WHILE IN CHILDBED.
BY childbed is usually meant the period of delivery, but I mean to
include the lying-in period, from the moment the mother has the first
signs of her approaching delivery, to the time when she is supposed to
have fully recovered and is able to be out of her bed and about.
If the suggestions that were thrown out in a former chapter are
complied with, there will be little reason for uneasiness for the
prospective mother, but it will be conducive to her welfare if she be
buoyant in spirit and hopeful of the best possible result.
The nurse should be a quiet, orderly woman, and neither too young or
too old; she should have had experience in nursing during confinements
and taking care of newborn babies; with all this she should not be set
in her ways, but should be accommodating and active, so that she will
carry out conscientiously the instructions of the attending physician.
The choice of a physician should not be delayed until the last moment,
but it should be made several months before the expectation of
delivery, and a woman should never engage a doctor for her confinement,
unless she knows that he has had practical experience in at least ten
cases of confinement, for some of our leading medical colleges and all
of the poor ones, graduate hundreds of doctors each year who never
attended a single case of confinement, and some have, even, never
seen one; yet the newly fledged doctors are turned loose upon the
unsophisticated communities to attend women in the most trying period
of their lives, and at a time when both the experience and science of
her physician should be her sheet anchor of hope. A physician who is
not always sober, of good moral character, and cleanly in his habits
and appearance, should never be allowed in the lying-in chamber, nor
one who is prating of the many severe confinements he has attended,
or who boastingly speaks of the number of times it was necessary for
him to use instruments, for it is quite likely, that the many severe
confinements of which he spoke, were either fictitious or due to
his ignorance of the subject, and the frequency with which he used
instruments was owing to a lack of patience on his part or to a desire
to be meddlesome and make himself officious. There are a great many
medical gentlemen who are not charlatans in disguise, and these should
be singled out. The pregnant female should have herself thoroughly
washed and bathed just before confinement, and the vagina should be
thoroughly rinsed out with half a gallon of warm water in which a
tablespoonful of pulverized borax has been dissolved; this precaution
will wash out any infectious germs that may cause inflammation.
The bed in which the confinement is to take place should be
scrupulously clean, and in order to insure this, it should be made a
rule that the bedstead be taken apart, and taken out-of-doors where it
is thoroughly washed and afterwards exposed to the purifying influence
of the sun and air. The mattress must also be taken out for a similar
dusting and cleaning, and kept for a time exposed to sun and air. The
confinement chamber should go through the same renovating ordeal;
the carpet of this particular chamber should be taken up, the floor
thoroughly scrubbed and the walls and ceiling washed off and whitened.
It will be better if a few clean mats or rugs can be substituted,
and the old carpet not relaid until after the confinement, when the
woman is up and around again. These precautions will guard against
the possibility of infection and the dangers of childbed fever, and
the many different phases of inflammation which are the result of
carelessness in the details of cleanliness. Of course, the nurse and
attending physician must be equally anxious of their own personal
cleanliness. If he or she leave any of the infectious diseases, like
scarlet fever, measles, typhoid fever, erysipelas and puerperal
fever, either of them is quite sure to communicate the contagion to
the innocently ignorant lying-in woman, and entail upon her endless
suffering and death. In France and Germany, stringent precautions for
nurse and physician against the dangers of infections are mandatory
under the laws, but in free America such legal injunctions would be
considered as curtailing our liberty; in the meantime, innocent lives
are sacrificed, through lack of systematized regulations, at the cost
of liberty degenerating into license.
On the day of confinement the bed is held in readiness for the
occasion, by spreading over the mattress a large piece of oiled cloth,
or what is preferable, rubber cloth; this must reach up high enough
so as to afford proper protection and lap over the side of mattress
and bedstead. Beside the bed an extra mat should be laid, to catch any
fluid that may run down the rubber cloth on the floor.
The preliminary signs of labor pains that make themselves felt by the
pregnant female, are of considerable interest to her and I believe,
that if she will familiarize herself with their character she will
have less anxiety and more confidence in a happy termination of her
condition. For some days, and occasionally for two or three weeks prior
to the commencement of actual labor, a sense of uneasiness about the
uterus will be felt by the female; this uneasiness will be observed
several times during the day and night. When the patient complains of
this local disturbance, she may feel, by placing her hands over the
region of the womb, that the organ becomes hard for the time being,
and as soon as the sense of uneasiness passes away, the womb becomes
soft again. These symptoms are called the “independent contractions
of the uterus” and in the first pregnancy they are felt earlier than
afterwards. This is simply a muscular irritability of the womb and is
not accompanied by “bearing down” which is the true characteristic
of labor. These preliminary skirmishes must not be mistaken for
the commencement of labor, otherwise great mischief may be done by
harassing the case into a premature delivery which might sacrifice the
child. The pregnant female will often become very anxious when she
first experiences these independent pains and she may imagine that
something is wrong; for this apprehension there is no reason, because
experience has taught that the greater this local disturbance before
the beginning of labor, the more favorable the progress of labor will
be when true labor pains set in.
