Apparently, then, there is some factor operating slightly in favor of

the purposeful activities of the male-producing spermatozoa. But so far

no accurate means has ever been found whereby it was possible to

influence the development or discover the sex of a child before its

birth.

There is a wide difference of opinion concerning the time of the month

when fertilization is most likely to occur. Observations made upon the

wives of sailors and under a variety of conditions suggest that the most

favorable period is just before or just after menstruation which

represents the second stage of the menstrual cycle.

Dr. Williams believes, however, that fertilization is most likely to

occur about midway during the intermenstrual period. But since it is

probable that spermatozoa are constantly present in the tubes of women

who are exposed to the possibility of becoming pregnant, it is difficult

to do more than speculate about the time of the month at which fertility

is greatest.

Another moot question relates to the age of the woman at which it is

most desirable that the first child shall be born. Recent observations

made by Dr. John W. Harris upon a large number of pregnancies occurring

in very young girls indicates that from a standpoint which considers

solely the physical welfare of the mother and her infant, sixteen years

is the most satisfactory age at which to bear the first child.

However, when motherhood is considered from all standpoints, social,

ethical, spiritual as well as physical, the consensus of opinion seems

to be that the twenty-third year is the most favorable age for

motherhood to begin. Children have been born to little girls nine years

old and to women of sixty-two, but the extremes of the reproductive

years are not favorable periods for child-bearing.

As soon as a spermatozoon enters an ovum, it disappears and is

completely absorbed, and, as the ovum in turn is instantly possessed of

new powers, the result of this union is a cell which was previously

non-existent.

This new cell is not only capable of reproduction by means of

_segmentation_ or cell division, but in the course of its sub-division

and proliferation, it forms groups of cells which develop into tissues

and structures widely different from each other. The entire complex

human body, in addition to the placenta, cord, and membranes, arises

from the single, extraordinary cell.

It first divides into two; these two divide into four; the four into

eight and thus the process of division and sub-division continues until

a solid mass is formed, shaped something like a mulberry and called the

_morula_. (Fig. 18.)

While these developmental changes are taking place, the morula is being

carried down the tube toward the uterus, by the sweeping motion of the

ciliated membrane. The time consumed by this journey has not been

definitely ascertained and though possibly it may be made in a few

hours, it probably takes from five days to a week. Since the embryo is

constantly moving during this time, it quite evidently has no attachment

to the mother and cannot, therefore, derive any great amount of

nourishment directly from her. The growth and development to this point,

then, must be due chiefly to inherent powers within the mass of cells

itself.

In all probability, the embryo is still in the morula stage and is about

the size of the head of a pin when it reaches the uterus, where it finds

that the endometrium has been prepared for its reception by the

premenstrual swelling. The mucosa has grown thicker, more velvety and

vascular, and its glands have increased in number and activity. The

columnar epithelium of the endometrium is replaced by a thick layer of

large, vacuolated cells, called decidual cells, and the uterine lining

from now on is termed the _decidua gravidatis_. While the normal uterine

mucosa is thin, averaging from 1 to 3 millimetres (0.039 to 0.117 inch)

in thickness, it increases to a thickness of about 1 centimetre (⅞ inch)

during pregnancy.

[Illustration:

FIG. 18.—Diagram of segmenting rabbit’s ovum.

]

The point at which the embryo attaches itself to this spongy membrane is

entirely a matter of chance. It usually rests somewhere in the upper

part of the uterine cavity, promptly destroys the minute underlying area

of tissue by digestive action and burrows into the decidua. As the

margins of the opening thus made meet and fuse above the ovum, it is

completely incapsulated in a cavity of its own that has no connection

with the uterine cavity. (Fig. 19.)

After this occurrence the decidua consists of three portions: the

hypertrophied membrane which lines the uterus as a whole, called the

_decidua vera_, which atrophies during the latter part of pregnancy and

is also thrown off in part with the membranes during labor, and later in

the uterine discharges; the _decidua basalis_, or the _decidua

serotina_, is that portion lying directly beneath the embryo which later

enters into the formation of the placenta; and the _decidua reflexa_,

which surrounds and covers the buried embryo, consists of the developed

and fused margins of the pit in the mucosa, that have grown over the

embryo.

[Illustration:

FIG. 19.—Ovum about 13 days old, embedded in the decidua. (The

Bryce-Teacher ovum from Human Embryology by Keibel and Mall.)

]

As the cellular activity continues within the morula, fluid appears in

the centre with the result that the cells are rearranged and pushed

toward the periphery, thus forming a sac. At this stage the embryo is

called the _blastodermic vesicle_.

At one point on the inner surface of this vesicle the cells proliferate

and form a mass which is sometimes called the internal cell mass, or

_embryonic area_, and the single layer of cells comprising the remainder

of the vesicular wall, the _primitive chorion_. The cells in the mass

are at first disposed in layers, the outer layer being termed the

_ectoderm_; the inner layer the entoderm, while a third layer which

appears a little later is called the _mesoderm_.

Although these three primitive layers of cells have all arisen from the

single cell formed by the fused spermatozoon and ovum, they are even now

very different in character. The differences steadily increase until

finally all of the complex fetal organs and tissues, the membranes, cord

and placenta, result from their further specialization and development,

as follows:

=From the ectoderm= arises the skin with its appendages, and the

salivary and mammary glands; the nasal passages, upper part of the

pharynx and the anus; the crystalline lens, the external ear, the entire

nervous system, the sense organs and, in part, the fetal membranes.

=From the mesoderm= are derived the urinary and reproductive organs; the

muscles, bones, and connective tissues and the circulatory systems.

=From the entoderm= are developed the alimentary canal, the thymus,

thyroid, liver, lungs, pancreas, bladder and the various small glands

and tubules.

It was formerly believed that the human being existed in miniature in

the first cell and that its development during pregnancy was entirely a

matter of increase in size. But the microscope has disproved this, and

we now know that embryonic development comprises both growth and

evolution.

Much of the information accepted to-day is, of course, speculative,

having been deduced from observations made upon the reproductive

processes of lower mammals, since the youngest human ovum which has been

discovered and examined was probably two weeks old. But the evidence

points quite convincingly to the belief that the early stages of

development consist of proliferation of and alterations in the kinds of

cells, their arrangement into groups, and a differentiation of the

functional activity of these groups of cells before the mass assumes

human form and develops organs.

As to terminology, some authorities call this mass the embryo during

this stage of grouping and differentiation, which corresponds to the

first six weeks of pregnancy, and the fetus from then until the time of

delivery. By others it is designated the ovum during the first two weeks

of pregnancy, the embryo from the third to the fifth week, after which

it is known as the fetus.

From the nurse’s standpoint these distinctions are of no consequence,

for the mass may safely be called a fetus from the time that the

expectant mother looks to the nurse for guidance and care.

It is scarcely warrantable to take the time and space which would be

necessary to trace in detail through its various stages the intricate

development of the human body, with its attached membranes. But the

whole question is so important and so interesting that we shall at least

have a word of description as to its size and characteristics at

successive periods.

Although the exact length of time required for the maturation of the

fetus is not known, it is estimated that two hundred and eighty days, or

ten lunar months, elapse between the beginning of the last menstrual

period and the beginning of labor. And in spite of the difference in

size among the mothers, it is found that the products of conception

develop and grow at a fairly uniform rate of speed.

A new human being is the ultimate result of conception, but the chorion,

amnion, placenta and umbilical cord must also be created to serve as

aids in building and protecting the developing child during its uterine

life. The part played by these accessory structures is so vital, in

spite of being temporary, that it will be well for us to look into their

origin and functions before considering the fetus itself which they

serve.

=The Chorion and Placenta.= Very early in pregnancy, probably while the

fertilized ovum is journeying down the tube, tiny, thread-like

projections, called _villi_, appear over the surface of the primitive

chorion, giving it the shaggy appearance of a chestnut burr. Shortly

after this shaggy ovum reaches the uterus and is embedded in the lining,

the chorion, or the outer fetal membrane, is formed, being partly

derived from the ectodermal layer of cells growing within the

blastodermal vesicle. The chorion grows rapidly in size and thickness,

and the villi upon its surface increase in size, number and complexity

by frequent branching. In so doing the villi push their way into the

maternal tissues surrounding them, and destroy the capillary walls with

which they come in contact. Maternal blood escapes through the destroyed

walls, forming tiny hemorrhagic areas, or “lakes of blood.” The

chorionic villi float freely in these pools of maternal blood, which is

constantly being refreshed by an inflow of arterial and an outflow of

venous blood through the mother’s vessels.

Blood vessels soon appear in these chorionic villi, and fetal blood then

circulates through them. It becomes apparent, therefore, that the

maternal and fetal blood streams are in such close relation that they

are separated by only the thin membrane which forms the walls of the

vessels in the villi. (Fig. 20.)

[Illustration:

FIG. 20.—Diagram of fetus, cord, membranes and placenta in utero at an

early stage of their development.

]

This arrangement makes it possible for the steadily proliferating villi

to discharge one of their functions, which is to receive from the

maternal blood nourishment for the embryo, and give up to the parent

waste products from the growing body. This exchange of nourishment and

waste matter takes place by means of osmosis. But freely as the exchange

of materials occurs, there is never any contact, or mixing of maternal

and fetal blood, nor does maternal blood at any time flow through fetal

vessels. It was believed at one time that the fetus was nourished by

milk which was in some way secreted by the gravid uterus, but this is

disproved by present knowledge of the placental function.

The second function of the villi, particularly after they have developed

to the placental stage, is to assist in securely attaching the embryo to

the uterine wall.

The villi are equally distributed over the surface of the chorion at

first, but as the sac increases in size and pushes out into the uterine

cavity, they gradually atrophy and disappear, excepting over the small

area beneath the vesicle where the chorion is in contact with the

decidua basalis. At this site the villi become much more abundant, and

it is here that the placenta eventually develops. This part of the

chorion is termed the _chorion frondosum_, while the remainder, which is

in contact with the decidua capsularis, is the _chorion læve_.

As pregnancy advances and the fetal sac enlarges, the chorion læve

covered by the decidua capsularis, or reflexa, is pushed farther out

into the uterine cavity, until finally it quite reaches the opposite

wall, meets the decidua vera and obliterates the entire space which had

existed between the two membranes. This means that instead of a uterine

cavity lined with decidua, and a tiny capsule somewhere off to the side

lined with chorion, the latter has distended until it completely fills

and really becomes the cavity within the uterine walls, thus lining the

uterus with chorion and crowding the original lining out of existence.

The decidudae capsularis and vera fuse in time and finally the

capsularis degenerates and disappears.

=The Amnion.= Returning for a moment to the blastodermal stage of the

ovum, we find that the amnion, or inner membrane, first appears as a

tiny vesicle over the dorsal surface of the embryo. Very soon, however,

it invests the embryo completely, and the membranous sac is intact,

excepting where it is pierced by the umbilical cord. The amnion, too, is

derived in part from the ectoderm, but is a stronger, denser membrane

than the chorion. At first there is an appreciable space, and some

fluid, between the two membranes, but as the amnion increases in size

with the advance of pregnancy, it comes in contact with and is loosely

adherent to the chorion.

Very early in its development the amniotic sac contains a pale yellow

fluid known as the _amniotic fluid_, or _liquor amnii_, in which the

fetus floats. This fluid increases in amount until the end of pregnancy

and though the quantity is variable, it usually amounts to about a

quart.

The source of the liquor amnii is not definitely known, but it is

generally believed to be of maternal origin, secreted from the amniotic

membrane, though the possibility of its consisting partly of fetal urine

cannot be overlooked. It is about 99% water, containing particles of

dead skin and lanugo, a soft downy hair cast off from the body of the

fetus, traces of albumen and both organic and inorganic salts.

[Illustration:

FIG. 21.—Diagram showing general structure and relation of membranes,

placenta and cord.

]

The amniotic fluid serves a variety of purposes. Since the intestines of

the fetus contain lanugo and particles of dead skin, it is evident that

the child swallows some of this fluid during its uterine life, and

possibly obtains in this way much of the fluid necessary for its

development.

The increasing bulk of the fluid serves to distend the fetal sac and

surrounding uterus, and thus provides the fetus with room for growth and

movement. It also prevents adhesions between the child’s skin and the

amnion, which are a factor, when by mischance they do occur, in causing

monstrosities and intrauterine amputations. The fluid with which it is

surrounded keeps the fetus at an equable temperature in spite of

variations of temperature in the mother’s environment, and minimizes the

danger of injury to the fragile little body, from pressure or blows on

the mother’s abdomen. And by acting as a water wedge, forced down by

uterine contractions at the time of labor, it dilates the cervix

sufficiently to permit the expulsion of the full term child.

[Illustration:

FIG. 22.—Placental blood vessels. Note their branching, tree-like

arrangement. (Photographed from an injected specimen in the

Obstetrical Laboratory, Johns Hopkins Hospital.)

