First month.--There are indications of the eyes, mouth and anus. The
extremities are rudimentary. The heart is 4/10 of an inch long.
Second month.--It is now about one inch long. The eyes, nose and ears can
be distinguished. External genitals. There are suggestions of the hands
and feet.
[516 MOTHERS' REMEDIES]
Third month.--The ovum is now the size of a goose-egg. Fingers and toes
separate, nails look like fine membranes. The neck separates the head from
the body. The sex can now be told. Length is five inches. Weight about 460
grains.
Fourth month.--Six inches long and now weighs 850 grains. Short hairs are
present. Head equal to about one-fourth entire body. May perceive
quickening.
Fifth month.--Ten inches long; weighs eight ounces. Eyelids begin to
separate. Heart sounds can be heard. Quickening takes place.
Sixth month.--Twelve inches long; weighs 23-1/2 ounces. There is hair on
the head, eyebrows and eyelashes are present. Testicles show near the
abdominal rings (openings).
Seventh month.--Fifteen inches long; weight 41-1/2 ounces. Pupillary
membrane disappears.
Eighth month.--Sixteen inches long; weight 3-1/2 pounds. Left testicle has
descended into the scrotum. Nails protrude to end of finger tips.
Ninth month.--Eighteen inches long; weighs 4-1/2 to 7 pounds. Features are
complete.
While this growth goes on in the embryo the womb itself shows changes. The
virgin womb averages 2-3/4 inches in length, 1-3/4 inches in width and 1
inch in thickness and weighs about 12 drams. At term (confinement) the
womb is about 14 inches long, 10 inches wide, and 9-1/2 inches thick. This
increase in size is necessary for its growing contents and is due to both
an enlargement of its tissues (hypertrophy) and to an increase in the
number of its cells (hyperplasia). The muscular fibres are elongated to
about 11 inches, and they are five times thicker than they are in a womb
that is not pregnant. The cervix or neck of the womb participates but
little in these changes, and remains practically the same until a few
weeks before confinement. It becomes softened as the result of congestion,
and the glands are more active, secreting a thick glairy mucus. The canal
also is more or less dilated.
While this process is going on in the womb, various other conditions show
themselves, sometimes in the parts of the body so distant that it may not
be easy to discover the connection with the womb. Almost any part of the
body is liable to show changes from its normal condition; and yet some of
these changes are so constant and regular as to be regarded as signs of
pregnancy. It must not be forgotten, however, that sure signs of
pregnancy, such as cannot be induced by other causes, are very limited,
especially in the early months.
[OBSTETRICS OR MIDWIFERY 517]
Changes occur in the genital organs that may lead a physician to suspect
that pregnancy may exist; but the first symptom that attracts the
attention of the woman, is the passing of the monthly period. This is not
an absolute sign of pregnancy, since other things or conditions may cause
it. The effect of the mind upon the body may cause it, and it also occurs
sometimes in early married life without any appreciable cause, unless it
may be then due to the effect upon the nervous system of the marital
relation. Again, the monthly sickness sometimes continues in a greater or
less degree, during a part or even the whole of pregnancy. Usually this
discharge is due to some diseased condition of the cervix. The fear of
impregnation in unmarried women after illicit intercourse will
occasionally suspend menstruation for one or two months.
Nausea and Vomiting.--Another symptom upon which considerable dependence
is placed is the morning sickness (nausea and vomiting). While this
symptom is common, yet its absence does not prove that the woman is not
pregnant. Some women go through the whole pregnancy without any sign of
this symptom.
Nausea accompanied or not by vomiting may appear at the very time of
conception, but it usually appears about the fourth or fifth week of
pregnancy and continues until the sixteenth week or longer. In some cases
it may last but a short time, in others it may continue until confinement.
It may be light or severe; It generally manifests itself upon arising in
the morning and subsides in a short time, but it may occur at any time of
the day and continue during the entire waking hours. It may be absent
entirely and, in rare instances, manifest itself in the husband alone. I
have known of one such case. This nausea may be excited only by various
odors or sights or may be caused by constipation. An increased secretion
from the salivary glands usually accompanies the stomach disturbances and
in some cases it may amount to salivation. An irresistible desire for
certain articles of food or drink, generally of a sour or acid nature, is
often developed. Indigestion, gas in the bowels and belching of gas are
frequently present. The appetite is often capricious or it may be entirely
lost (anorexia).
Breasts.--Changes in the breasts also constitute a sign of pregnancy. As
an early symptom, there may be a feeling of fullness, sometimes pain. They
become larger and firmer from the development of the individual lobules,
which have an irregular knotty feel. A fat deposit takes place between the
lobules and in the other parts of the breast. The nipples increase in
size, are harder to the touch, become more prominent. A few drops of a
turbid fluid, colostrum, may be pressed from the nipple as early as the
third month. The veins under the skin become larger and more conspicuous.
The rose-colored circles (rings) around the nipples are broadened and are
slightly elevated above the surrounding skin and there is a marked
increase in their pigmentation, the color varying with the complexion of
the individual from reddish pink to brown and black. These changes usually
occur at the beginning of the third month, and if the woman has already
had a child the question of pregnancy has been decided by inspection of
these breast changes.
Bladder.--This is sometimes irritable in the later months, causing a
frequent desire to pass urine. It sometimes occurs in the second or third
week and is sometimes followed, later, by an inability to retain the urine
which escapes at any time. This, however, is not frequent.
[518 MOTHERS' REMEDIES]
Abdominal changes.--There is a slight flattening of the lower abdomen at
the second month, due to the sinking of the womb. There is also a slight
retraction (drawing back) of the navel. After the third month, when the
womb begins to ascend out of the pelvis, a progressive enlargement of the
abdomen begins and continues until near the end of pregnancy, when the
womb again sinks and the so-called lightening occurs. The protrusion of
the abdomen is more marked usually on the right side. There is often an
increased deposit of fat in the lower portion of the abdomen, as well as
on the hips and thighs. The navel may protrude after the sixth month,
Pigmentation.--Pigmentation or darkening of the middle line of the abdomen
begins by the eighth or twelfth week, and a dark band about 1/8 of an inch
wide extends from the pubis (bone) to and around the navel or even higher.