“The righting of the organ” will be observed for some days previous
to the confinement, by a change of the position of the pregnant womb.
The womb places itself, as it were, in readiness for the expulsion of
the child, which is shortly to begin. This is done by the body of the
uterus inclining forwards and sinking downwards, and correspondingly
relieving from pressure the organs of the chest; this makes breathing
easier, and in proportion as the body of the womb comes down, so will
the lower portion of the organ descend, and this may give rise to
irritation of the bladder and frequent desire to pass water; sometimes
the passage of urine may be entirely obstructed, so that the water must
be drawn off by means of a catheter. Some women become very nervous
just before the commencement of labor; this is generally due to fear
or anxiety, for which there is no reason, and agreeable companionship
will generally dispel all evil forebodings and restore her to
self-confidence.
Labor pains are divided into _true_ and _false_, and this distinction
is entirely based upon their different sources. True labor pains are
due to the contractions of the muscles of the uterus, and at the
beginning they are slight. They commence in the back and run on down
to the thighs; one feature about them is that they are intermittent,
that is, that they are not continuous; there is always an interval,
especially at the beginning of labor, in which there is no pain at all.
When labor sets in, the pains are grinding or cutting, but as soon as
the mouth of the uterus is fairly opened or dilated, the character of
the pain changes to a bearing down or forcing out nature. If the hand
is applied over the region of the womb, during the presence of a pain,
the organ can be felt hardened and swollen; this subsides with the
pain, and in the interval, the organ relaxes. This is a wise provision
of nature, for it gives the woman an opportunity to recover and regain
fresh strength for each succeeding effort. False labor pain has no
connection with the process of child-bearing, but is only an incidental
complication. It may be caused by gas in the intestines, indigestion,
diarrhea, constipation, disease of the kidney, neuralgia, or rheumatism
of the muscles of the abdomen or bowels, and by the passage of
gallstones; where the false pains have been traced to their origin they
can be properly dealt with.
A muco-sanguineous discharge from the vagina is another sign that labor
has begun, but it will sometimes happen that it is absent, and this
constitutes a _dry labor_. The mucous discharge which is thus observed,
subserves a very important object in lubricating the parts and relaxing
the neck of the womb and the vagina. There is often a slight tinge of
blood, due, perhaps, to a rupture of small blood vessels in the mouth
of the womb; this is called a show, which some women have for several
days before labor commences.
“Stages of labor” are arbitrary divisions, so as to simplify the
explanation of the entire process of labor from the time the womb
begins to act, up to the last act of parturition, which is the
expulsion of the afterbirth, and these have usually been divided into
three stages. The first stage is the dilation or opening of the mouth
of the womb, including also the breaking of the membraneous sac which
holds the fluid in which the child floats, so as to protect it from
pressure that the walls of the uterus would be continually exercising,
which would prevent its proper development. In this stage the woman
should not exert herself by bearing down; this will only waste her
strength which she should preserve for the second stage, when the mouth
of the womb has opened and the progress of the child into the world
has commenced; during this stage, the female should make an attempt
to relieve her bladder, and if she has had no stool for several hours
before, it will be a good thing to use an enema of warm water, and
empty the bowels.
The second stage of labor begins when the bag of water has broken
and the waters escape; the contractions of the womb increase now in
violence and become decidedly of a bearing down character. At this
period the patient should be furnished with something that she may
grasp with her hands; a sheet attached to the post of the bed is the
best for this purpose, and with her feet steadily braced, holding her
breath she bears down whenever a pain comes on; bearing down between
pains, only exhausts the patient and does no good. During this stage of
labor, the pain in the patient’s back will sometimes become intense,
she exclaims: Oh, dear, doctor, my poor back feels like breaking! what
shall I do? The greatest relief that can be given at this time is to
support the back with the flat surface of the hand, or by folding
a towel and placing it under the back, the two ends being held by
assistants.
As the birth of the child progresses and it approaches the vulva, the
patient will feel an urgent inclination to go to stool; upon this she
must not insist, for at this advanced period of labor she may injure
herself and child. The desire is caused by the pressure of the child’s
head against the rectum; any fecal matter that is thus pressed out
should be at once removed by the nurse.
The third stage of labor consists in the expulsion of the placenta or
afterbirth.