]

=The placenta.= The placenta, in lay parlance the after-birth, is really

a thickened, amplified portion of the fetal sac, which has developed at

the site of the implantation of the ovum. It is partly fetal and partly

maternal in origin, being developed jointly from the chorion frondosum

with its branching villi, and the underlying decidua basalis.

The chorionic villi already referred to grow and branch in a tree-like

fashion (Fig. 22), and push their way farther and farther into the

uterine tissues creating the intervillous spaces which fill with

maternal blood. From the time that the first fetal blood vessels appear

in these floating villi, until the child is born, there is a constant

exchange of nutriment and waste matter between the maternal and fetal

blood; the arterial maternal blood in the intervillous spaces giving to

the fetal blood in the villi the oxygen and other substances necessary

to nourish and build the growing young body, and receiving in return the

broken-down products of fetal activity. The waste is carried by the

maternal blood stream to the mother’s lungs, kidneys and skin, by which

it is excreted.

This exchange of substances is accomplished by osmosis and also by

selective powers of the cells in the villi. Thus the placenta virtually

serves the fetus as lungs, stomach, intestines and kidneys throughout

its uterine life.

In addition to the nutritive substances in the mother’s blood, such as

albumen, iron and fat which are so altered by cell action as to be

absorbable through the villi, certain protective substances as the

anti-toxines of diphtheria, tetanus, colon and typhoid bacilli are

evidently transmitted from the maternal to the fetal circulation. It is

claimed by some authorities that pathogenic organisms, for example,

anthrax, pneumonia and tubercle bacilli, may be transmitted from mother

to fetus, but the reported cases are so rare that the accepted belief is

that organisms are seldom transmitted, if the placenta is healthy and

intact. But, according to Dr. Williams, the transmission of typhoid

occurs frequently, though malarial parasites cannot pass through the

villous membranes.

Only during comparatively recent years has accurate knowledge of the

origin and function of the placenta been available. Many varied and

interesting beliefs and superstitions gained currency in the past, but

all of them were erroneous.

The description of the circulation of the blood by William Harvey in

1628 shed considerable light upon this puzzling question concerning the

exchange of fuel and ash between the parent and fetal bodies. But a

mistaken belief that the maternal blood actually entered and flowed

through the fetal vessels resulted from his valuable discovery.

[Illustration:

FIG. 23.—Maternal surface of the placenta, surrounded by the membranes

and cord. (From a photograph taken at Johns Hopkins Hospital.)

]

When we examine this interesting structure, the placenta, after it is

cast off, we find it to be a flattened, fairly round, spongy mass, eight

or nine inches in diameter, about an inch thick where the cord arises

and thinning out toward the margin. Continued from the margin are the

filmy fetal membranes, which together form a ruptured sac. The rupture

in these membranes is the opening through which the amniotic fluid

escapes, and the child passes during birth.

[Illustration:

FIG. 24.—Fetal surface of the placenta showing origin of cord. (From

photograph taken at Johns Hopkins Hospital.)

]

The placenta weighs about a pound and a quarter, or ⅙ as much as the

child, and accordingly varies in size and weight with the baby. The

maternal surface (Fig. 23) having been detached from the uterine wall,

is rough and bleeding and is irregularly divided into lobes while the

inner, or fetal, surface is smooth and glistening and covered with the

amnion. The fetal surface (Fig. 24) is traversed by a number of large

blood-vessels which converge toward the point of insertion of the

umbilical cord, from the vessels of which they really arise. These

vessels branch and divide until their termination in the innumerable

chorionic villi floating in the lakes of maternal blood.

=The Umbilical Cord.= The cord, or _funis_, is a bluish white cord about

three-quarters of an inch in diameter, twisted and tortuous throughout

its length of about twenty inches. It is the one actual link between the

mother and her unborn child, one end being attached to the abdomen of

the fetus, about midway between the ensiform and the pubis, and the

other to the inner surface of the placenta. The cord is derived from the

_abdominal pedicle_ and is merely an extension of the caudal or tail end

of the embryo. It is covered with a layer of ectoderm which is

continuous with the ectodermal covering of the fetus.

The cord consists of a gelatinous mass known as Wharton’s jelly, in the

centre of which are embedded three blood vessels; two arteries through

which the vitiated blood flows to the placenta, where it gives up its

ash; and one vein which carries oxygenated, nourishment-bearing blood

back to the fetus. The life of the fetus, therefore, is absolutely

contingent upon an uninterrupted, two-way flow of blood through the

cord.

=The Fetus.= In tracing the development of the ovum after its

implantation in the uterine lining, we begin, as previously stated, with

a shaggy-looking vesicle, containing fluid, with a clump of cells

hanging toward the centre from their point of attachment on the inner

surface of the sac. This clump develops into the embryo.

=During the first month= the mass increases in size, becomes somewhat

elongated and curved upon itself with the two extremities almost in

contact. The abdominal pedicle, which later becomes the umbilical cord,

appears; the alimentary canal exists as a straight tube and the thymus,

thyroid, lungs and liver are recognizable. The heart, eyes, nose, ears,

and brain appear in rudimentary form and the extremities begin to be

evident as tiny, bud-like projections on the surface of the embryo.

=By the end of the fourth week= the sac is about the size of a pigeon’s

egg and has two walls. The outer wall, or chorion, as we have already

seen, is covered with villi, and the amnion, or inner wall, is smooth;

the contained embryo is surrounded by amniotic fluid and measures about

10 millimetres or 4 inches in length.

[Illustration:

FIG. 25.—Embryo, about 5.5 centimetres long in amniotic sac; uterine

wall incised, chorion split and turned back. Drawn by Max Brodel.

(From The Umbilicus and Its Diseases, by Thomas R. Cullen, M.D.)

]

=By the end of the second month, or eighth week=, the head end of the

embryo has greatly increased in size and is about as large as the rest

of the body. Bone centres appear in the rudimentary clavicles; the

kidneys and supra-renal bodies are formed; the limbs are more developed,

webbed hands and feet are formed, the external genitalia are apparent

but the sex is not distinguishable. The amnion is distended with fluid,

but it is not yet in contact with the chorion; the chorionic villi have

become more luxuriant on that part of the chorion resting on the decidua

basalis, the future site of the placenta. The approximate weight of the

embryo is 4 grams and its length 25 millimetres or an inch.

=By the end of the third month, or twelfth week=, centres of

ossification have appeared in most of the bones, the fingers and toes

are separated and bear nails in the form of fine membranes; the

umbilical cord has definite form, has increased in length and begun to

twist. The neck is longer, teeth are forming and the eyes have lids. The

amnion and chorion are now in contact, and the villi have disappeared

excepting at one point where a small, but complete placenta has

developed. The embryo is about 9 centimetres long and weighs about 30

grams.

[Illustration:

FIG. 26.—Diagram showing appearance of fetus at different stages in

its development.

]

=By the end of the fourth month, or sixteenth week=, all parts show

growth and development; lanugo appears over the body; the sex organs are

clearly distinguishable and there is tarry fæcal matter, called

_meconium_, in the intestines. The placenta is larger, the cord longer,

more spiral and also thicker because of the Whartonian jelly which is

beginning to form. The fetus is about 15 centimetres long and weighs

about 120 grams.

=By the end of the fifth month, or twentieth week=, the fetus has both

grown and developed markedly. It is now covered with skin on which are

occasional patches of _vernix caseosa_, a greasy, cheesy substance

consisting largely of a secretion of the sebaceous glands. There is some

fat beneath the skin but the face looks old and wrinkled. Hair has

appeared upon the head and the eyelids are opening. It is usually during

the fifth month that the expectant mother first feels the fetal

movements which are commonly referred to as “quickening.” The body is

about 25 centimetres long and weighs about 280 grams.

=By the end of the sixth month, or twenty-eighth week=, the fetus still

looks thin and scrawny, the skin is reddish and is well covered with

vernix caseosa and the intestines contain an increased amount of

meconium. If born at this time the child will move quite vigorously and

cry feebly. Although it is not likely to live for any length of time,

every effort should be made to save its life, for it may be that the

high rate of mortality at this age is due to the inadequacy of the

attempts which are usually made to save the child rather than to the

frailty of the child itself. It is about 35 centimetres long and weighs

about 1200 grams.

=By the end of the eighth month, or thirty-second week=, the child has

grown to about 42 centimetres in length and 1900 grams in weight, but

continues to look thin and old and wrinkled. The nails do not extend

beyond the ends of the fingers but are firmer in texture; the lanugo

begins to disappear from the face but the hair on the head is more

abundant. If born at this stage, the baby will have a fair chance to

live, if given painstaking care. This is true in spite of the ancient

superstition, still widely current, that a seven months’ baby is more

viable than one born at eight months (meaning calendar months). The fact

is that after the eighth lunar month, a little more than seven calendar

months, the probability of the child’s living increases rapidly with the

length of its intra-uterine life.

=By the end of the ninth month, or thirty-sixth week=, the increased

deposit of fat under the skin has given a plumper, rounder contour to

the entire body; the aged look has passed and the chances for life have

greatly increased. The baby now weighs about 2500 grams and is about 46

centimetres long.

=The end of the tenth month, or fortieth week=, usually marks the end of

pregnancy. (Fig. 27.) The average, normally developed baby has attained

a length of 50 centimetres (20 inches), and a weight of 3250 grams, or

about 7¼ pounds, boys usually being about three ounces heavier than

girls.

It must be remembered, however, that these figures merely represent the

average drawn from a large number of cases, for there may be a variation

in weight among entirely normal healthy babies from a minimum of 2300

grams (5 pounds) to as high as 5000 grams (11 pounds), or more. Babies

actually weighing more than 12 pounds are seldom born, in spite of

legends and rumors to the contrary.

The length of a normal baby is less variable than the weight. In fact,

it is so nearly constant in its increase during the successive months of

pregnancy, that the age of a prematurely born fetus may be fairly

accurately estimated from its length. This fact is of no little

practical importance, since it aids the obstetrician in making a

prognosis as to the child’s prospect of living, for he can estimate its

intra-uterine age from its body length.

The size of the baby is affected by race, colored babies, for example,

averaging a smaller weight than white babies. And, as might be expected,

the size of the parents is likely to be reflected in the size of their

infants, large parents tending to have large children and vice versa.

The number of children which the mother has previously borne is also a

factor, since the first child is usually the smallest, the size of those

following showing an increase with the mother’s age up to her

twenty-eighth or thirtieth year, provided the successive pregnancies do

not occur at too frequent intervals.

The expectant mother’s general state of health, her state of nutrition,

the character of her surroundings and her mode of living may be expected

to influence her baby’s welfare. Hence, women who live in comfortable,

or luxurious circumstances usually have more robust babies than those

who are run down, poorly nourished or overworked. All of which hints at

the great value of prenatal care which will be taken up in detail in a

later chapter.

[Illustration:

FIG. 27.—Full term fetus in utero. Drawn by Max Brodel. (Used by

permission of A. J. Nystrom & Co., Chicago.)

]

=A multiple pregnancy= is one in which the pregnant uterus contains two

or more embryos, these being termed twins when there are two and

triplets when there are three; quadruplets, quintuplets and sextuplets

when there are four, five and six embryos, respectively, six being the

largest accredited number on record.

The tendency to multiple pregnancies is apparently inherited, and it

sometimes happens that several members of the same family connection

have this predisposition, as evidenced by the number of twins and

triplets to be found among relatives. It is estimated that twins occur

once in 90 pregnancies and triplets once in about 7000 cases.

Twin pregnancies may result from the fertilization of one or of two ova,

and are designated as single ovum or double ovum twins respectively. In

single ovum twins the egg becomes divided early in its development and

two embryos are formed. In such a case there is one placenta, one

chorion and two amnions and the babies are of the same sex.

In double ovum twins two ova are fertilized; both may come from the same

ovary or there may be one from each side. When double ovum twins occur,

there are two placentæ, as a rule, though they may be somewhat fused;

two amnions and two chorions and the babies may be of the same sex or

each of a different sex.

Twins are often prematurely born and each one is likely to be smaller

than a baby resulting from a single pregnancy, but their combined weight

is greater than that of one normal baby.

=An extra-uterine pregnancy= may be defined as a pregnancy which

develops outside of the uterus, usually in a tube or ovary. Although in

the normal course of events the fertilized ovum travels down the tube

and becomes attached to the uterine lining, it is possible for it to

stop, and more or less completely develop at any point along the way

between the Graafian follicle, from which it has been projected, and the

uterus toward which it is traveling. If the fetus develops in the ovary,

it is termed an ovarian pregnancy, and a tubal pregnancy if it occurs in

the tube, the latter being the most frequent variety of extra-uterine

pregnancy.

In the opinion of Dr. Mall, only about 1 per cent of all extrauterine

pregnancies are capable of going to term. There may be an abortion, when

the fetus and membranes are partly or completely extruded from the

fimbriated end of the tube into the peritoneal cavity; or a rupture of

the tube, when the fetus, with or without the membranes, may be expelled

into the peritoneal cavity, or between the folds of the broad ligament.