This shows plainer in brunettes, where it is quite conspicuous.
Discolorations also appear on other parts of the body, especially on the
face, "moth patches."
Quickening.--This is caused by the movement of the child (foetus) in the
womb. The impact of the enlarging womb, through the child (foetal)
movements, against the abdominal wall about the sixteenth week of
pregnancy gives rise to this sensation called quickening. Some women claim
to have experienced this sensation at a much earlier date, and by some it
is not felt at all. Gas in the bowels and contraction of the muscles of
the abdomen may give a chance for mistakes. In the later months of
pregnancy, the movements sometimes become so violent as to produce
perceptible movements of the womb and the abdominal muscles, and sometimes
they are the cause of the pain.
The Blood.--The blood is increased in quantity and slightly altered in its
composition. The water, fibrin and white corpuscles are increased; the red
cells are at first relatively diminished, but later return to normal.
Nervous System.--The nervous system is over sensitive and the disposition
of the woman may undergo a radical change, mental exaltation and
depression are often exhibited.
Constipation is the Rule.--Neuralgias in different parts of the body,
especially in the face and teeth, are common. Palpitation of the heart and
difficulty in breathing may be experienced. A discharge from the vagina is
almost always present, due to the increased circulation in the cervix and
vagina.
The Foetal Heart-beat.--This is the one positive sign of pregnancy and it
may be heard as early as the sixteenth to the twentieth week. It has been
compared to the ticking of a watch under a pillow. It ranges in frequency
from one hundred and ten to one hundred and fifty to a minute.
[OBSTETRICS OR MIDWIFERY 519]
Pelvic Signs.--As early as the first month of pregnancy a faint violet
color of the anterior wall of the vagina just below the opening of the
urethra may be distinguished. In the third month this color has become
purplish and pronounced. This sign is present in eighty per cent of cases.
There is also a more or less marked lividity of the vaginal portion of the
cervix from the first month of pregnancy. Also there is softening of the
cervix as early as the sixth week, and as pregnancy advances the whole of
the cervix is softened.
Duration of Pregnancy.--This is for all practical purposes two hundred and
eighty days.
How to Determine Date of Confinement.--The best rule is to count backward
three months from the first day of the last menstrual period and add seven
days to it. To be more accurate, in April and September only six days
should be added; in December and January, five days; and in February, four
days.
Position of the Womb.--At four months the top of the womb has risen above
the pelvic brim bone in front; at five months, it is midway between the
bone (pubic) and the navel; at six months, it is at the navel; at seven
months, it is four fingers breadths above the navel; at eight months, it
is midway between the navel and the bottom of the breast bone; at nine
months, it is to the breast bone; from the middle to the end of the ninth
month, the top of the womb sinks to about the position occupied at the
eighth month.
Twins occur about once in ninety to one hundred and twenty, triplets once
in one thousand eight hundred and seventy-five, and quadruplets once in
three hundred and seventy-one thousand one hundred and twenty-six
pregnancies. The causes are unknown. Twin conception is more common in
women who have borne children, and more so in the elderly than in the
young, first bearing women (primiparae).
Sex.--Children from the same ovum (egg) are always of the same sex. Of
twins in general, more than one-third are males, less than one-third are
females, and in the remaining one-third both sexes occur. The after-birth
is always, at least at first, double.
Diagnosis.--In twin pregnancy the symptoms and disorders of pregnancy are
apt to be exaggerated, and watery swelling above the pubic bone is almost
always present in the latter months. The abdomen is larger and broader and
there may be a depression dividing the abdominal wall in two spaces. The
womb is much distended and the walls are thin.
Hygiene of pregnancy.--In pregnancy the dividing line between health and
disease is often so shadowy that every care should be given the pregnant
woman, not only that she shall escape dangers that may come, but that the
future health of the coming baby may be safeguarded.
The care taken in pregnancy therefore should include attention to
clothing, food, exercise, rest, sleep, functions of all excreting organs,
the breasts, nervous system and the mind.
[520 MOTHERS' REMEDIES]
Clothing.--This should be worn loose. The heavier garments should not be
held by the waist but suspended from the shoulders. Flannels, if possible,
should be worn next the skin excepting, possibly, during the warmest
weather. Every precaution should be taken not to take cold or to chill the
surface of the body, as this might bring on an acute trouble of the
kidneys. As soon as the womb has risen out of the pelvis during the fourth
month, the corset should be absolutely abandoned, since pressure upon the
enlarging womb tends to cause acute Bright's disease and uraemia, and
these troubles are always to be guarded against. During the later months
of pregnancy, when the abdominal enlargement is great, a linen or elastic
bandage may be worn with great comfort, but it must be so put on as to
support and not press upon the womb.
Food.--The food of the pregnant woman should be simple, wholesome,
nutritious, of the kind that is easily digested and enough to satisfy the
demands of her system; excessive eating should be avoided. A mixed diet is
to be preferred, but the diet should be of such kind as to help to
overcome the constipation, usual in pregnancy. Meat should not be eaten in
as great quantities. It not only tends to produce more constipation but
also has injurious effect upon the kidneys, and anything that in any way
puts a greater burden upon the kidneys in pregnancy should be avoided. All
foods that are likely to produce indigestion, heart burn, or irritation of
the stomach and liver, such as sweets, fried, greasy, highly spiced foods;
greasy rich gravies, or pastry should not be eaten.
The heartiest meal should be taken near midday and the stomach, especially
at night, should never be overloaded. Water should, be drank freely, as it
tends to overcome the constipation and wash out the kidneys. Some women do
better with lighter meals and taken more frequently. Some do better by
taking their breakfast before rising.
Bathing.--Extremes in hot and cold bathing should be avoided. The skin
should be kept active by daily comfortable baths, followed by a brisk
rubbing with a rough towel. The Bowels and Bladder.--The bowels, as before
stated, are usually constipated and should be kept open by coarse foods,
fruit and, when necessary, mild laxatives; mineral waters and enemas
especially should not be given. It should not be forgotten that in some
women injections into the bowel are liable to bring on contractions of the
womb.