There is a natural detachment of the placenta and a natural expulsion,
but one must have the patience to wait. What presumption of the
officious doctor or midwife to suppose that nature was so derelict as
to require some meddlesome assistant, immediately after the birth of
the child, to drag or pull on the placenta: no, more than that, carry
the hand up into the cavity of the womb and detach the placenta with
the fingers and bring it down and out. When I first started out to
practice I was foolish enough to believe and do the same thing, and
afterwards I congratulated myself how wonderfully skilled I was, but
now I am convinced that this procedure was due to ignorance of the laws
of nature. The truth of the matter is, that the sooner and the more one
pulls and feels on the placenta, the more irritable the womb becomes,
and the more will the uterus contract, as though it protested against
interference.
I have had it happen, and others must have had the same experience,
that the womb closes and contracts firmly in ten to twenty minutes
after delivery, the afterbirth becoming tightly inclosed so that one
not experienced would be frightened into the belief, Oh! here the
placenta has grown to the womb. This is a delusion which may lead to
an interference that may entail dangerous consequences to the mother.
The condition is simply this, that as the afterbirth was not completely
detached at the birth of the child, the uterus contracted immediately
upon and around the retained placenta, and for two physiological
reasons: (1) to accomplish the very object which was imagined was
not accomplished, namely, by contracting, the uterus naturally peels
itself off from the placental attachment, and (2) were it not for this
immediate contraction of the uterus after the expulsion of the child,
the mother would likely _flood_ from the uterine vessels of the partly
detached placenta. Of late years I never experienced a single case in
which the placenta did not detach itself, and if I had known twenty
years ago as I do now, I never would have had one.
After the delivery of the child, the woman should be made as
comfortable as possible for the time being, and by the time the child
is washed and dressed, the placenta will generally present itself in
the vulva. If the afterbirth has not come away at once there is no need
to become alarmed. I have waited for six to eight hours for that event
to take place, and if there is delay over an hour, two teaspoonfuls of
fluid extract of ergot will so excite contractions of the womb that its
contents will be expelled.
Whether the afterbirth comes away immediately after the birth of the
child, or is delayed, it must not interfere with putting the mother
in a warm, dry, comfortable condition. Everything that is damp from
perspiration or wet from the waters, both dress and bed linen must
be removed and replaced with warmed, dry, clean linen; this insures
against taking cold. To me it looks like a crime against science and
nature to allow a woman to remain in the wet and soiled bed after her
confinement for twelve or more hours, and the doctor or nurse who
permits this, is ignorant and negligent of his duties.
After the placenta is removed, the binder or bandage is applied; this
is simply a piece of unbleached muslin about eighteen inches wide and
long enough to reach one and a half times around the body; it should
be brought down to cover the hips and then fastened with strong safety
pins. The object of the binder is to give support to the flabby and
relaxed abdominal muscles, which is a great comfort and aid to restore
the muscles to their former shape.
How a woman should lie after confinement is of much greater importance
than how she should lie during childbirth; in fact it does not matter
much how she lies during labor so long as she feels comfortable,
but after confinement and during her convalescence, her position in
bed has an important bearing on her recovery; to avoid repetition I
refer the reader to pages 73 and 250 of this work. Vaginal douches
of hot water, of a temperature of 104 degrees F. serve a very useful
purpose in washing out the secretions that will naturally accumulate
in the vagina, and after a short time undergo septic decomposition;
these rinsings also assist nature to repair and heal the tissues. The
quantity of fluid that should be used at once is half a gallon of water
in which a tablespoonful of powdered borax has been dissolved. Great
care should be exercised by the nurse, lest the bed and linen of the
patient get wet, and through this she become liable to take cold. The
second day after the delivery is about the right time to begin using
the douche, and about this time the mother should also get a mild
laxative, either of castor oil or of Femina laxative syrup, which is
very palatable and suitable for the occasion.
The last throes of labor which usher the child into the world
constitute the climax of the parturient effort and as there is little
or no interval between the pains, the pains at this period have been
appropriately termed _double_ labor pains. There is more or less
excitement and apprehension on the part of the lying-in female and the
experienced practitioner or nurse will concentrate his effort to calm
and encourage the sufferer in the last minutes of her travail.
It is best to wait a few minutes after the child is born before tying
the cord, so as to give the circulation time to equalize itself;
especially is this desirable when the cord was wound around the child’s
neck or when it is otherwise compressed. The cord is tied about an inch
above the navel, and half an inch higher the cord is cut with a pair
of sharp scissors. In the meantime, the nurse, if properly instructed,
will have in readiness on the side of the bed a warm flannel or blanket
which is to receive the little stranger. There is a proper way to
pick up a newborn babe, so that it will not roll or slip from the
hands, which I have known to happen. The little baby must be taken
hold off with the same gentle firmness as an older child. To prevent
any accident, place the posterior surface of the child’s neck in the
space bounded by the thumb and index finger of one hand, and with the
other hand gently seize the thighs and in this manner place it into the
blanket, to be conveyed to a warm place of safety,—the newborn child
must be kept warm, for its very life may depend upon it. After the
mother has had her temporary wants satisfied, the nurse prepares for
the _first toilet_ of the child.