If the greater part of the placenta remains attached to the site of its

development, in the case of a ruptured tube, it is possible for the

fetus to live and grow and even go to term. But if the placenta is

nearly, or completely separated, the fetus perishes and may be largely

absorbed by the maternal organism, or mummified, or putrefactive changes

may take place. It is usually customary to terminate an extra-uterine

pregnancy as soon as it is diagnosed, for only a very small number can

be expected to go to term, the majority aborting, or rupturing the tube,

with serious hemorrhage from the mother as a frequent result.

To sum up the normal pregnancy, we find that in the course of ten lunar

months, following the fertilization of an ovum, the uterus grows from a

small, flattened, pelvic organ, three inches in length, to a large,

globular, muscular sac, constituting an abdominal tumor about fifteen

inches long; it increases its weight thirty-two times, that is from two

ounces to two pounds, while the capacity of the uterine cavity is

multiplied five hundred times. Within the cavity is a child weighing

about seven and a quarter pounds, surrounded by a quart or so of

amniotic fluid. This fluid is contained in the sac composed of the fetal

membranes, the amnion and chorion, which are excessively developed at

one point into the placenta. The placenta, in turn, is attached to the

child by means of the umbilical cord. The total weight of the uterus and

its contents at term is usually about fifteen pounds.

Quite as mysterious and inexplicable as the development of these complex

structures from one tiny cell is the fact that when the new human being

is ready to begin life as a separate entity, further changes occur

within the mother’s body which produce uterine contractions of such a

character as to entirely empty the uterus of its contents.

CHAPTER IV

GROWTH AND PHYSIOLOGY OF THE FETUS

Although the fetus at term is in many respects simply a diminutive,

immature man, or woman, its anatomy and physiology present certain

characteristics which have adapted it to a protected existence in a sac

of fluid. Some of the fetal structures and functions become increasingly

active after birth, while others subside and disappear.

We have seen that after the first month of pregnancy the placenta serves

the fetus as a combined respiratory and digestive apparatus, not alone

in supplying the oxygen and nourishment requisite for life and growth,

but also in excreting the broken-down products of fetal life. It

apparently acts somewhat as a liver, too, in performing something akin

to a glycogenic function.

Obviously, then, the fetus must possess a circulatory mechanism which is

peculiar to itself alone, and not found in the independently existing

human body, in which the lungs and alimentary tract are functioning as

intended. This mechanism is provided by means of certain structures

which exist in the fetal circulatory system and which automatically

disappear shortly after birth. The nurse must be aware of these

anatomical changes that take place, in addition to growth, if she is to

have an intelligent grasp of her tiny patient’s possible needs.

The structures which change or disappear after birth are the _foramen

ovale_, a direct opening between the right and left auricles, and four

blood vessels: the _ductus arteriosus_, _ductus venosus_ and the two

_hypogastric arteries_. An understanding of the functions of these

vessels involves an understanding of the course followed by the fetal

blood currents, as indicated in Fig. 28, page 85.

We see that there are three vessels within the umbilical cord: the

umbilical vein and two arteries. In spite of its name, the vein conveys

arterial blood from the placenta to the fetus. After piercing the baby’s

abdominal wall, it divides into two vessels; the larger one, called the

ductus venosus, empties into the inferior or ascending vena cava, while

the smaller branch joins the portal vein, which enters the liver. The

relatively large amount of arterial blood sent directly to the liver may

in part account for the large size of this organ in the fetus. Upon its

emergence from the liver, this blood stream flows into the inferior vena

cava.

[Illustration:

FIG. 28.—Diagram showing course of fetal circulation through

hypogastric arteries, ductus venosus, ductus arteriosus and the

foramen ovale. (From The American Text Book on Obstetrics.)

]

The ascending vena cava, then, pours into the right auricle a mixture of

arterial blood, which has come directly from the placenta, and venous

blood returned from the liver, intestines and lower extremities. There

is a difference of opinion concerning the course of the blood stream

after reaching the right auricle. The general teaching, however, is that

the eustachian valve, guarding the foramen ovale, deflects the current

through this opening from the right into the left auricle. It then pours

into the left ventricle, is pumped into the arch of the aorta, from

which most of the blood is sent to the head and upper extremities,

though a small part carries nourishment to other parts of the body.

The descending, or superior, vena cava, carrying blood returning from

the head and arms also empties into the right auricle; this stream

presumably crosses the stream which is directed toward the foramen

ovale, flows into the right ventricle by which it is pumped into the

pulmonary artery. The circulation of blood through the lungs, however,

is for their own nourishment, and not for aëration as with the adult.

For this reason most of the contents of the fetal pulmonary artery

empties into the aorta through the ductus venosus, one of the temporary

fetal structures already referred to. From the aorta the stream is

directed in part to the lower extremities and the pelvic and abdominal

viscera, but most of it flows into the hypogastric arteries. These are

also temporary arteries. They lead to the umbilical cord and, as the

umbilical arteries, carry the venous or vitiated blood through the cord

to the placenta where it is oxygenated, freed of its waste in the

chorionic villi and returned to the fetus through the umbilical vein.

As soon as the child is born and it is obliged to obtain its oxygen from

the surrounding air, its pulmonary circulation of necessity becomes

immediately more important and is greatly increased in volume. In fact,

the entire fetal circulation is readjusted to meet the needs of the new

and independent functions which the little body now assumes. The

temporary structures are obliterated, since they are no longer needed,

and the lungs and intestines become more active in compensation.

[Illustration:

FIG. 29.—Diagram showing circulation of the blood after birth, with

hypogastric arteries, ductus venosus, ductus arteriosus and foramen

ovale in process of obliteration and pulmonary circulation greatly

increased. (From The American Textbook on Obstetrics.)

]

As the ductus venosus and hypogastric arteries terminate in blind ends

and become useless as soon as the umbilical cord is cut, they soon begin

to atrophy and are obliterated within a few days after birth. This means

that less blood is poured into the right auricle, which naturally

results in relatively less tension in the right heart and an increased

pressure in the left, which tends to close the foramen ovale. The

foramen ovale does not entirely disappear at once, however, but closes

gradually, sometimes remaining open for months. Occasionally it remains

open permanently, and though some people have gone through life

comfortably with a patent foramen ovale, its ultimate failure to close

usually results in serious circulatory trouble. This is also true of the

ductus arteriosus, which sometimes, but not often, fails to close.

The rule is that as the lungs expand and an increased amount of blood is

carried to them for aëration, the ductus arteriosus deflects a steadily

diminishing stream from the right ventricle to the arch of the aorta.

Thus it gradually ceases functioning in most cases and disappears in the

course of a few weeks. The abandoned vessels may degenerate and

disappear in time or they may persist in the form of small fibrous

cords. (Fig. 29.)

Although the circulatory system shows the most elaborate adjustments to

the protection afforded by intra-uterine life, there are also other

adaptations made by the fetal organism.

The baby acquires about 90 per cent of its weight during the latter half

of pregnancy, as well as a steadily increasing proportion of solids and

a decrease of fluids in its tissues, for in its early days the embryo

consists largely of water. But for all of that, its existence and growth

in utero, and the functioning of its heat producing centre require

surprisingly little oxygen and nourishment. The amniotic fluid keeps the

fetus at an equable temperature, about 1° above that of the mother, and

as space within the uterine cavity permits of only limited movement,

there is very little combustion for the liberation of heat and energy.

=The kidneys= assume functional form at a very early fetal age, probably

about the seventh week, and the presence of albumen and urea in the

amniotic fluid suggest that small amounts of urine may be voided,

particularly during the latter part of pregnancy.

=The bowels=, on the other hand, are normally inactive, this is in spite

of the fact that the baby evidently obtains fluid, and possibly some

nutriment by swallowing amniotic fluid. But a discharge of meconium may

be caused by pressure on the cord or by any condition which interferes

with the umbilical circulation. For this reason, meconium stained fluid

escaping during labor in a head presentation may be taken as an evidence

of imminent asphyxiation, due to an interruption of the umbilical

circulation.

=The head= is the most important part of the fetus, from an obstetrical

standpoint, since the process of labor is virtually a series of

adaptations of the size, shape and position of the fetal skull to the

size and shape of the maternal pelvis. And since the pelvis is rigid and

inflexible the adjustment must all be made by the fetal head, which is

mouldable because of being incompletely ossified at birth. If the head

passes through the inlet safely, the rest of the delivery will usually

be accomplished with comparative safety. But a marked disproportion

between the diameters of the head and pelvis, or limited mouldability of

the head, constitutes a serious complication, which will be discussed

later in connection with obstetrical operations.

A baby’s head is larger, in proportion to its body, than an adult’s,

while the face forms a relatively smaller part of the baby’s than of the

adult’s head. The major portion is the dome or vault-like structure

forming the top, sides and back of the head, which in turn is made up of

separate and as yet ununited bones. They are the two _frontal_, two

_parietal_, two _temporal_ and the _occipital_ bone, with which the

wings of the _sphenoid_ bones, though less important, may be included.

These bones are not joined in the fetal skull, but are separate

structures, with soft, membranous spaces between their margins, called

_sutures_; while the irregular spaces formed by the intersection of two

or more sutures are called _fontanelles_, possibly so called by the

early observers because the pulsation of the soft tissues beneath these

spaces suggests the spurting of a fountain.

The sutures are named and situated as follows: The _frontal_ lies

between the two frontal bones; the _sagittal_ extends antero-posteriorly

between the parietal bones; the _coronal_ between the frontal bones and

the anterior margins of the parietal, while the _lambdoidal_ suture

separates the posterior margin of the parietal from the upper margin of

the occipital bone. There are also the temporal sutures between the

upper margins of the temporal bones and the lower margins of the two

parietals, but they are of no obstetrical importance, as they cannot be

felt on vaginal examination. (Fig. 30.)

There are two fontanelles of obstetrical significance. The greater, or

_anterior fontanelle_, also called the _bregma_ or _sinciput_, is

located at the meeting of the coronal, sagittal and frontal sutures. It

is diamond or lozenge shaped, about an inch in diameter and is not

obliterated during labor.

[Illustration:

FIG. 30.—Side and top views of fetal skull giving average length of

important diameters.

]

The smaller or _posterior fontanelle_ is the triangular space at the

inter-section of the sagittal and lambdoidal sutures, and may be

obliterated as the surrounding bony margins approach each other during

labor.

The coronal, frontal, lambdoid and sagittal sutures and the anterior and

posterior fontanelles are of greatest diagnostic value as they can be

felt through the vagina during labor. It is by recognizing and locating

these sutures and fontanelles at this time that the accoucheur is

enabled to determine the exact position and presentation of the fetus.

The fact that the skull is made up of separate bones, with soft

membranous spaces interposed between them, permits of its being

compressed or moulded to a considerable extent as it passes through the

birth canal. Opposing margins may meet, or even overlap, to such a

degree that the diameter of the head will be appreciably diminished and

permit of its passage through a relatively narrow canal. This

mouldability varies greatly, however, and the difference in the degree

of compressibility of heads of approximately the same size may spell the

difference between an easy and a difficult, or even an impossible labor.

A new-born baby’s head may be so distorted and elongated by the moulding

process that it is unsightly and gives the young mother great concern.

But the nurse can be quite confident in her assurances that the little

head will assume its normal, rounded outline in a very few days.

The five most important diameters of the new-born baby’s head are:

=1. The occipito-frontal= (abbreviation, O.F.), measured from the

root of the nose to the occipital protuberance, is 11.75

centimetres.

=2. The biparietal= (B.I.P.) is the longest transverse diameter,

being the distance between the parietal protuberances, and measures

9.25 centimetres.

=3. The bi-temporal= (B.T.) is the greatest distance between the

temporal bones and measures 8 centimetres.

=4. The occipito-mental= (O.M.) is the greatest distance from the

lower margin of the chin to a point on the posterior extremity of

the sagittal suture, and measures 13.5 centimetres.

=5. The sub-occipito bregmatic= (S.O.B.) is measured from the under

surface of the occiput, where it joins the neck, to the centre of

the anterior fontanelle, a distance of 9.5 centimetres.

The greatest circumference of the fetal head is at the plane of the

occipito-mental and biparietal diameters and measures 38 centimetres.

The smallest circumference is at the plane of the sub-occipito-bregmatic

and biparietal diameters, and measures 28 centimetres.

These figures, however, like all of those which it is possible to give,

simply represent averages taken from a large number of cases. Individual

variations will be found among normal babies, for boys’ heads, for

example, are usually larger than girls’ while the head of the first

child is likely to be smaller than the heads of those born subsequently.

CHAPTER V

SIGNS, SYMPTOMS, AND PHYSIOLOGY OF PREGNANCY

=Signs and Symptoms of Pregnancy.= Unfortunately for all parties

concerned, the exact duration of pregnancy has never been ascertained,

since there is no way of knowing when the ovum is fertilized, the moment

which marks the beginning of pregnancy.