No woman, and especially no pregnant woman, should ever neglect the
bowels, as much discomfort and ill health are caused by improper
eliminations of the bowel contents. The bladder should also have proper
care. This is apt to be irritable during the early and later months of
pregnancy, owing to being pressed upon by the womb. A mild inflammation
arises in some cases. The woman should take plenty of water, either pure
or effervescing, to induce sufficient secretion in the kidneys, and also
to flush them. This is also very good for an irritable bladder. In order
that the physician may keep himself informed regarding the condition of
the kidneys, the urine of every pregnant woman should be examined, both
chemically and microscopically, every two weeks from the beginning of
pregnancy; during the late months of pregnancy the urine analysis should
be made weekly. Catherized specimens should be used because leucorrheal
discharges, so common in pregnancy, may give the albumin reaction. If the
above advice of Dr. Manton, of Detroit, was followed in every case there
would be fewer cases of trouble during the confinement. I remember one
case; the lady was seven months along when I was called. She was feeling
badly and complained much of her eyes; an analysis of the urine showed
thick with albumin. The failure of her sight was due to thc condition of
her kidneys. If the urine had been examined early and often, her condition
might have been prevented. Watch the kidneys, have the urine examined
frequently and carefully.
[OBSTETRICS OR MIDWIFERY 521]
Exercise, Rest and Sleep.--Plenty of exercise in the open air should be
taken daily, without this health cannot be maintained. It should not be
violent or so great as to fatigue and overtire. Slow riding in a carriage
and walking will give the best results. Horseback riding and riding in an
automobile should be avoided. The woman should sit out of doors as much as
possible. Plenty of sleep is also necessary. Eight hours are not too much
at night, and lying down an hour or two during the forenoon and afternoon
is very restful and desirable.
The Vagina.--When there is a profuse discharge of leucorrhea, a daily
vaginal douche is necessary. This should consist of a quart of warm
solution (as much as the water will dissolve) of boric acid, or an equal
amount of mild carbolic acid (one to eighty). The temperature of the
solution should be about 100 degrees F., and it should be injected slowly,
and without any force to the stream.
It is also best to remain in the recumbent position for some time after
the injection, to rest.
The Breast and Nipples.--These should be bathed once or twice daily in
cool or tepid water until the last month or two of pregnancy. Astringent
application should not be applied to the nipples to harden them. If the
nipples are small, undeveloped or retracted they should be pulled out
several times daily by the fingers and gently rubbed, and this will
usually stimulate their growth. Cocoa butter or castor oil may be applied
during the last month.
Nervous System and the Mind.--The pregnant woman is very susceptible to
annoying conditions of the social and domestic surroundings; such should
be removed, if possible, and excitement of every kind should be avoided.
Everything should be made bright and comfortable around her, cheerfulness
should be the rule in the home and she should be treated with every care
and consideration. Surroundings will influence the coming baby's future.
[522 MOTHERS' REMEDIES]
Disorders of Pregnancy.--Nausea and vomiting.--The simple nausea and
vomiting of pregnancy needs no treatment. This kind generally disappears
by the third or fourth month, but it may persist in a mild form during the
greater part of pregnancy. Generally the regulation of the diet and
attention to the bowels are all that is necessary to be done for this
trouble. Foods should be chosen carefully and only such foods taken that
agree with the stomach and lessen the constipation. Sometimes taking a
light breakfast in bed saves the usual morning sickness. It is best then
to remain lying for some time after eating. When the condition is annoying
the following powder will give much relief: powder Ingluvin, oxalate of
cerium, of each five grains. Mix thoroughly and take one, every one or two
hours as needed. A physician should be consulted if this trouble is very
severe.
MOTHERS' REMEDIES.--1. Pregnancy, A Great Aid for.--"Soothing syrup or
Mother's friend, while pregnant. Two ounces each of cramp bark, blue
cohosh, slippery elm, raspberry leaves, squaw vine, orange peel and bitter
root. Simmer gently in sufficient water to keep herbs covered for two
hours, strain and steep gently down to one quart. Let it stand to cool,
then add one cup granulated sugar, and four ounces alcohol. Dose.--One
tablespoonful two or three times a day for several weeks before the birth
of the child. This has been thoroughly tried and causes an easy birth
where difficulty has been expected."
2. Nausea of Pregnancy, Menthol and Sweet Oil for.--"Vomiting and nausea
of pregnancy; a twenty per cent solution of menthol in sweet oil; use ten
drops on sugar when nausea appears." The menthol acts on the stomach and
quiets it. This will be found very beneficial.
3. Pregnancy, Bouillon or Broth for.--"Was weak and generally run down.
Family physician warned me I would never survive the birth of another
child. I bought each day several beef bones and boiled them for three
hours. I also bought chicken feet, scalded them and scraped them until the
outside skin peeled off, then boiled the chicken feet with the bones. Skim
surface from time to time. I would then heat up a raw egg in a glass and
fill glass with this broth and drink it warm." This lady would take a
glass whenever thirsty or six or seven times a day. She increased in
strength immediately, within a year was the mother of a healthy baby girl
now nineteen years old and believes her life was saved by the above.
Anyone will find this worth trying.
[OBSTETRICS OR MIDWIFERY 523]
Indigestion and Heart-burn.--This should be treated the same as under
other conditions. Diet, habits, should be regulated. The bowels and
kidneys should be regulated and do their eliminating work. For heart-burn
the popular remedy, magnesia may be taken or dilute hydrochloric acid with
nux vomica. One teaspoonful or effervescing citrate of magnesia dissolved
in water and drank, is a convenient remedy. Also, five drops of diluted
hydrochloric acid in water, taken after meals, through a tube, and one or
two drops of nux vomica before meals is beneficial. The following is an
excellent combination from Dr. Hare, of Philadelphia:
Dilute Hydrochloric Acid 2 drams
Essence of Pepsin 1 ounce
Compound Tincture of Gentian enough to make 4 ounces
Mix. Take one or two teaspoonfuls in a little water with meals.
