great
Britain the woman is always placed upon the left side, with the thighs
flexed, that is drawn up toward the body, and the hips brought close to
the right side of the bed. The same position is usually adopted in this
country; but on the Continent, the woman is placed on her back to be
delivered. This, I am inclined to think, is the most favorable, as well
as most agreeable position, although perhaps not the most convenient for
the medical attendant.
_Exercise._—During a considerable portion of an ordinary labor, it is
doubtless better for the patient, especially if she feel inclined to it,
to sit up, and walk about a little from time to time. This not only
affords some relief, but likewise aids in causing more efficient
contraction of the uterus.
_Food and Drink._—It would always be better, so far as food is
concerned, for the patient to fast a meal or two before labor comes on.
She should, however, be allowed all the drink she desires, pure soft
water being the best she can have. If she drink pretty freely, it will
be of essential service to her in keeping off feverishness, and in
helping the renal organs to act properly. If the pains are tardy, taking
now and then a drink of cold water, even against the inclination, will
help on the pains. Even ice is used with good effect for this purpose.
LETTER XXVIII.
MANAGEMENT AFTER DELIVERY.
Importance of Attention to this Period—Evils of too much
Company—Bathing—The Bandages, Compresses, etc.—Sleep—Sitting up soon
after the Birth—Walking about—The Food and Drink.
Supposing that the mother has been safely delivered, the child
separated, and the after-birth cast off, what advice have we to give in
regard to her recovery?
I have before remarked that the birth of the secundines is the most
dangerous part of labor, although not the most painful. I have now to
remark, that the _real_ danger in midwifery does not commence until
after the whole birth is completed. Childbed fever, inflammation and
abscess of the breasts, these are the sad mishaps which we have to fear
in these circumstances, and for which I feel an anxious solicitude in
your behalf.
You may think me strange when I inform you, that I have had more trouble
in the practice of midwifery from the one circumstance of the woman
having too much mental excitement within a few days after delivery, than
from all other things combined. I am sure I am not mistaken when I
assert that I have known more accidents and mishaps to occur from this
one cause of seeing company too soon after the birth, than from all
other causes put together. So important do I consider it for you to
keep, as it were, quiet in this respect, I should think my labor in
writing these letters a hundred-fold rewarded, if I could be successful
in warning you of the danger of over-excitement at the time when you are
getting up from confinement. As the most important advice, then, which I
can give in regard to all the subjects connected with midwifery, DO NOT
ALLOW YOURSELF TO SEE COMPANY FOR MANY DAYS AFTER THE BIRTH.