It is obviously impossible, therefore, to foretell exactly the date of

confinement. But labor usually begins about ten lunar months, forty

weeks or from 273 to 280 days after the onset of the last menstrual

period.

Thus the approximate date of confinement may be estimated by counting

forward 280 days or backward 85 days from the first day of the last

period. Or what is perhaps simpler, and amounts to the same thing, one

may add seven days to the onset of the last period and count back three

months. For example, if the last period began on June third, the

addition of seven days gives June tenth, while counting back three

months indicates March tenth as the approximate date upon which the

confinement may be expected.

This is probably as satisfactory as any known method of computation, but

at best it is only approximate, being accurate in about one case in

twenty. But it comes within a week of being correct in half the cases,

and within two weeks of the date in eighty per cent of all pregnancies.

Another method sometimes employed by obstetricians is to estimate the

month to which pregnancy has advanced by measuring the height of the

fundus, and thus forecasting the probable date of confinement. It is

generally agreed that the ascent of the fundus is fairly uniform and

that at the fourth month it is half way between the symphysis and

umbilicus; at the sixth month, on a level with the umbilicus; at the

seventh month, three fingers’ breadth above; at the eighth month, six

fingers above the umbilicus and at the ninth month just below the

xiphoid. At the tenth month, or term, the fundus sinks downward to about

the position it occupied at the eighth month. (Figs. 31, 32 and 33.)

This method, however, is measuring by months, not days, and leaves a

wide margin for conjecture as to the exact date.

[Illustration:

FIG. 31.—Height of fundus at each of the ten lunar months of

pregnancy.

]

Still another method is to count forward 20 or 22 weeks from the day

upon which the expectant mother first feels the fetus move. As we shall

see presently, this experience, termed “quickening,” usually occurs

about the 18th or 20th week, but is so irregular that it is unreliable

as a basis for computation.

The possibility of estimating the date of confinement is still further

complicated by the fact that there is evidently considerable variation

in the length of entirely normal pregnancies. Many healthy children are

born before ten lunar months have elapsed, while more deliveries occur

after than on the expected date. The first pregnancy is usually shorter

than subsequent ones, and women who are well nourished and well cared

for have longer pregnancies, as a rule, than those less favored.

[Illustration:

FIG. 32.—Contour of abdomen at ninth month of pregnancy, or before the

waistline drops.

]

[Illustration:

FIG. 33.—Contour of abdomen at tenth month of pregnancy, or after the

waistline has dropped.

]

Although the symptoms of pregnancy have been observed throughout the

ages by women who have borne children, and accoucheurs of one sort and

another who have attended them, a positive diagnosis at an early stage

of this condition is sometimes still baffling to the most experienced

obstetricians.

So many symptoms of pregnancy are known to women the world over, that an

expectant mother frequently recognizes her pregnant state at a very

early date. This is particularly true of women who have previously borne

children. But as these same symptoms closely resemble those of other

conditions, they are not infrequently ascribed to impaired health, with

the result that the pregnancy is not discovered until it is well

advanced, and then sometimes only by accident. And one even hears of an

occasional case in which a woman is entirely unaware of her condition

until she goes into labor.

The converse is also true, for women sometimes erroneously believe

themselves pregnant because of the appearance of well recognized

symptoms, which are due to other causes. This condition is known as

_pseudocyesis_, or spurious pregnancy, and is usually found in women

approaching the menopause or in young women who intensely desire

offspring. It is a pathetic occurrence, and the patient is usually so

tenacious of her belief in her approaching motherhood that the

obstetrician dispels it only with great difficulty.

For all of these and other reasons it is customary to divide the signs

and symptoms of pregnancy into three groups, under self-explanatory

headings, namely: _presumptive_ symptoms, and _probable_ and _positive_

signs. Although it is never within the province of a nurse to make a

diagnosis, it is important that she be familiar with symptoms. In

obstetrics this seems to be particularly true, and especially so if the

nurse be engaged in prenatal work or in any branch of public health

nursing that brings her in touch with possible or expectant motherhood.

The wider her grasp of obstetrical knowledge, the more helpful and

reassuring can be her relation to her patient. To this end, therefore,

we will take up the most reliable symptoms and signs of pregnancy.

=The presumptive signs=, which consist largely of subjective symptoms

observed by the patient herself, are as follows:

=1. Cessation of menstruation.= This is usually the first symptom

noticed. A period may be omitted from any one of several causes, as

has been explained in Chap. II but in a healthy woman of the

childbearing age, whose menses have previously been regular, the

missing of two successive periods after intercourse is a strong

indication of pregnancy.

=2. Changes in the breasts.= These also occur early. The breasts

ordinarily increase in size and firmness, and many women complain of

throbbing, tingling or pricking sensations and a feeling of tension

and fullness. The breasts may be so tender that even slight pressure

is painful. The nipples are larger and more prominent, while both

they and the surrounding areolæ grow darker. The veins under the

skin are more apparent and the glands of Montgomery larger. If in

addition to these symptoms it is possible to express a pale

yellowish fluid from the nipples of a woman who has not had

children, pregnancy may be strongly suspected. But practically all

of these symptoms may be due to causes other than pregnancy, and, in

the case of a woman who has borne children, milk may be present in

the breasts for months, or even years, after the birth of a child.

=3. “Morning sickness,”= as the name suggests, is nausea, sometimes

accompanied by vomiting, from which many pregnant women suffer

immediately upon arising in the morning. It varies in severity from

a mild attack when the patient first lifts her head to repeated and

severe recurrences during the day, and even into the night. More

frequently, however, the discomfort passes off in a few hours. When

the vomiting persists, it is termed “pernicious vomiting” and is

usually accepted as a possible symptom of a reflex, toxic or

neurotic condition, all of which will be discussed with the

complications of pregnancy. Morning sickness may begin immediately

after conception, but sets in as a rule about the sixth week and

continues until the third or fourth month. It occurs in about half

of all pregnancies and is particularly common among women pregnant

for the first time. But on the other hand, it must be borne in mind

that many non-pregnant women suffer from nausea in the morning; many

women go throughout the entire period of gestation without any such

disturbance, while others are entirely comfortable in the morning

and nauseated only during the latter part of the day.

=4. Frequent micturition.= There is usually a desire to void urine

frequently during the first three or four months of pregnancy, after

which the tendency disappears, but recurs during the later months.

The inclination may be due in part to nervousness, but is largely

caused by pressure exerted by the enlarging uterus upon the bladder,

and not to any functional disturbance of the kidneys, as is

sometimes believed. Pressure on the outside of the bladder gives

much the same sensation as is experienced when the bladder is

distended with urine. After the uterus rises from the pelvic cavity

into the abdomen, it no longer crowds the bladder, until it drops

during the last month or six weeks, when it again presses upon this

organ and cause a desire to void.

=5. Increased discoloration= of the pigmented areas of the skin, and

also of the mucous membranes, is another early symptom of pregnancy.

In addition to the deepened tint of the nipples and surrounding

areolæ, the so-called _linea nigra_ appears upon the abdomen,

extending from the pubis toward the umbilicus. There are also the

dark bluish or purplish appearance of the vulval and vaginal

linings; the yellowish, irregularly shaped blotches which sometimes

appear on the face and neck, known as _chloasma_: dark circles under

the eyes and the _striæ_ on the abdomen.

=6. “Quickening”= is the widely used term which designates the

mother’s first perception of the fetal movements. It occurs about

the eighteenth or twentieth week, and is regarded by some

obstetricians as a positive and by others as merely a strongly

presumptive sign of pregnancy. The sensation is likened to a very

slight quivering or tapping, or to the fluttering of a bird’s wings

imprisoned in the hand. Beginning very gently, these movements

increase in severity as time goes on until they become very

troublesome toward the latter part of pregnancy, amounting then to

sharp kicks and blows. Women who have had children can usually be

relied upon to distinguish between quickening and the somewhat

similar sensation caused by the movement of gas in the intestines,

but a woman pregnant for the first time may be deceived.

There are many other possible symptoms of pregnancy, but their value is

very uncertain. Even the ones described above are not entirely

dependable, but if two or more of them occur coincidently, they probably

indicate pregnancy. Dr. Slemons sums it up by saying, “If, for example,

menstruation has previously been regular and then a period is missed,

the patient has good reason to suspect she is pregnant; if the next

period is also missed and meanwhile the breasts have enlarged, the

nipples darkened, and the secretion of colostrum has begun, it is nearly

certain that she is pregnant; whether morning sickness and the desire to

pass urine frequently are present is of no importance.”[2]

=The probable signs of pregnancy= are chiefly discoverable by the

physician after careful examination. They also are numerous and

uncertain, but there are four which are considered fairly trustworthy.

=1. Enlargement of the abdomen=, which is first in order of

importance, is apparent about the third month. At this stage the

growing uterus may be felt through the abdominal wall as a tumor

which steadily increases in size as pregnancy advances. Rapid

enlargement of the abdomen in a woman of child-bearing age,

therefore, may be taken as fair, but not positive, evidence of

pregnancy. But too much reliance cannot be placed in this sign, as

the abdomen may be enlarged by a tumor, fluid or a rapid increase in

fat.

=2. Changes in the size, shape and consistency of the uterus= which

take place during the first three months of pregnancy are very

important indications. These are discoverable upon vaginal

examination, which shows the uterus to be more ante-flexed than

normal, considerably enlarged, somewhat globular in shape and of a

soft, doughy consistency. About the sixth week the so-called

_Hegar’s sign_ is perceptible through bimanual examination, the

fingers of one hand being pressed deeply into the abdomen, just

above the symphysis and two fingers of the other hand passed through

the vagina until they rest in the posterior fornix, behind the

cervix. The lower segment of the uterus, which may be felt between

the finger tips of the two hands, is extremely soft and

compressible. This sign, named for the man who first described it,

is one of the most valuable signs in early pregnancy.

=3. Softening of the cervix= occurs, as a rule, about the beginning

of the second month. In some cases, such as certain inflammatory

conditions and in carcinoma, this sign may not appear.

=4. Painless uterine contractions=, called _Braxton Hicks_ from

their first observer, begin during the early weeks of pregnancy and

recur at intervals of five or ten minutes throughout the entire

period of gestation. The patient is not conscious of these

contractions, but they may be observed during the early months by

bimanual examination, and subsequently by placing the hand on the

abdomen. One feels the uterus growing alternately hard and soft as

it contracts and relaxes.

But all of the probable signs of pregnancy, like the presumptive

symptoms, may be simulated in non-pregnant conditions; hence the

appearance of any one of them alone may not be deeply significant. But

two or more occurring coincidently constitute strong evidence of

pregnancy.

=The positive signs of pregnancy=, of which there are three, are not

apparent until the 18th or 20th week, and all emanate from the fetus.

=1. Hearing and counting the fetal heart beat= is unmistakable

evidence of pregnancy. The sound of the fetal heart beat is usually

likened to the ticking of a watch under a pillow. The rate is from

120 to 140 per minute, being about twice as fast as the maternal

pulse. So long as its rhythm is regular, however, the rate may drop

to 100 or increase to 160 beats per minute without being considered

abnormal, or indicative of trouble with the fetus.

=2. Ability to palpate the outline of the fetus= is also a positive

sign of pregnancy, if the head, breech, back and extremities are

unmistakably made out through the abdominal wall.

=3. Perception of active and passive movements of the fetus= is

accepted as a third incontrovertible sign of pregnancy. There is

some difference of opinion concerning the value of “quickening”

alone as a positive sign of pregnancy. But if the fetal movements

are also perceptible by the obstetrician through the mother’s

abdominal wall or by vaginal examination, there can be no doubt

about the diagnosis. The movements felt by placing the hand upon the

abdomen are termed _active movements_, while the _passive movements_

result from internal or external _ballottement_. Ballottement is

accomplished by giving a sharp or sudden push to the head or an

extremity, and feeling it rebound in a few seconds to its original

position. Passive movements may be felt early in the fourth month,

and active movements after the 18th or 20th week.

PHYSIOLOGY OF PREGNANCY

A general understanding of the physiology of pregnancy is indispensable

to an appreciation of the importance of observing the present-day

teachings about the hygiene of pregnancy. Upon this, in turn, must rest

intelligently administered prenatal care, one of the most important

branches of obstetrics.

The physiology of pregnancy really represents an adjustment of the

various functions of the maternal organism, which are altered to meet

the demands made upon the mother’s organs by the body which is

developing, growing and functioning within hers. These adjustments are

in the nature of an emergency service, since they come into existence

and operate only while needed, which is during pregnancy, and promptly

disappear when the need for them ceases with the birth of the child. The

mother’s body then begins to return to its normal, non-pregnant state,

which, with the exception of the breasts, which function for nine or ten

months, is accomplished in a few weeks.