In cases where it is impossible to eat anything the patient must be fed by
the rectum. In such cases a doctor must be called. Fortunately such severe
cases are very rare. The following for rectal feeding is given by Dr.
Manton, of Detroit, and is a good combination. Give every four hours:
Liquid Beef Peptonoids 3 drams
White of an Egg
Whisky 3 drams
Beef Tea or Warm Water enough to make 3 ounces
The rectum should be washed out once or twice daily in the interval
between the feeding.
Teeth.--The teeth are often affected during pregnancy, softening and
decaying rapidly, causing severe neuralgia. The teeth should be cleaned
frequently during the day to get rid of the secretions of the mouth, and
at night before retiring. Milk of magnesia should be held in the mouth for
a few minutes; cavities in the teeth should be stopped with a temporary
filling. Teaspoonful of lacto phosphate of lime can be taken three times a
day with benefit.
Constipation.--The enlarging womb pressing upon the rectum and also
irregularity in diet causes constipation at this time. Daily free bowel
movements are necessary to prevent the kidneys from overworking. As stated
before, the diet should be strictly regulated. Cascara sagrada cordial is
a good mild laxative to take, if necessary.
Difficult Breathing.--This usually comes late in pregnancy and is due to
the pressure of the womb upon the diaphragm; the patient should avoid
excitement and sleep with the shoulders well elevated. In the ninth month
the womb drops lower and the breathing is better.
Varicose Veins and Piles.--Varicose veins: These are due to the pressure
on the veins so that the return flow of blood is impeded and occur as a
rule late in pregnancy. They are seen oftenest on the inner side of the
thighs, the lower extremities, the vulva, and in the region of the anus.
As a rule, they do not give much trouble. When they become painful or
inflamed the patient should lie down, with the legs elevated and use water
of witch-hazel applied with cloths. Elastic stockings, properly fitted,
give much relief when the trouble is on the thigh and leg.
[524 MOTHERS' REMEDIES]
Piles.--When these are troublesome the rectum should be emptied by a small
dose of salts, and the parts thoroughly washed with warm water, the piles
pushed back and local lotions applied (see treatment of piles). Hot
fomentations of witch-hazel frequently give great relief to the piles as
well as to the varicose veins. Regular movements of the bowels usually
will prevent piles. Piles will not usually give rise to much trouble
unless constipation exists.
Albumin in the urine. (Albuminuria).--While the urine of about six to ten
per cent of all pregnant women contains albumin, the appearance of this
symptom should always be regarded with apprehension. Women who are in
their first pregnancy are most frequently affected. If the woman has had
disease of the kidneys before her pregnancy began this symptom will likely
appear in the early months; if it is caused by pressure, etc., it may not
appear until after the sixth month, but both acute and chronic.
inflammation of the kidneys may develop at any period of pregnancy. Dr.
Manton, of Detroit, states, "In the majority of cases, the albuminuria is
due to the so-called kidney of pregnancy, in which there is no
inflammation, but a fatty infiltration of the epithelial cells associated
with anemia of the organ." The urine may also contain casts. Whatever the
cause it indicates a condition of insufficiency of the kidney which may
lead to serious consequences to the mother and it is also injurious to the
(foetus) child. If this symptom develops suddenly the danger to both is
greatly increased. For this reason physicians should urge pregnant women
to have their urine examined frequently, especially during the later
months of pregnancy.
Treatment.--Regulation of the diet; in pronounced cases the diet should
consist entirely of milk and the patient should take three or four quarts
in twenty-four hours. Meats, pastry and sweets must be prohibited, but
vegetables such as squash, spinach, salads may be added to the dietary in
ordinary cases. Vichy water may be taken alone or with the milk, and may
be taken freely. The bowels should be kept open with citrate of magnesia
(one to two teaspoonfuls in water) or epsom salts in peppermint water.
Exercise in the open air can be taken in moderation. Warm clothing should
be worn and flannel next the skin; exposure to cold and draughts should be
carefully avoided. If the more special symptoms appear, such as persistent
headache, vertigo, ringing in the ears, black or bright spots floating
before the eyes, dimness of vision, an abortion of miscarriage should be
induced without delay. Fortunately such cases are rare and with care from
the beginning seldom occur. Pregnant women should inform their family
physician at the beginning of pregnancy of their condition, and in the
great majority of cases serious troubles can be prevented. Physicians
expect this information and receive it as a matter of course, and no woman
should hesitate to inform her physician either personally or through her
husband.
[OBSTETRICS OR MIDWIFERY 525]
Abortion, Miscarriage, Premature Labor. (Accidents of pregnancy).--These
three terms indicate a premature expulsion of the products of conception.
Let us medically define these terms as follows; Abortion implies expulsion
of the foetus before the sixteenth week. Miscarriage, the expulsion
between the sixteenth and twenty-eighth weeks. Premature labor designates
the time of expulsion as between the twenty-eighth week to within a few
weeks before the normal termination of pregnancy. Miscarriage is the term
popularly used for the accidental loss of the products of conception.
Abortion, in the popular mind, expresses the intentional loss of the
products of conception. Abortion in the medical sense, takes place about
once in every four or five pregnancies. It occurs more frequently in those
who have borne children, occurring generally in the third or fourth
pregnancy, or toward the end of the child-bearing period, and it takes
place more frequently between the ninth and sixteenth week, when the
after- birth is in process of formation; and it is more liable to occur at
the time of the month when the normal menstruation would be due. It should
be borne in mind also that abortion occurring at this period is quite
dangerous to the mother's future health, and also dangerous to life; so
that at the first indication of abortion a physician should be called for
this trouble, because it needs care, both to prevent it and to assist the
woman to a successful ending when it is impossible to prevent it. This is
more dangerous to life than confinement at full term, and is apt to leave
behind a tendency to recurrence at the same time in the future
pregnancies, and also makes the woman liable to inflammatory conditions of
the womb.
Causes.--Abortion may be induced by many causes due to the mother, father,
and child. Among maternal causes may be mentioned any serious disease,
especially fevers, when accompanied by a rash on the skin, such as
smallpox, measles, scarlet fever. It is hard for a pregnant woman to go
through one of these diseases, without having an abortion. Syphilis,
tuberculosis, malaria, organic heart and kidney disease, diabetes, anemia,
and systemic poisoning also are causes; nervous disturbances as shock,
fright, sorrow, convulsions, chorea; mechanical causes, violent exercise,
lifting, blows, falls, coughing, vomiting; local causes, as wrong position
of the womb, inflammation of the womb, etc.; all are causes.
Causes. Due to the Father. Paternal.--Syphilis, alcoholism, lead
poisoning, excessive venery, extremes of youth or old age.
Foetal Causes.--Disease of the after-birth, other parts, of cord, death of
the foetus, placenta pravia, and yet many women are subjected to falls,
blows, etc., who carry their child to full term.
[526 MOTHERS' REMEDIES]
Symptoms.--These vary with the period of pregnancy where they occur. In
the earlier months the symptoms are those of profuse menstruation,
sometimes accompanied by more pain perhaps than usual. The ovum is then so
small that it escapes notice. In the profuse flow there may be
unaccustomed clots of blood; when this trouble occurs later in pregnancy
there are two constant symptoms which, together with the history of the
case, render the diagnosis easy. These prominent and constant symptoms are
pain and bleeding. The symptoms may be preceded by a bearing down feeling
in the lower abdomen, with backache, frequent calls to pass urine, and a
discharge from the vagina, that is a mixture of mucus and water. After
these symptoms last for a shorter or longer time, labor pains set in, the
bleeding increases and the contents of the womb are discharged. The ovum
may be expelled whole when it looks like a huge blood clot, or it may be
expelled partly and the membranes left behind; or the embryo (child)
alone, surrounded by the transparent membrane, escapes.
If the after-birth has formed it may be cast off entire or piecemeal. The
embryo (child) alone may escape, the neck of the womb contracts and shuts;
bleeding persists for an indefinite period, for weeks and weeks, until the
health of the poor woman is seriously affected. Persistent bleeding of
this kind is almost always due to the retention of portions of the
after-birth or membranes, and should prove to the woman that there is a
serious condition existing which should be speedily corrected. A physician
should be called who should make a thorough examination; and if such a
condition as above described is found, should free the womb from its
retained products, which are not only sapping the woman's life, but also
rendering the future health of the womb very uncertain.
Threatened Abortion.--If a bleeding takes place in the woman who is
pregnant, abortion may be assumed to threaten; a careful examination will
usually settle this matter.
Inevitable Abortion.--The abortion is probably inevitable if the bleeding
becomes persistent and free, the cervix softens, the womb dilates and the
labor pains set in. Still in spite of all these conditions, the bleeding
and pain may cease, and the pregnancy go on to full term, The result of
these cases, if carefully and properly treated, is favorable as far as the
mother is concerned.
Treatment. Preventive. In women where repeated abortions have occurred,
the cause should be diligently sought for. If syphilis exists the
treatment should be begun at the beginning of pregnancy. But when no
special cause can be found, and an irritable condition of the womb is
suspected to be present, the patient must be kept quiet in bed, especially
at the time when menstruation would normally occur. She should also be
guarded against lifting, fright, worry, over-exertion; and medicines like
bromide of potash, five to fifteen grains at a dose, given to quiet and
allay the nervous irritability.
Treatment of Threatened Abortion.--The patient should go to bed, lie down
and remain there, and if possible be not only quiet physically, but also
quiet mentally. The main remedy is opium, and if necessary to obtain a
quick action it can be given hypodermically in the form of morphine.
Otherwise, laudanum may be given by the mouth, twenty drops, repeated
cautiously, every three or four hours as required, or it can be given in
thirty-drop doses combined with a couple of ounces of starch water by the
rectum. Extract of opium in pill form, one grain three times a day by the
month; or a suppository of opium, one grain, may be inserted into the
rectum every four to six hours. After the bleeding and pain have ceased,
the emergency is probably passed; but rest in bed and quiet should be the
routine for one or more weeks, and the patient should always rest in bed
at the usual time of the menstrual period, during the remainder of the
pregnancy.
[OBSTETRICS OR MIDWIFERY 527]
Treatment of the Inevitable Abortion.--If the cervix is hard and the canal
is not dilated, especially if the bleeding is free, the vagina should be
packed full at once, if possible, with iodoform gauze. Rolls five yards
long and two inches wide can be bought perfectly adapted to this purpose.
A speculum should be used (Sims' or Graves') and the gauze should first be
packed tightly into corners (fornices) around the cervix, then over the
cervix and well down to the outlet. This should be held in place by a
proper (T) bandage. The gauze can be removed in from twelve to twenty-four
hours, and the ovum will generally be found lying upon the upper part of
the packing, or in the canal that is now dilated, from which it can easily
be removed. Sometimes it is necessary to repack and allow it to remain for
another twelve hours as the canal has not been sufficiently dilated by the
first packing. This packing not only causes the canal to dilate but
usually stops the bleeding. After the ovum has been expelled an antiseptic
vaginal douche should be given twice a day for a week or longer.
If at the first examination the cervix is found softened and the mouth of
the womb is open, but the womb has not yet expelled its contents, the
sterile (clean) finger may be introduced into the womb and the ovum and
membranes loosened and taken away, while this is being done counter
pressure should be made over the abdomen. After the womb has been cleared
of all its contents an antiseptic solution should be used, carefully, in
the womb to wash it out, and this followed by washing out of the vagina.
The after treatment is the same as that for labor at full term. The woman
should remain in bed at least ten days.
Placenta Praevia.--The after-birth is placed in the lower part of the
womb; (after-birth before the child). This is a dangerous condition and
terrible bleeding may occur. It occurs about one time out of every one
thousand. The main symptom is bleeding and this may occur at any period of
pregnancy. It usually appears from the seventh to the ninth month. The
outset is without any appreciable reason and without pain. The amount of
blood lost at the first attack may be so slight as to escape notice or
copious enough to endanger the life of the mother. This flow may occur at
any time during these months, and it may be small or great. If during the
course of pregnancy the bleeding occurs at intervals in the increasing
amount, the greater will be the loss of blood during the labor.