But in addition to the normal changes in physiology in the course of

pregnancy, there are frequently abnormal changes, too, which may be

symptoms of grave complications. The detection of these symptoms, and

the employment of treatment which they indicate, constitute one of the

most valuable aspects of prenatal care.

Although, as might be expected, the alterations in the structure and

functions of the maternal organism are most marked in the generative

organs, there are definite changes in other and remote parts of the body

as well. And there are adjustments in metabolism, which, though not

wholly understood, are now widely recognized as important. It is pretty

generally believed that as a direct, result of pregnancy, certain

substances are created, possibly by the corpus luteum, which circulate

in the blood and definitely influence the maternal functions. It is

possible that a development of the present imperfect knowledge of these

substances will result ultimately in the discovery of a blood reaction

which will serve to diagnose pregnancy in an early stage.

At present, we know that, in spite of the creation of an infant body

weighing upwards of seven pounds, a placenta weighing more than a pound,

together with an increase of about two pounds in the weight of the

uterine muscle, all in the short span of nine months, the expectant

mother has to eat very little more during this period than she

ordinarily does to maintain her own bodily functions. This suggests a

highly developed economy in the use of nutritive material by maternal

cells.

We also know that the mother excretes waste materials for the fetus and

must assume that this requires an increased, or adjusted, functional

activity of her excretory organs, the skin, lungs and kidneys. Moreover,

the secretory activity of the previously inactive mammary glands, in

spite of their remoteness from the pelvis, suggests a nervous or

chemical stimulation, or both, which occurs only during pregnancy.

The changes in the =uterus= itself, however, are unquestionably the most

marked that take place during the period of gestation. Those that relate

to the lining have been described in a previous chapter. The change and

growth in the muscle wall are amazing. New muscle fibres come into

existence; those already there increase greatly in size and there is a

marked development of connective tissue.

The actual substance of the uterus is so increased that it is converted

from an organ weighing two ounces into one weighing two pounds. From a

firm, hard, thick walled, somewhat flattened body in its non-pregnant

state, the gravid uterus assumes a globular outline and grows so soft

that the fetus may be felt through the walls.

During the first few months the =uterine walls= increase in thickness,

but later they grow progressively thinner, until by the end of pregnancy

they are only about 5 millimetres thick.

This early growth of the uterus is doubtless brought about by general

systemic changes rather than by the presence of the contained embryo.

Evidence of this is found in the case of tubal pregnancies when there is

a definite enlargement of the uterus during the early weeks. After the

third month, however, the growth of the uterus is apparently due to

pressure which the growing fetus makes on the uterine walls.

=The cervix= does not enlarge as a result of pregnancy, but it loses its

hard cartilaginous consistency, becoming quite soft, and the secretion

of the cervical glands is much more profuse.

The changes in the =vagina= are chiefly due to increased vascularity.

The blood vessels are actually larger, the products of the glands are

greatly increased and the normal pinkish tint of the mucous lining

deepens to red or even purple.

The most important changes in the =tubes and ovaries= is in their

position because of their being carried up from the pelvis by the

enlarging uterus into the abdominal cavity. Although they increase in

vascularity, ovulation is ordinarily suspended during pregnancy.

=The abdomen= as a whole changes in contour as it steadily enlarges, and

the skin and underlying muscles are somewhat affected as a result. The

tension upon the skin is so great that it may rupture the underlying

elastic layers which later atrophy and thus produce the familiar _striæ_

of pregnancy, known variously as the _striæ gravidarium_ and the _linea

albicantes_. Fresh striæ are pale pink or bluish in color, but after

delivery they take on the silvery, glistening appearance of scar tissue,

which they really are.

In a woman who has borne children, therefore, we find both new and old

striæ; those resulting from former pregnancies being silvery and

shining, while the fresh tears are pink or blue. Striæ may be found also

on the breasts, hips and upper part of the thighs, and as they are of

purely mechanical origin, are not necessarily associated with pregnancy

alone. They may result from a stretching of the skin by ascites, a

marked increase in fat or an abdominal tumor.

The same distension that causes striæ sometimes causes a separation of

the _recti muscles_. This separation, known as _diastasis_, is sometimes

slight but frequently very marked, the space between the muscles being

easily felt through the thinned abdominal wall.

The =umbilicus= is deeply indented during about the first three months

of pregnancy. But during the fourth, fifth and sixth months the pit

grows steadily shallower, and by the seventh month it is level with the

surface. After this it may protrude, in which state it is described as a

“pouting umbilicus.”

The increased pigmentation at the umbilicus and in the median line is

scarcely to be classified among the abdominal changes, as the skin

elsewhere presents the same discolored appearance. The degree of

pigmentation varies with the complexion of the individual, as blondes

may be but slightly tinted while the discolored areas on a brunette may

be dark brown, sometimes almost black.

The changes in the =breasts= during pregnancy were practically all

included in the enumerated signs and symptoms of pregnancy. They

increase in size and firmness and become nodular; the nipple is more

prominent and together with the surrounding areolæ, grows much darker;

the glands of Montgomery are enlarged; the superficial veins grow more

prominent, and after the third month a thin, yellowish fluid can be

expressed from the nipples. This fluid, called _colostrum_, consists

largely of fat, epithelial cells and colostrum corpuscles and differs

from milk, in its yellowish color, and in the fact that it coagulates

like the white of an egg when boiled. The previously quiescent mammary

glands develop very early in pregnancy an ability to select from the

blood stream the necessary materials to produce a secretion. Colostrum

is the product of their activity until about the third day after

delivery, when milk appears.

Changes in the =cardio-vascular system= are among those which are not

altogether understood, and it is still a moot question as to whether or

not there is an actual increase in the amount of maternal blood during

pregnancy. But results of the most recent investigations suggest that

there is a definite increase in both the cells and the plasma. This

increased amount circulating through the heart subjects it to a certain

amount of strain, with the result that the organ is slightly

hypertrophied and the pulse pressure is higher.

The =respiratory organs= do not show any marked alterations. The upward

pressure of the enlarging uterus gradually shortens the height of the

thoracic cavity, but if it grows sufficiently wide in compensation,

there is no decrease in the capacity of the lungs. If this does not

occur, the patient may suffer from shortness of breath. The larynx is

sometimes reddened and edematous, a fact which explains the damaging

effects which child-bearing may have upon the voice of singers.

Changes in the =digestive tract= during pregnancy are the morning

sickness already described, and constipation. The latter is suffered by

at least one half of all pregnant women, and is due chiefly to pressure

of the uterus on the intestines, though impaired tone of the stretched

abdominal muscles may be a factor. This condition is most troublesome

during the latter part of pregnancy. There also may be gastric

indigestion causing acidity, flatulence and heartburn, and intestinal

indigestion giving rise to diarrhea and cramp-like pains. The appetite

may be very capricious during the early weeks, and become almost

ravenous later on.

Changes in the =urinary apparatus= include frequency of micturition

mentioned among the symptoms of pregnancy.

The changes in the =bony structures= of the pregnant woman are

characterized by partial decalcification. This is accounted for by the

fact that the developing fetus requires a definite amount of calcium in

the formation of its osseous structures, and unless the expectant mother

absorbs an adequate quantity from her food, it must be extracted from

the bones and similar structures, such as the teeth. Her bones and teeth

accordingly grow softer, and we have the well-known adage, “for every

child a tooth,” as well as the fact that fractures during pregnancy

unite very slowly. There are also the softened cartilages which were

referred to in connection with the anatomy of the pelvis. A part of the

softening of the pelvic cartilages, however, is due to a temporarily

increased blood supply. As will be explained in the chapter on

nutrition, this partial decalcification of the mother is entirely

unnecessary, and the newer knowledge of nutrition points the way to its

prevention.

The =skin changes= consist chiefly in the appearance of striæ and the

increased pigmentation to which reference has already been made. There

is also an increased activity of the sebaceous and sweat glands and the

hair follicles, the latter sometimes resulting in the hair becoming much

more abundant during the period of gestation. Although the pigmented

areas on the breasts and abdomen never quite return to their original

hue, the _chloasmata_, sometimes called the “masque des femmes

enceintes,” practically always disappear and leave no trace, a fact that

is frequently a comfort to an expectant mother.

The =carriage= is somewhat affected during pregnancy because the

increased size and weight of the abdominal tumor shifts the centre of

gravity. In an effort to preserve an upright position the woman throws

back her head and shoulders and finally assumes a gait that may be

described as a waddle, particularly noticeable in short women.

=Temperature changes= are probably not caused by pregnancy _per se_,

though some authorities believe that there is normally a slight

elevation during the latter part of the day.

=Mental and emotional changes= are usually included among the

alterations which occur during pregnancy, but the present status of

psychiatry suggests that this may not be altogether true. It is a fact

that many pregnant women show marked mental and emotional unbalance, but

as yet there seems to be no evidence that these states are inherently

due to pregnancy, though the same condition may recur in the same woman

each time that she is pregnant.

We shall consider this important subject more at length in the chapter

on mental hygiene, so it may be enough simply to say at this juncture

that, in a sensitively strung or uncertainly poised woman, the state of

being pregnant may be merely the last straw, so to speak, that upsets

her equilibrium; and that some other experience, which would be an equal

strain upon her slender ability to make adjustments, would result in

exactly the same mental or emotional distortion, just as certain

physical signs in pregnancy may be produced also in the non-pregnant

state, and are not, therefore, necessarily inherent to the gravid state.

Changes in the =ductless glands= are in much the same category.

Functional disturbances of these glands occurring at any time may give

rise to great irritability, excitability or to other mental symptoms. A

non-pregnant woman with even a very slight degree of hyperthyroidism,

for example, may be noticeably unstable mentally or emotionally. Since

there is evidently an inter-relation and inter-dependence of the

functions of the ductless glands, and since ovulation, the function of

one of these glands, is suspended during pregnancy, we can readily

believe that other glands would undergo changes as a result. Alterations

in the thyroid are particularly apparent as it becomes enlarged and more

active in the majority of pregnant women, as does also the anterior lobe

of the pituitary body. This increased activity may tend to compensate

for the suspended function of the ovaries. But the alterations in the

functions of the other glands, compensatory though they be in part,

apparently produce much the same sort of nervous symptoms that they are

capable of producing in a non-pregnant woman.

Taking the condition as a whole, pregnancy is usually characterized by

an improved state of health. During the first few months there may be

lassitude and loss of weight, but the latter part of the period is

notable for an unusual degree of general well being and for an increase

in flesh over the entire body, which may amount to as much as

twenty-five or thirty pounds.

About fifteen pounds of the increased weight is lost at the time of

labor and a still further reduction occurs during the succeeding weeks

when the mother’s body returns approximately to its original condition.

But it sometimes happens that the improved state of nutrition acquired

during pregnancy becomes permanent.

There was a time when you were not,

You merry sprite, save as a strain,

The strange dull pain

Of green buds swelling

In warm, straight dwelling

That must burst to the April rain.

A little heavy I was then

And dull—and glad to rest. And when

The travail came

In searing flame ...

But, sprite, that was so long ago!—

A century!—I scarcely know.

Almost I had forgot

When you were not.

—EUNICE TIETJENS.

PART III

THE EXPECTANT MOTHER

CHAPTER VI. PRENATAL CARE. Instruction of the Mother, Examinations,

and Observations. Importance of Prenatal Care. The Nurse’s Part.

Personal Hygiene of Pregnancy. Excretions. Kidneys. Urine Tests.

Skin. Bowels. Clothes: corsets, binders, shoes. Diet. Fresh Air and

Exercise. Rest and Sleep. Care of the Breasts. Teeth. Travelling.

Marital Relation. Common Discomforts during Pregnancy. Nausea and

Vomiting. Heartburn. Distress. Flatulence. Diarrhea. Pressure

Symptoms. Swelling of the Feet. Varicose Veins. Hemorrhoids. Cramps

in the Legs. Shortness of Breath. Vaginal Discharge. Itching. Early

Symptoms of Complications of Pregnancy: Toxemias, Premature

Terminations, Hemorrhage.

CHAPTER VII. MENTAL HYGIENE OF THE EXPECTANT MOTHER. Common Causes of

Mental and Nervous Breakdown during Pregnancy. Nurse’s Attitude.

CHAPTER VIII. PREPARATION OF ROOM, DRESSINGS AND EQUIPMENT FOR HOME

DELIVERY.

CHAPTER IX. COMPLICATIONS AND ACCIDENTS OF PREGNANCY. Premature

Terminations of Pregnancy. Definition of Terms. Abortions. Causes:

Abnormalities of Fetus; Abnormalities in the Generative Tract; Acute

Infectious Diseases; Mental or Emotional Stress; Physical Shocks.

Premonitory Symptoms. Prevention, Treatment, and Nursing Care of

Threatened, Incomplete, and Complete Abortions. Missed Abortion.

Therapeutic Abortion. Clerical and Legal Aspects of Abortion.