Treatment.--There is little danger of dangerous bleeding before the
seventh month, and a waiting treatment may be adopted, but the woman
should be closely watched and told what the trouble is, so she will be
willing to remain quiet. Rest in bed, the avoidance of all muscular
exercise and quieting medicines may enable the mother to carry the child
until it can live, when pregnancy must be quickly terminated. If the child
is dead the womb must be emptied at once. After the seventh month an
expectant treatment is no longer allowable, and authorities declare the
pregnancy should be terminated without delay. The mother is in great
danger from sudden free flow. This treatment must be given by an
experienced hand and only a physician can do it. If the pregnancy is
allowed to continue to full term the danger to the woman is very great, as
the mortality runs from thirty to sixty-five per cent; but under modern
treatment it has been brought down to five to ten per cent. The death rate
of the child is between fifty and seventy-five per cent.
[528 MOTHERS' REMEDIES]
Labor.--Labor may be defined as the physiological termination of pregnancy
whereby the mature foetus (child) and its appendages (after-birth, etc.),
are separated from the maternal organism.
Premonitory Signs of Labor.--Premonitory signs of labor, usually observed
from one to two weeks before the onset of the labor pains, is a sinking
down of the womb in the abdomen, whereby some of the unpleasant features
of pregnancy are relieved, and the so-called "lightening" takes place. The
waist line becomes small, the breathing is easier and the general
well-being of the woman is better, so that her friends are attracted by
her feeling of relief. But as a result of the womb descent and the
consequent pressure, irritation of the bladder and rectum may occur, and
she may have frequent calls to empty these organs. The vagina secretes
more actively, the veins enlarge, some dropsy may appear in the
extremities, and the womb contractions of pregnancy, which have been
painless, begin to cause more and more discomfort.
These false pains recur at regular intervals of hours or even days, and
generally at night, last for a varying period and usually disappear in the
morning. They often deceive the woman and lead her to the belief that the
labor has already begun; but examination of the cervix will reveal that
this is not so. It is well to bear in mind that the true labor pains
usually begin in the back, extend down to the thighs and often around to
the front and they recur at regular intervals, and with increasing
intensity.
The beginning of labor is characterized by recurring pains at regular
intervals and of increasing severity. There is also a discharge from the
vagina of mucus, and this is sometimes tinged with blood, "the show." If
an examination is now made, it will be found that the cervix (neck of the
womb) is shortened, and that the mouth of the womb is beginning to dilate.
At the beginning, the pains are usually in the back and spread to the
abdomen and down the thighs; but they may be felt first in the abdomen.
They return every half hour or twenty minutes, but as labor goes on the
interval is shortened, so that toward the end of the second stage when the
child is being born, they appear to be continuous, and the patient feels
as if she is encircled by a belt of pain; however, with all this, she will
bear the suffering easier and better for she knows that progress is being
made, and that she will soon be over the pains and the child born. A pain
rarely lasts more than one minute.
[OBSTETRICS OR MIDWIFERY 529]
STAGES OF LABOR.--First stage extends from the beginning of labor until
the mouth of the womb is dilated. Second stage, from the complete dilation
until the complete birth of the child. Third stage, from the birth of the
child until the expulsions of the after-birth--Placenta.
The First Stage.--The first stage varies greatly in different women. The
average duration of this stage is from ten to fourteen hours in the woman
with the first child, and six to eight hours in the woman who has borne
children. During this stage the woman prefers to remain on her feet, sit,
stand or walk about. The amount of pain experienced varies greatly,
according to the temperament of the patient; in nervous women it may be
excessive. The pains now have nothing of that bearing down character which
they afterward acquire; they are described as "grinding," are usually felt
in the front. The genitals become bathed with secretions, which are
sometimes tinged with blood. This is an especially trying period to a
young wife, for she cannot see that the pains are doing any good, only
making her restless, tired and nervous. Little can be done by the
physician in this stage except to encourage and explain what is really
being accomplished by these seemingly futile pains and by tact and proper
encouragement, a physician tides this stage over and gives great comfort
to the needy patient. This stage ends with the opening and dilation of the
mouth of the womb and the second or expulsive stage sets in, with pains
altered in character.
Second Stage.--The pains now become more frequent and severe and last
longer, and the patient now manifests a strong desire to expel the
contents of the womb. The woman now feels better in bed and when the pains
come she involuntarily bears down, with each contraction she sets her
teeth, takes a deep breath, fixes the diaphragm, contracts the muscles of
the abdomen and bears down hard if you allow her to do so. The knowledge
that she is working to overcome an obstacle gives her some satisfaction
and she feels that she is accomplishing something by the efforts she is
making. The physician can aid greatly by suggesting to the patient how to
use the pains and how much bearing down to do. He can tell her when not to
bear down, and so save her strength for the next real pain when bearing
down will do good. Although the pains are really harder in this stage,
nervous women suffer no more, for their mind is now concentrated upon the
work at hand. Sometimes at the beginning of this stage the patient feels
chilly or has a severe chill; a hot drink and more covering counteract
this. Another phenomena is the escape of the waters and a lull in the
pains for a little time, when they come on more effectively than before as
the womb contracts down upon the child and is not hindered by the "bag of
water." The pains keep on at intervals until the child is born and the
physician can now be of help by guiding, directing and assisting the birth
of the head. This stage averages about two hours.
[530 MOTHERS' REMEDIES]
Third Stage.--The birth of the head is very soon followed by the shoulders
and the rest of the body, and the woman is now at comparative rest. The
cord is now tied and cut and the child laid away, if all right, in a warm
place until it can be washed and dressed. Following the birth of the child
there is a short resting period, the contractions of the womb cease and it
becomes smaller through retraction. After a few minutes the pains begin
again, the after-birth separates from its attachment in the womb, and
together with the membranes is extruded into the vaginal canal and vulvar
opening; whence it can be easily delivered by pressing upon the abdomen
over the lump (womb) and by guiding the after-birth with the cord. This
should be done slowly so that the membranes will all come away with the
after-birth.
This should always be examined to be certain that everything has come
away. A greater or less amount of clots of blood come with the
after-birth. The contraction of the womb stops the bleeding, one hand
should be kept on the abdomen over the womb, to see that it remains hard
and retracted. The womb moves under the hand. If it softens, gentle
rubbing should be kept up and the womb will soon remain contracted. This
stage averages about fifteen minutes.
MANAGEMENT OF LABOR.--Preparation of the Bed.--The bed should be high,
springs not soft, with a firm and smooth mattress. It should be placed so
that both sides are accessible. The bed should be made up on the right
side as a rule, as the woman usually lies on her left side when delivered.
Place a rubber, or an oil cloth sheet, over the mattress, and over this an
ordinary muslin sheet and secure this with safety pins to the corners of
the mattress. This is the permanent bed; on top of this is the second
rubber sheet and this is covered with another muslin sheet and both held
by safety pins. This is the temporary bed. Plenty of hot and cold boiled
water should also be at hand. Frequently only a temporary bed is made with
rubber or oil cloth underneath, blanket and sheet above this. They should
be fastened so that the movements of the woman will not disorder them.
These can be removed after the confinement and new, clean warm clothes put
in their place. The objection to this is the woman may be too tired to be
moved, while, with the permanent and temporary bed arrangement she need
not be moved at all, only lifted, while the temporary bed is being removed
and she is then let down easily upon clean bedding.
Preparation of the Patient.--The patient, if she desires, can take a full
bath. The bowels should be moved thoroughly with a soap and water
injection so that the rectum will be fully emptied. This makes labor not
only easier, but pleasanter, as no feces will be discharged during labor.
The bladder should also be emptied. The external organs should be
scrupulously cleansed and bathed with some antiseptic solution, like
glycothymoline, listerine, borolyptol, etc. A fresh suit of underwear may
then be put on and over this a loose wrapper.
[OBSTETRICS OR MIDWIFERY 531]
Examination of the Patient.--The physician needs to satisfy himself as to
the position of the child, etc. This can be done by an examination of the
abdomen and also of the vagina. He must determine whether the child is
alive, its position, the condition of the cervix and mouth of the womb. In
making such examination a routine plan should be adopted. The coat must be
removed, the shirt sleeves turned up and the hands and arms washed with
soap and water. The abdomen should be thoroughly palpated (felt) and
listened to with the ear or stethoscope to determine the character of the
child's heart beat, whether it be very slow, one hundred and twenty or
less, or a very rapid one, one hundred and fifty or more. It may indicate
danger to the child and necessitate a hurried delivery. After these things
have been done, the hands and arms must again be thoroughly washed and
sterilized, the fingers anointed with carbolated vaselin and the
examination of the vagina made.
This cleanliness is necessary, and if this plan were carried out by
everyone connected with the patient during the whole confinement, there
would be fewer cases of "child-bed" fever, with its resultant diseases.
The patient should lie on her back with the knees drawn up. There is no
need for any exposure now, for the covering can be held up by an attendant
so that it will not touch the physician's hands. The soft parts are now
separated by the fingers of one hand while the examining fingers are
introduced into the vagina. These fingers should never touch any external
part and especially the parts near the anus. If the cervix is found to be
long and the canal still undilated, or only slightly so, and especially if
it is the first child (primipara), the physician's presence is not needed
and he may safely leave for an hour or two. But if the mouth (os) of the
womb is dilated to the size of a silver dollar he should on no account
leave the house.
Frequent examination of the vagina should not be made. In ordinary cases
during the first stage, the woman should be up and encouraged to walk
about the room, to sit or assume any comfortable position. During a pain
she may stand beside the bed resting her hands upon something or kneel in
front of the bed or chair. The standing position assists in the birth. The
bladder should be emptied frequently, as a distended bladder retards labor
and may even stop the womb contractions. The pains become more frequent
and severe as the end of this stage approaches and each contraction is now
accompanied by straining or a bearing down effort on the part of the
woman, and as a rule the membranes rupture spontaneously about this time.
An examination of the vagina should now be made with the woman in bed, and
if the membranes have not broken and the womb is completely dilated as
shown during the pain, they may be ruptured by pressing against them with
a finger-nail during a pain. Sometimes we use every means to retain the
membranes intact, but that is when protection for the child is needed for
sometime longer. If the suffering is very severe, during this stage,
fifteen grains of chloral hydrate, well diluted with water, may be given
every fifteen or thirty minutes until sixty grains have been given. (This
medicine should never be given to a person with heart trouble). I find one
drop doses of the tincture of Gelsemium every fifteen to thirty minutes of
benefit, especially if the womb does not dilate well, or the patient is
very nervous. The patient may receive and can receive light nourishment
during this stage.
[532 MOTHERS' REMEDIES]
Management of the Second Stage.--After the rupture of the membranes the
labor proceeds faster and a termination may be expected within a
reasonable time. There is a short lull in the pains, usually, after the
waters have escaped and during this time the patient should remove her
clothing and put on a night dress, and to prevent its being soiled roll it
well up under the arms and retain it there. After labor it can be very
easily pulled down and made comfortable for the patient. A folded, clean,
sterile sheet is now placed about the body and extremities and held in
place by a cord around the waist. The opening in the sheet should be in
the right side, as this will allow the assistance being given as needed.
The powerful force of the abdominal muscles is now brought into action;
the force is best utilized with the woman lying on her back.
She should now be encouraged to bear down during the pains and she will be
greatly assisted by pulling on a sheet or long towel tied to the foot of
the bed, or by holding the hand of the nurse. A support for her feet
frequently aids the woman. Pressing low on her back relieves her to some
extent. In the intervals between the pains she should rest, do nothing,
and be perfectly passive. It is now that an anesthetic may be used to
relieve the suffering. She should not be put completely under its
influence for that is not only unnecessary, but injurious. Chloroform when
used should be given on a handkerchief opened and loosely held over the
woman's face, and administered drop by drop on the handkerchief. The
handkerchief should be placed over the face at the beginning of the pain
and be taken away as soon as the pain is stopped. The woman inhales the
chloroform during the pains and their sharpness is blunted. Given in that
way it is not considered dangerous. It should only be pushed to
unconsciousness during a forceps delivery, and even then it is not always
necessary to render the woman unconscious. I have used the forceps without
giving an anesthetic. They should be placed without causing any special
pain, and assist in delivery without causing any more pain when the head
is down low. Of course if the forceps must be used when the head is high
up a greater amount of anesthetic is needed.