Criminal Abortion. Premature Labor: Causes, Treatment and Nursing

Care. Ante-partum Hemorrhage. Placenta Prævia: Cause, Symptoms,

Treatment and Nursing Care. Premature Separation of a Normally

Implanted Placenta: Cause, Symptoms, Treatment and Nursing Care.

Toxemias of Pregnancy. Pernicious Vomiting of Pregnancy. Symptoms,

Treatment and Nursing Care of Reflex Vomiting, Neurotic Vomiting,

Toxemic Vomiting. Pre-eclamptic Toxemia: Symptoms, Prevention,

Treatment and Nursing Care. Eclampsia: Symptoms, Treatment and

Nursing Care. Nephritic Toxemia: Cause, Symptoms, Treatment and

Nursing Care. Acute Yellow Atrophy of the Liver: Cause, Symptoms,

Treatment and Nursing Care. Other Important Complications of

Pregnancy: Syphilis. Heart Lesions. Pulmonary Tuberculosis.

Thyroidism. Pyelitis. Gonorrhea.

CHAPTER VI

PRENATAL CARE

The day is long since past when the obstetrician’s concern for his

patient began when she went into labor. The obstetrician of to-day

watches and cares for his patient throughout pregnancy, for he knows

that by so doing he greatly increases her chances of surviving the

ordeal of childbirth, and the baby’s prospect of living through that

perilous first year.

Although many conditions that result in invalidism or death occur during

labor or the puerperium, they have their beginnings during pregnancy.

Their prevention, then, or early recognition, followed by prompt and

efficient treatment, will avert many of the dreaded complications and

emergencies associated with childbearing.

In order to prevent these disasters it is necessary to supervise the

expectant mother and care for her from early in pregnancy—from the time

of conception if possible—until the onset of labor, and this is prenatal

care. It may be divided into instruction, examinations and observations,

as follows:

1. a. Teaching the expectant mother the principles of personal

hygiene, as especially adapted to meet her needs, and helping her to

adopt them;

b. Describing to her the more apparent, normal changes of pregnancy

which she is likely to notice and perhaps not understand, and also

the common symptoms of complications which she may detect and should

report;

2. The doctor’s preliminary examination, early in pregnancy,

comprising a study of the size, shape and proportions of the pelvis,

and later their relation to the size and mouldability of the baby’s

head; a Wassermann test for syphilis; urinalysis and measuring the

blood pressure. In addition to these, a complete physical survey is

made, consisting of examinations of the heart, lungs, breasts,

abdomen, a vaginal smear for gonorrhea, and the patient’s height,

weight and temperature;

3. Constant watching for early symptoms of the complications of

pregnancy, with speedy treatment of such symptoms when they appear,

and relieving the common discomforts of pregnancy; making

observations upon the presentation and size of the fetus, later in

pregnancy, in order to plan ahead of time for the delivery, if the

patient’s condition makes this advisable.

Prenatal care of this character is essentially preventive for both the

mother and the new-born baby.

We gain a faint impression of what it may prevent when we learn that

year after year, about 17,000 young women die in the United States from

causes associated with childbirth, which are known to be largely

preventable (during 1918 the number was 23,000); and that each year

about 112,000 babies are born dead, and 100,000 of those born alive

perish during the first month of life, also from causes which are

largely controllable.

But 17,000 dead mothers and 200,000 dead babies, most of whom might have

lived, are not all that enter into the annual erection of this national

monument to neglect. There are also the unrecorded and uncounted victims

of little or no obstetrical care who have had too much vigor to succumb

completely and die, and who, therefore, live on through years of

wretched invalidism. Sometimes, it is true, their disability is slight,

so slight as to be uninteresting, and of no statistical importance. But

to the woman herself, who must resume the functions of mother,

homemaker, wife and general utility person, the disability may be enough

to make life endlessly dreary and discouraging. And yet, she is perhaps

only just below the physical level upon which she could live her life

with joy and eagerness; and proper care when the baby came would have

left her upon that level.

The effect of the mother’s impairment reaches far beyond her own

invalidism, for such women are not as well able to rear and care for

their children satisfactorily as are fresh, buoyant mothers. Whatever

makes for good obstetrics, therefore, makes for a better race, and, as

we shall see later, measures that tend to improve the health of the race

tend to lessen the hazards of childbearing.

Ideal prenatal care, then, would really begin during the expectant

mother’s own infancy, but we must be content here with a description of

the care that is advisable, and desired, for expectant mothers from the

beginning of pregnancy.

There is considerable difference of opinion among physicians concerning

the stage of pregnancy at which it is desirable to see the expectant

mother for the first time, and the frequency of subsequent observations.

But the growing tendency is for the doctor to see his patient as early

as possible, for the preliminary examination, and to follow a fairly

uniform routine in the kind and frequency of subsequent observations,

and in the personal hygiene which the patient is advised to adopt.

Thus, it has become generally customary to see the patient, take her

temperature, pulse and blood pressure and make a urinalysis once a month

during the first half of pregnancy, and then every two weeks until the

onset of labor, or possibly once a week toward the end. These periodic

examinations keep the physician constantly informed about his patient’s

condition, and frequently disclose very early symptoms of a complication

which is easily amenable to treatment at that stage, but which might

prove serious if allowed to progress unchecked. Albumen in the urine,

for example, or an increase in the blood pressure, in a woman who had no

other symptoms, would suggest the advisability of watching for further

symptoms of toxemia; while an elevation of temperature, even though the

patient was not uncomfortable, might lead to the early discovery of

tuberculosis, pyelitis or some other infection not otherwise apparent.

It is this stitch in time that means so much to the pregnant woman and

her expected baby.

But the most painstaking obstetrician requires the co-operation of his

patient in innumerable little ways, if she is to have the fullest

benefits of his skill; for it is not so much what the doctor advises

that counts as how the patient lives.

It is at this point that nurses are more and more being given

opportunity for immensely gratifying service. A private patient who is

in the care of an obstetrician is, of course, supervised and instructed

by her doctor. But there are other patients—women who cannot afford this

individual care, but who need care none the less. And it is these

expectant mothers that nurses are helping the doctors to instruct in the

principles of right living, and are watching for danger signs, through

visiting nurse societies, out-patient departments of hospitals and

through prenatal clinics.

The character and extent of the instruction and supervision given by the

nurses is, of course, decided by the medical board of her organization,

and is often affected by the conditions under which the work is

conducted. The nurses in a rural community, for example, may take blood

pressures and test urine for albumen, while in cities, rich in doctors

and medical institutions, these observations might not be among their

duties.

In addition to this definite relation to expectant mothers, nurses are

meeting them, unofficially and informally, at every turn; women who are

needing, but not receiving, care from a doctor or an organization; women

who are puzzled or troubled over their condition, but do not know where

nor how to obtain advice; women who could employ a physician but do not

appreciate the importance of his care.

Every nurse should recognize it as her duty to advise an unsupervised,

pregnant woman to place herself under medical care, no matter under what

conditions she meets her.

In the discharge of her duties, the nurse will sometimes need no little

ingenuity to adapt the routines of prenatal care, as prescribed by her

organization, to the mentality, traditions and varied demands of the

daily lives of her patients. But this will have to be done, for though

in a general way the needs of all expectant mothers are the same, their

circumstances and personalities are infinitely varied.

It may require undreamed-of tact and resourcefulness to convince a

patient that details of care, which seem wholly unrelated to her or her

baby’s welfare, will actually increase their chances for life and

health. For this reason, it is of almost prime importance that the nurse

win her patient’s friendship and confidence. She will then scarcely

realize that she is being taught, but will do and continue to do as she

is advised, because of an almost insensible reliance upon the judgment

and sincerity of her counsellors.

It is not the single examination of a specimen of urine that counts, nor

the exercise taken with pleasure and enthusiasm during the first few

days of its novelty. It is not the rest, fresh air nor proper food,

taken according to rule for a week or two, that will keep her fit. It is

the aggregate and repetition of the infinite number of details that make

up the expectant mother’s mental and physical life during twenty-four

hours in each day, seven days a week, throughout forty long weeks, that

grow longer and more monotonous as pregnancy advances; it is the mosaic

that she makes out of the minutiae of her daily life that counts. And

paradoxical as it seems, she must shape her days to meet her own and her

baby’s needs with such steady persistence that she finally lives them

almost unconsciously of what she is doing, and also without

introspection.

Obviously, then, the expectant mother’s mental attitude is of

considerable importance.

She should in general continue the diversions, work and amusements that

she is accustomed to and enjoys, if they are not contra-indicated;

cultivate a cheerful, hopeful frame of mind; guard against being

self-centred and over watchful of symptoms, and at the same time not

adopt the dangerous habit of uncomplainingly ascribing to pregnancy all

of the discomforts and unfamiliar conditions which may arise. In short,

to forget that she is pregnant in so far as that is consistent with the

care that she should take of herself.

She should understand that childbearing is a normal function, but, like

other normal functions, may become abnormal if neglected; and that a

sick pregnancy is not a normal one.

In connection with the patient’s mental attitude and her anxieties, the

nurse may be of great comfort in helping to dispel superstitions and the

widely credited and depressing beliefs concerning maternal impressions.

After one has traced the development of the human body in the uterus,

and even faintly understood its growth and method of nourishment, it is

impossible to believe that the mother’s thoughts or experiences could in

any way deform or mark her child, or alter its sex. That the mother’s

“reaching up,” for example, could slip the cord around the unborn baby’s

neck is manifestly absurd, as well as the previously mentioned

superstitions about the eight-month baby’s slender chances for survival.

But superstitions are always fondly cherished, for, as Gibbon tells us,

“the practise of superstition is so congenial to the multitude, that if

they are forcibly awakened, they still regret the loss of their pleasing

vision.” We can scarcely wonder however that even intelligent and

educated people hold utterly improbable beliefs about pregnancy, for the

most fanciful of them are quite as easy to believe as the thing that we

know actually occurs—the development of a human body from a single cell.

These fanciful beliefs, however, are sometimes serious matters to the

young woman who is traveling, day by day, toward a great and mysterious

event, and they should not be laughed to scorn, but explained away

seriously and with sympathy. She may be told quite simply, that after

conception she gives her baby only nourishment; that the baby’s

connection with her body is through the cord and placenta, in neither of

which are there nerves; and that even if the blood could carry mental

and nervous impulses, which it cannot, the maternal and fetal blood

never come in actual contact with each other. A tale which she has heard

about a woman who saw something distressing and later gave birth to a

marked child may cease to worry her if she is reminded of the

innumerable babies, beautiful and unmarked, which are born to women who

have had equally shocking experiences. It is scarcely probable that any

woman lives through the ten months of pregnancy without seeing, hearing

or thinking things that would disfigure a baby if maternal impressions

could produce such results, and yet newborn babies are very rarely

blemished. Although the ultimate causes of marks and deformities of the

fetus are not definitely known, they are probably to be found in faulty

development very early in the embryonic life, and, therefore, are not

preventable.

HYGIENE OF PREGNANCY

In coming to the expectant mother’s personal hygiene, we find that an

understanding of the physiology of pregnancy almost of itself indicates

what this hygiene should include. We shall take it up in detail,

however, and describe what is at present considered a reasonable outline

of the routine desired for the average pregnant woman, who is found by

careful examination to be normal and free from complications, and

needing only to keep well. But, as has been said, and must be oft

repeated, the ideal routine cannot be deposited _en bloc_ upon all

expectant mothers. It must be adjusted to the individual and to her

circumstances.

EXCRETIONS. Although, as has been explained previously, the pregnant

woman does not have to eat for two, she does have to eliminate the waste

and broken-down products from two bodies, through her own excretory

organs: the kidneys, skin, lungs and bowels. True, the amount of the

baby’s ash is not great, but is of such a character that its elimination

is important and increases the strain upon the maternal excretory

apparatus.

=Kidneys.= One of the most important factors in prenatal care is

promoting the function of the kidneys and watching their output. It is

probably more true of the kidneys than of any other organs that a slight

abnormality which would not give trouble at other times may, if

neglected during pregnancy, produce very grave results. The amount of

urine passed in twenty-four hours should be measured, and a specimen

prepared, once a month during the first half of pregnancy and every two

weeks afterward. If less than three pints are passed the patient should

know, without further instruction, that she is not taking enough water

and must take more. And so it is the nurse’s duty, in this connection,

to convince her patient of the importance of drinking an abundance of

water, and periodically measuring her urine and sending specimens to the

doctor for examination.

She is very likely to follow such advice if she is told that by so doing

she will help to prevent convulsions, for most women know of this

complication and dread it.

In preparing a specimen, a covered or corked receptacle which is large

enough to hold the voidings for twenty-four hours, must be thoroughly

washed and scalded; in it should be collected the total amount of urine

voided during twenty-four hours and kept in a place that is cool enough

to prevent putrefactive changes. The additional precaution of putting a

teaspoonful of chloroform into the receptacle is wise and does not

injure the specimen. The patient should be instructed to empty her

bladder at any designated hour, and then keep all urine voided from that

time until the corresponding hour on the following day. The urine should

be shaken so as to mix thoroughly the different voidings, and six or

eight ounces poured into a bottle which has been washed and scalded,

carefully corked and labelled with the date, patient’s name, address and

the total amount for twenty-four hours.