Dr. Manton, of Detroit, says:--"The dangers of anesthetics are the same
when employed for obstetric purposes as in surgery, and then use should be
governed by the same rules in each instance." As soon as the head begins
to dilate the vulvar opening, the patient should be turned on her left
side with her knees drawn up and her body lying diagonally across the bed,
with the buttocks close to and parallel with the edge. This position
allows the physician to give better assistance and is no harder for the
patient.
[OBSTETRICS OR MIDWIFERY 533]
The physician with his hands thoroughly sterilized and with a clean
sterilized gown, seats himself on the edge of the bed and watches the
progress of the labor, ready to assist the woman at any moment. And at
this time he can do much by words of encouragement and proper directions
to the laboring woman how to use her pains so as to get the most from
them; and also by manipulation of the soft parts and the head. The head
advances more and more with each succeeding pain, and the perineum is put
on the stretch, each contraction is followed by a resting pause during
which the head slips back a little and relieves the perineum. Tear of the
perineum is liable to take place when the head is about to escape through
the vulvar opening, especially if the contractions are strong, the woman
bears down forcibly and the interval between the pains is short, so that
the head is forced out before the parts have time to completely dilate and
soften. Here is where the physician's work comes in, by holding the head
back and fully flexed (bent), chin upon the breast, and keeping the back
of the head (occiput) well up towards the bone in front (pubic arch) until
thc perineum is completely dilated.
The effect of the pains can be lessened, if necessary, also, by telling
the woman to open her mouth and not to bear down during the pain for a few
times. In this way the perineum will dilate properly and be torn little,
if at all, and perhaps much future trouble for the woman saved. I always
tell my patient why I ask her to do certain things in labor and I have
never found any woman who, when able, was not willing to do as I asked. A
torn perineum is not desirable, because even when sewn up immediately
after labor, it may not unite thoroughly, and thus cause displacements of
the womb in the future. A little time and care at the time of labor will
save the perineum and every woman is willing to do her share when the
conditions are plainly explained to her. It takes only a few minutes
longer, and only a few more pains to bear. When the head begins to stretch
the opening, the left hand of the physician should be carried over the
woman's abdomen and between the thighs, her right leg being supported by a
pillow placed between her knees, and this left hand presses the back of
the head (occiput) forward and against the "pubic arch." The right hand
may also press the head upward by being placed against the posterior
portion of the dilated perineum. The edge of the perineum should now be
closely watched. A small towel wrung out of a bowl of hot water placed
handy on a chair, should be held constantly against the perineum to hasten
the softening and dilatation of these tissues. Plenty of hot water and
small towels should be at hand. The head advances with each pain and again
recedes until the parts are properly dilated, and the perineum slips
backward over the child's face.
[534 MOTHERS' REMEDIES ]
If torn, it should be sewed before the physician leaves, as it can be done
easily and without pain to the mother. As the head of the child emerges,
the anesthetic should be pushed, or the woman told to open her mouth and
cry out. This lessens the pain and the child's head emerges slower, and
the perineum is saved. The child's head should be received in the hand.
After the head is born, there is a lull for a few moments. Then the
shoulders rotate into the proper position and are easily born. There may
then be a flow of watery fluid for a few seconds. Before this time the
physician has examined to see whether the cord is around the child's neck,
released it if it has been, and also cleaned out the child's mouth. The
child usually cries a little about this time and it is soon seen whether
it needs quick attention. The perineum should be guarded also while the
shoulders are being born as it can be torn by them. The shoulders are
generally born without any help. The child's head is held in the
physician's hand. As soon as the body is born, the child should be laid
upon the bed behind the mother's thighs, and the cord pulled down to
prevent it pulling upon the after-birth. After the beating in the cord has
ceased, generally from five to ten minutes have elapsed, the cord is then
tied, tight enough so it will not bleed afterward, about one or one and
one half inches (some say more) from the body and tied a second time an
inch or so from the first ligature, and the cord cut between the two
ligatures. Care should be taken so as not to cut a finger or toe of the
baby. If the cord is very thick it is best to pinch it at the point of
tying and the contents stripped away before the first ligature is applied.
After the cord is cut it should be wiped off to determine that bleeding
from the vessels has been permanently cut off, and if not it should be
tied again. The child is now taken up by placing the back of its neck in
the hollow between the thumb and forefinger, and the other hand over the
backbone. It should then be placed in a warm receiving blanket, and put in
a safe place.
Management of the Third Stage,--The contractions of the womb are renewed
and with the second or third the after-birth may be expressed. The top
(fundus) of the womb is grasped by the hand through the relaxed abdominal
walls, and squeezed, and at the same time make a downward pressure. The
after-birth is loosened from the womb and slides through the vagina and
outlet, and it may be caught in a tray which has been placed between the
patient's legs, or by the hand and given a few twists in order to roll the
membranes together; while this is being done, gentle rubbing should be
applied to the womb, when the membranes will slip out without tearing; no
drawing on the cord should be done in delivering the after-birth.
From the time of the birth of the head to the delivery of the after-birth
the womb must be controlled by the firm pressure of the hand on the
abdomen. It is well for the nurse, when the after-birth is separating from
the womb to follow the womb, throughout this whole stage, by keeping her
hand upon it and if, while the physician is attending to the child, the
womb softens and enlarges she should at once notify him. There may be
bleeding within the womb. After the womb is empty, friction should be made
over the womb whenever it softens at all in order to stimulate the womb to
perfect contraction, and it should be kept up at intervals for one hour
after the after-birth and membranes have been delivered.
[OBSTETRICS OR MIDWIFERY 535]