If the nurse is called upon to test for albumen, either of the following

will serve, unless the doctor specifies a test which he prefers:

_Heat and acetic acid test_: Fill a test tube about half full of urine

and gently boil the upper part in a flame; add five drops of 2% to 5%

acetic acid and again boil gently. The presence of albumen is shown by a

white cloud in the upper part of the urine.

_Esbach’s test_: Fill a test tube half full of urine; add eight or ten

drops of Esbach’s Solution. The presence of albumen is shown by a white

flocculent precipitate in the upper part of the urine.

=Skin.= Under ordinary conditions, the skin serves as a protective

covering for the body, helps to regulate the body temperature and acts

constantly as an excretory organ. This last function is performed by the

sweat glands which open upon the surface of the body, and we are told

that there are some twenty-eight miles of these minute, tube-like

structures in the skin. These glands should be, and usually are,

constantly active and they daily pour upon the surface of the body an

oily substance that lubricates the skin and something over a pint of

water containing waste matter, that is inimical to health if retained in

the body. We are not aware of this constant excretion of fluids, which,

therefore, is termed “insensible perspiration,” but it continues even in

cold weather and must not be interrupted if health is to be preserved.

If the oil, dust, particles of dead skin and the waste material left by

dried perspiration are allowed to remain upon the surface of the body,

they will clog the pores and gland openings and thus interfere with

their functions. The removal of this material, then, is an imperative

health measure. This is done automatically, in part, for the fluid

evaporates, and much of the solid matter is rubbed off on the clothing.

But the most important aids to the skin’s activity are the drinking of

plenty of water, deep breathing, exercise and warm baths; baths serving

the double purpose of removing waste matter already on the surface, and

stimulating the glands to increased activity in giving off still more.

This explains the importance to the expectant mother of thorough and

regular bathing, and of keeping her body evenly warm. Most doctors

advise a warm, not hot, shower or tub bath every day, with soap used

freely over the entire body, followed by a brisk rub. The best time for

this warm, cleansing bath, as a rule, is just before retiring, as it is

soothing and restful and tends to induce sleep. Very hot baths are

fatiguing, particularly during pregnancy, and should never be taken

except with the doctor’s permission; but cold baths usually may be

continued throughout pregnancy if the patient is accustomed to them and

reacts well afterwards. Under these conditions the morning cold plunge,

shower or sponge is beneficial, as it stimulates the circulation and

thus promotes the activity of the skin. Some doctors forbid tub bathing

of any kind after the seventh month, on the ground that as the patient

sits in the tub her vagina is filled with water, which may contain

infective material. Should labor occur shortly afterward an infection

might result. As the patient is heavy and somewhat uncertain on her

feet, there is also the danger of her slipping and falling while getting

in or out of the tub.

Other doctors permit tub baths throughout pregnancy, up until the onset

of labor; while as to hot foot baths, there seems to be no reason for or

against them at any time during the nine months.

Bathing in a quiet stream or lake is apparently harmless, but sea

bathing, if the surf is rough, is inadvisable because of the impact of

the waves upon the abdomen and the general violence of the exercise.

The importance of keeping the body evenly warm throughout pregnancy

cannot be overemphasized, for a sudden chilling or wetting may so check

the excretory function of the skin as to throw a greater burden upon the

kidneys than they can meet, in their effort to eliminate the skin’s

share of the body waste. Accordingly, a single chilling will sometimes

be enough to precipitate an eclamptic seizure. This may be one reason

why we see eclampsia more frequently during cold weather or after a

sudden drop in the temperature after warm or mild days.

=Bowels.= The bowels, also, eliminate a certain amount of toxic material

and if they do not move thoroughly at least once a day, deleterious

substances are absorbed into the system and an extra tax is placed upon

the kidneys in an attempt to excrete them.

Unhappily, a large proportion of pregnant women suffer from

constipation, particularly during the later weeks, though women who have

always had a tendency of this kind may have trouble from the very

beginning of pregnancy. Sluggish peristalsis, due to pressure by the

enlarged uterus upon the intestines, is probably the prime cause, though

impaired tone of the stretched abdominal muscles also may be a factor.

The bowels should move regularly every day, and to this end the patient

should regularly attempt to empty them, immediately after breakfast

usually being the best time. The importance of regularity in making the

attempt cannot be overemphasized, even though the bowels do not always

move.

Exercise, the intake of an abundance of fluids, eating fresh fruit,

coarse vegetables and bulky cereals, such as bran, to stimulate

peristalsis, and drinking a glass of hot or cold water upon retiring and

arising are all laxative in their effect. As the regular use of enemata

only tends to lessen intestinal tone, they should not be employed unless

ordered by the doctor; nor should the patient take cathartics without

the doctor’s order. But she may safely increase the amount of her fluids

and the bulk of her food, in order to regulate her bowels, and may also

take senna and prunes cooked together. A simple way of preparing prunes

for this purpose is to pour a quart of boiling water over an ounce of

senna leaves and allow it to stand for about two hours. A pound of well

washed prunes should soak over-night in this infusion, which has been

strained, and the combination cooked until tender. They may be sweetened

with two tablespoons of brown sugar, and the flavor improved by adding a

stick of cinnamon or slice of lemon while they are cooking. Half a dozen

of these prunes, with some of the syrup, may be taken at the evening

meal to start with, and increased or decreased in number as necessary.

CLOTHES. The chief purpose of clothes under all conditions is to aid in

keeping the body warm, thus helping to preserve an even circulation and

the activity of the sweat glands. As has been pointed out, this is of

especial importance during pregnancy. The expectant mother’s clothes

should be not only sufficiently warm, but they should be equally warm

over the entire body. They should be light and porous, and fairly loose,

so as not to interfere with the circulation or other body functions.

There must be no pressure on chest or abdomen; no tight garters, belts,

collars or shoes.

The patient’s clothes, like every other detail in her care, will have to

be adapted to her environment and mode of living. If her house is well

and evenly heated during the cold months, she may quite safely dress

lightly while indoors; if it is not, she should be advised to wear

underwear with high neck, long sleeves and drawers, both indoors and

out, except when the weather is warm enough to induce free perspiration.

At all times, however, the warmth of her clothing must be adjusted to

the temperature of the home, the climate and to the state of the

weather.

Bearing in mind the importance of diversion and amusements, it becomes

apparent that in addition to the hygienic qualities mentioned, the

expectant mother’s clothes should be as pretty and becoming as is

consistent with her circumstances. She is much more likely to go about

and mingle with her friends if she is fortified with the consciousness

that she is becomingly and well dressed. Which, of course, is not

peculiar to pregnant women.

The expectant mother’s clothes should be so made that their weight will

hang from the shoulders instead of from the waistband.

And that brings us to the question of _corsets_, one of the most

discussed garments in her wardrobe. Women who have not been accustomed

to wearing corsets will scarcely feel the need of adopting them during

pregnancy, except perhaps during the later weeks when the heavy,

pendulous abdomen needs to be supported for the sake of comfort. This is

particularly true of women who have borne children and whose flaccid

abdominal walls give but poor support to the uterus.

Women who have been wearing comfortable, well-fitting corsets probably

will not feel the need of making a change until the third or fourth

month. By this time the uterus has pushed up out of the pelvis into the

abdomen and accordingly the corsets must be so constructed that they

will accommodate themselves to an abdomen that is steadily increasing in

size and also changing in shape; will provide support for both abdomen

and breasts and still not compress nor disguise the figure. To be

entirely satisfactory in their adjustability, the maternity corsets must

be made of very soft material and have elastic inserts and side, as well

as front or back lacings. They should extend well down in front and fit

snugly over the hips. The upper part may be fitted with adjustable

shoulder-straps that will support the breasts and help to suspend some

of the abdominal weight from the shoulders; but at the same time will

not interfere with the development of the breasts nor compress the

nipples. Many women find great comfort in wearing a short-waisted

maternity corset and a brassiere.

The front-lace corset is usually found to be the most satisfactory, for

the patient may lace it from below upward while lying on her back. This

enables her to draw it in snugly about the hips, below the abdomen, and

adjust the garment to the abdominal curve so as to really support,

without compressing the uterus. Other excellent corsets lace both front

and back and are capable of very comfortable adjustments. If the nurse

clearly understands the purpose of a maternity corset, she will be able

to explain to her patient why the same style as she ordinarily wears, no

matter how large, will not be satisfactory during pregnancy, and may be

even harmful.

Even a properly fitting maternity corset may become uncomfortable during

the last few weeks of pregnancy, and have to be replaced by an abdominal

supporter of linen or rubber. And when this stage is reached, even the

woman who has worn no corsets may be made more comfortable by adopting

such a support, particularly at night. There are many admirable binders

on the market, or the nurse and patient may fashion some such an one as

is shown in Figs. 34, 35, 36 and 37. Comfortable and inexpensive

stocking supporters, which meet all practical requirements, may be made

by the patient from tapes or strips of muslin. (Figs. 38 and 39.)

[Illustration:

FIGS. 34, 35, AND 36.—Front, side and back views of home-made binder

for supporting heavy, pendulous abdomen during later weeks of

pregnancy. It is adjusted as the patient lies down, the ends being

crossed in the back and pinned to the lower margin of the front,

thus giving additional support.

Also breast-binder made of a straight strip of soft cotton material,

10 or 12 inches wide and 2 yards long. This is crossed in front and

held with safety pins, the ends being carried over the shoulders and

pinned to the back of the binder. It should be snug below the

breasts but loose over the nipples. The openings over the nipples

show how this binder may be used to support the breasts of the

nursing mother. (From photographs taken at the Maternity Centre

Association, New York.)

]

[Illustration:

FIG. 37.—Abdominal binder used in Figs. 34, 35 and 36, showing darts

at top of front to fit it over the abdomen.

]

[Illustration:

FIGS. 38 AND 39.—Front and back view of home-made stocking supporters

made of webbing or 1–inch strips of muslin and a pair of child’s

side garters. The straps are sewed together in the back, but pinned

in front to permit adjustment as the abdomen enlarges. (By courtesy

of the Maternity Centre Association, New York.)

]

The expectant mother’s _shoes_ also merit considerable attention and

thought. Her feet are larger than usual because they are likely to be

somewhat swollen during the latter part of pregnancy, and the increased

weight of her body tends to spread them. This added weight also

increases the strain put upon the arch and flat foot is a not infrequent

result, unless the arch is well supported. Another reason for the need

of proper shoes is that, as pregnancy advances, the body’s centre of

gravity changes. The pregnant woman becomes unstable on her feet and

needs low, broad, firm heels. They need not necessarily be flat at

first, if the patient has been accustomed to wearing moderately high

ones, for the sudden lowering of the heels may injure her arches. High

French heels, of course, should be avoided because they not only

increase the difficulty and discomfort of walking but cause backache, as

well, by forcing a posture that adds to the pressure on the lower part

of the abdomen. They also increase the risk of turning the ankles,

tripping and falling.

The patient’s shoes should be an inch longer than those she ordinarily

wears; they should have broad toes and fit snugly over the instep, in

spite of being large. If her shoes are not comfortable the expectant

mother will tire easily and tend to take less exercise than she should.

DIET.—It is advisable for both nurse and patient to understand, and keep

clearly in mind, the purposes which are served by the food intake of the

expectant mother, and what foods and practices will defeat, and what

will accomplish these purposes. Her food should provide nourishment, as

under ordinary conditions; it should promote the functions of her skin,

kidneys and bowels, because of the waste from her own and her baby’s

body which she must excrete; it should be adequate to build and nourish

the baby’s body without drawing materials from the mother’s own tissues.

Moreover, proper food during pregnancy is an essential factor in

preparing the mother to nurse her baby, which is as important as

nourishing the fetus _in utero_.

In order to accomplish these various ends the patient must not only eat

suitable food, but she must digest and assimilate it. This requires that

she sedulously guard against overeating, constipation and indigestion of

any kind. Indigestion may be avoided during pregnancy exactly as it is

at other times, by eating proper food; by cultivating a happy frame of

mind; by exercise, fresh air, adequate rest and sleep.

If accustomed to a fairly simple, well-balanced, mixed diet, the average

expectant mother will need to make little or no change, excepting to

make her evening meal light if it has been a hearty one; for she uses

her nutritive material with surprising economy and does not have to “eat

for two,” as is so commonly believed. It is a safe general principle

that an amount and kind of food that keeps the expectant mother,

herself, in a state of health and good nutrition, is favorable to

satisfactory development of the fetus until the latter part of

pregnancy.

She will probably be able to understand why this is true if it is

explained that her baby gains nine-tenths of his weight after the fifth

month, and one-half of his weight during the last eight weeks of

pregnancy; also that if she takes too much food, the excess is stored up

in both her own and the baby’s tissues; if too little, the fetus is

nourished and her body deprived.

It is very unwise for the mother to diet with the idea of keeping the

child small, and thus make labor easy, unless she is so ordered by her

physician. In general, it is the size of the fetal skull that makes

labor easy or difficult, and not the amount of fat distributed over the

child’s body. And if the patient cuts down the minerals in her diet to

make the fetal bones soft, and thus increase the compressibility of the

skull, the fetus will extract lime from her bones and teeth, so that the

only effect is upon herself.

The expectant mother’s meals should be taken with clock-like regularity,

eaten slowly and masticated thoroughly. Three meals a day will usually

suffice during at least the first half of pregnancy. The possible need

for slight additional food after that may be supplied more

satisfactorily by lunches of milk, cocoa or broth and crackers or toast,

between meals and upon retiring, than by taking larger meals. But if the

patient has a tendency to nausea, early in pregnancy, she will often be

able to control it by taking a little food regularly five or six times

daily, instead of the usual three meals.

In general the expectant mother should eat an abundance of fruit and

vegetables, taking at least some uncooked fruit and a green salad,

daily, and making sure that her food contains a good deal of residue,

such as is provided by fruit and coarse vegetables. This residue

increases the bulk of the intestinal contents, which stimulates

peristaltic action and thus helps to overcome the tendency toward

constipation. As fat is less easily digested, and more likely to cause

nausea during pregnancy, than carbohydrates, it is better for the

patient to eat no more fat than usual, but to supply the additional

energy needed after about the sixth month, by taking a little more

starch. But after all, only a slight increase is needed, and this

chiefly during the last three or four weeks.

It is of the greatest importance that every pregnant woman drink an

abundance of fluid, to act as solvent for her food and waste material,

and stimulate the activity of her kidneys, skin and bowels. She needs

about three quarts daily, and most of this should be water, the

remainder consisting of milk, cocoa, soup, and other liquids.

Alcohol should not be taken under any circumstances, except upon a

doctor’s order, while tea and coffee, if taken at all, should be used

with moderation. The patient should be advised to avoid fried food,

pastry, rich desserts, rich salad-dressings and any other food which

would ordinarily disagree with her. In fact any article of food that

disagrees with her in a non-pregnant state should be avoided during

pregnancy, no matter how valuable it may be as nourishment to the

majority of people.

On the other hand, it sometimes happens that an article of food which is

likely to disagree with other people will be easily digested by the

pregnant woman, and if it adds to the pleasure of her meals should not

be taboo, for the enjoyment of one’s meals promotes digestion. So-called

“cravings” are not as common in fact as they are in rumor, but the

expectant mother may have a capricious appetite and display strange

likes and dislikes for certain dishes, possibly because of her tendency

to be nauseated.

The average pregnant woman with no symptoms of complications will be

able to supply her needs, and at the same time keep within the bounds of

safety if she selects her diet from such groups as the following:

ANIMAL FOODS.—Milk and eggs are the most satisfactory, but for the

sake of variety, and to tempt her appetite, she will usually be

allowed to have fish, the various kinds of shell fish, beef, lamb,

chicken or game rather sparingly, preferably only once a day. Pork,

veal, and goose should be avoided as a rule, and particularly by

women with whom they ordinarily disagree.

SOUPS.—Thin soups and broths have little food value, but, because of

their appetizing flavor and aroma, are an aid to digestion, and

frequently will stimulate a flagging appetite and prompt the patient

to eat and assimilate more than she would without them. Cream soups

and purées obviously have a high food value, and, like thin soups

and broths, also supply a definite amount of fluid which the patient

must have.

VEGETABLES.—The group of vegetables usually designated as “leafy”

are of even greater importance to the expectant mother than they are

to the average person. Of these, she may safely eat onions,

asparagus, celery, string beans, spinach, and make a point of taking

a green salad, such as lettuce, cress, or romaine, at least once

daily. Sweet potatoes, white potatoes, rice, peas, Lima beans,

tomatoes, beets and carrots may also be eaten with safety as a rule,

but cabbage, cauliflower, corn, egg-plant, Brussels sprouts,

parsnips, cucumbers, and radishes should be taken with great caution

and avoided altogether if they cause flatulence or any kind of

distress.

FRESH FRUITS.—A necessary part of the diet is fresh fruit, and among

those fruits which are both beneficial and harmless are apples,

peaches, apricots, pears, oranges, figs, cherries, pineapple,

grapes, plums, strawberries, raspberries, blackberries, and

grapefruit. These are more likely to be laxative if eaten alone, as

before breakfast and at bedtime. Cooked fruits are also valuable

articles of diet, but are probably less laxative than raw fruit.

Some of the citrus fruits, oranges, grapefruit and lemons, should be

taken daily because of their antiscorbutic properties.

CEREALS.—For their nourishing and laxative qualities, cereals are

important, and their food value is increased by the milk and cream

which are usually taken with them. Cooked cereals should invariably

be cooked longer than the usual directions suggest. Bran, eaten

alone, as a cereal or in combination with other grains, is an

excellent laxative.

BREADS.—Graham, cornmeal, whole wheat and bran bread are all good.

In general the expectant mother will be on the safe side if she eats

sparingly, if at all, of very fresh or hot breads and hot cakes.

DESSERTS.—Desserts are very important for they add to the

attractiveness of most people’s meals, and if wisely chosen and

properly made, may supply a good deal of easily digested

nourishment. They may include, in addition to fresh and cooked

fruits and preserves, ice-cream, a wide variety of custards, creams

and puddings made largely of milk, eggs, and some ingredient to give

substance and firmness, such as gelatine, cornstarch, rice, tapioca,

farina, arrow-root and similar materials.

FRESH AIR AND EXERCISE. If the nurse has become aware of the value of

promoting all of the normal physiological processes of the pregnant

woman, she already realizes how important are fresh air and exercise to

the patient and her expected baby.

The average individual uses every minute the oxygen contained in four

bushels of air, and since the pregnant woman takes in through her lungs

the oxygen for both herself and the baby, she must have an adequate

quantity of constantly changing air to supply at least this amount. She

should spend at least two hours of each day in the open air. If the

weather is so stormy or severe as to make it undesirable for her to go

out from under cover, because of the danger of getting wet or chilled,

she may wrap up well and take her airing on a protected porch or in a

room with all of the windows wide open. But this is only a part of it,

for the air in her house, or rooms, must be kept fresh all day by being

constantly changed; this requires a steady inpouring of fresh air and

outpouring of stale, vitiated air.

A very good way to accomplish this is to have one or more windows open

slightly, top and bottom, all the time. But there must be no sudden

changes of temperature, nor drafts, for fear of chilling the patient’s

skin. At night she should sleep in a room with the windows open, taking

care to be well protected by light, warm coverings.

Each detail of the expectant mother’s daily routine seems to be more

important than the last. And so when we come to the question of regular

outdoor exercise we almost think that whatever else may be neglected,

this is indispensable, since it promotes digestion, stimulates the

functions of the skin and lungs; steadies the nerves, quiets the mind

and promotes sleep. And more than that, walking, which is probably the

most satisfactory form of exercise, also strengthens some of the muscles

that are used during labor. But exercise is downright injurious if

continued to the point of fatigue, no matter how little has been taken.

Each woman must be a law unto herself in this matter, therefore, and

must be impressed with the importance of stopping before she is tired.

She should start by walking only a short distance, increasing gradually

until she is able to walk possibly as much as an hour in the morning and

an hour in the afternoon, if she can do so without fatigue.

All violent exercises and sports are of course to be avoided,

particularly swimming, horseback riding, and tennis. While motoring and

carriage riding are pleasant diversions, they cannot be classed as

exercise. They should be taken only in comfortable vehicles and over

smooth roads, so that there will be no jarring nor jolting, and the

patient should not do the driving herself.

A certain amount of exercise, in the shape of light housework, may be

taken indoors. It is distinctly beneficial, if not continued to the

point of fatigue, both because of the exercise which it provides, and

also the diversion and interest, for these promote mental and physical

health. But this indoor exercise must not interfere with, nor to any

degree replace, the daily exercise out of doors; nor must it include

heavy work, such as washing, sweeping, heavy lifting, running a sewing

machine by foot nor much running up and down stairs. However, the amount

and kind of work which a woman may comfortably and safely do are so

related to what she has been accustomed to, that it is not possible to

offer more than general suggestions, which will help in the planning for

each individual. All patients will do well to moderate their activities

at the time when they would ordinarily menstruate.

There are patients to whom massage and gymnastics are beneficial during

pregnancy, when for some reason the out-of-door activities are

contra-indicated. This might be true of a patient with heart trouble,

for example, or one who is being kept in bed to avert an abortion, and

accordingly is a matter which must be entirely in the doctor’s hands.

REST AND SLEEP. When we studied the bony structures of the female body,

we found that as the abdominal tumor of pregnancy increased in size and

weight, the body’s centre of gravity changed and the pregnant woman was

required to make a constant, though unconscious effort to stand upright.

This is probably one reason for the fatigue which expectant mothers so

often feel without apparent cause, and for the fact that they are likely

to tire rather more easily than usual.

Accordingly, the patient may have to rest frequently during the day, in

order to avoid the ill effects of fatigue. She should work and exercise

in short periods rather than long, always lying down when tired, and for

an hour or two after the noon meal. She must be particularly careful not

to be over-active, nor to overexert herself at the time when

menstruation would occur were she not pregnant, for fear of bringing on

an abortion. This precaution is particularly important during the first

four months, the period when abortions occur most frequently.

Since eight hours’ sleep is usually considered necessary to keep the

average person in good condition, the pregnant woman cannot expect to

progress satisfactorily with less. In fact, it is so important to her

general well-being that she should be taught and persuaded to do

everything in her power to secure it.

Fresh air during the day and open windows at night; prudent eating; a

comfortable bed furnished with warm but light bedding; warm baths; a hot

water bag to the feet and a hot drink upon retiring are all conducive to

sleep.

But in addition to these, and perhaps of even more import, are

cheerfulness and a tranquil, untroubled state of mind. It is well for

the nurse to make a mental note of that intangible but influential fact,

for she can usually exert a great deal of influence in shaping her

patient’s or patients’ moods.

BREASTS.—Breast feeding is the most urgent single need of the baby, for

whose coming we are making preparation, and practically every mother,

excepting those with definite physical disability, can supply this need

of her baby’s, if she gives herself proper care both before and after

its birth. It is true, that everything that promotes her general health

helps to prepare her to nurse the baby, but there is need also for care

of the breasts and nipples themselves, to make the nursing satisfactory,

and to prevent sore nipples and possibly even breast abscesses.

Briefly, this local care consists of supporting heavy breasts, but

avoiding pressure; bringing out flat or retracted nipples and toughening

the skin which covers the nipples.

After they become heavy and uncomfortable the breasts may be supported

by brassieres, which are snug below the breasts, loose over the breasts

themselves and suspended from shoulder straps; or by some such binder as

is shown in Figs. 34, 35, and 36, which answers the same purpose.

If the patient’s nipples are flat or retracted, she should begin about

the fifth month to make them more prominent in order that the baby may

grasp them easily. There are several ways of accomplishing this, all of

them in the nature of massage, but whatever is done must be done

regularly and persistently. One simple and effective method is to grasp

the nipple between the thumb and forefinger, draw it out, hold it for a

moment, then release it and allow it to retract. This should be done

over and over, two or three times daily. Or the unstoppered opening of a

warm bottle may be placed over a flat nipple and held in place until the

nipple is drawn up into the neck of the bottle as it cools and forms a

vacuum.

The toughening of the nipples should be begun eight weeks before the

baby is expected. There are two general methods which seem to give about

equally satisfactory results; one is to harden the skin with astringents

and the other is to soften it with ointments. In either case, the

nipples should first be scrubbed gently with a soft brush or cloth, warm

water and soap, for about five minutes night and morning. They may then

be rubbed with lanoline, cocoa-butter or vaseline and covered with a

piece of clean soft cloth or gauze, to protect the clothing; or they may

be bathed with a wash consisting of equal parts of a saturated solution

of boracic acid and 95% grain alcohol. Tannin, benzoin and a great

variety of astringents are also used, and with satisfactory results. But

the essential is to decide upon some method of preparation, of proved

value, and then persuade the patient to employ it with faithful

regularity.

CARE OF THE TEETH. It is important that the pregnant woman give her

teeth excellent care, for in addition to the conditions with which we

all have to cope, she must combat the effect of her tendency to have an

acid stomach. And her teeth are prone to decay and crumble, since the

fetus extracts lime salts from her bones and teeth, unless she is

careful to take in through her food a supply which is adequate to meet

the fetal needs. It is therefore advisable for her to place herself

under the care of a dentist, as soon as she knows of her pregnancy, and

have any necessary work done at that time, as delay may be serious.