The care of the baby is differently understood by different persons,
and as a result of this difference of opinion I have observed a
great many unfortunate consequences. There is no reason why the care
of the baby should be resigned to custom and habit for both are
often extremely hazardous to the life of the child, and this I will
illustrate in the course of my remarks.
How often are newly born infants taken into a cold room in which, from
the arrangement of the doors, a draft sweeps through whenever a person
goes out or comes in? How the child is laid bare in readiness for the
ordeal of a thorough cleaning! The child is generally first rubbed
with oil and afterwards put into a bath tub or some other vessel of
sufficient capacity to drown several babies at once. It is now treated
to a soaping process, after which, by means of a cloth indifferently
selected, the child is scrubbed with an ambition which would have been
laudable if applied to the nurse’s own person, but why this little
innocent should be the object of such abuse has been a standing wonder
to me from the time I witnessed the first outrage. By the time the
nurse gets through bathing the child, it is shivering and blue from
cold. I had not been practicing medicine very long before I became
appalled by this barbarous procedure, nor had I practiced very long
before I was called upon to sign a number of death certificates of
infants who contracted colds that resulted in bronchitis, pneumonia and
congestion of the lungs, which caused their death.
There is no sense in this dousing and soaping of a newborn child, and
aside from its danger by undue exposure, it is absolutely useless. But
habit is often so thoroughly intrenched that the good judgment which
persons exercise in most of their duties may become entirely suspended,
when this force of habit has established a custom that is well-nigh
universal.
My method of directing the first toilet of the baby is without the
possible dangers to which I have referred, for it has for its object
not only to clean the child, but to dress it as quickly as possible
and again wrap it in flannel. Warmth is the life of the newborn babe;
it does not require much food, if any, the first twenty-four or
forty-eight hours of its life, but it requires to be kept warm. The
room in which the child is to be cleansed must be warm and free from
draft, and if there is a fire in the chamber where the mother is, the
toilet of the child had better be made here under her eyes and those of
the physician. The nurse or person delegated to dress the baby provides
herself with a vase or bowl of warm water and a saucerful of warm olive
oil or vaseline and a few soft cloths. She then seats herself in a low
chair, and by means of a small piece of flannel she applies the oil
all over the baby’s body, rubbing in an extra quantity in the armpits,
groins and other places where the cheesy substance is thickest. When
the oil has softened the sebaceous material, take a soft muslin cloth,
provided for the purpose, and beginning on the head the oil is wiped
off again; where there are blood stains left, wash these off with a
soft flannel cloth; at the same time the eyes are to be bathed and
the mouth washed out. I have not mentioned the use of soap, for the
reason that it is not at all necessary and very often injurious. The
oil removes all the caseous matter and what oil remains is rather an
advantage than otherwise; it preserves the warmth of the child and
protects its skin. If the soap comes in contact with the eyes of the
infant it often becomes a fruitful source of that annoying and often
dangerous disease of the eyes that is technically termed _purulent
ophthalmia_.
Never apply oil or any other greasy substance to the cord before it
comes off, for this will prevent its drying and delay its falling off.
When the cord has come off, you simply keep the navel clean by washing
it daily with a little warm borax water and afterwards apply a small
compress on which has been smeared a little zinc ointment. Always see
to it that the baby is lying dry and use dusting powder freely; the
_precipitated chalk_ is the best and cheapest infant powder that can
be used. The child that is nursed on its mother’s breasts has little
to fear from overfeeding, yet it should not be allowed to hang on the
nipple too long or sleep with the nipple in its mouth. Nurse the child
every two hours during the day and awaken it if it should sleep to give
it its nourishment, but at night allow it to sleep as long as it wants
to; this will cultivate regular habits in the child and it will thrive
much better. If the baby cries and is restless between times do not
imagine that it is always hungry, but rather colicky, for which there
is nothing better than the old German domestic remedy, _fennel seed
tea_; of this give the baby all it will drink every day and until it is
a year old.
Sore nipples are a great annoyance to a mother and often very obstinate
to treatment. The skin covering the nipple is made exceedingly tender
by the sucking of the child’s mouth and in a few days it cracks and
becomes fissured. Sometimes, the pain that the mother endures whenever
the infant nurses is excruciating, for every time the child is put
to the breasts the cracks open anew. The most fruitful cause of this
condition is to allow the child to hold the nipple in its mouth when it
does not nurse or perhaps to allow it to retain the nipple in its mouth
while it sleeps.
This practice must be at once discontinued, and the child must be at
once removed from the breast as soon as it is satisfied. The nipples
should be washed with borax water, and then a salve should be made by
mixing the yellow of one egg with half an ounce of Peruvian balsam.
This is to be applied by means of a camel’s hair brush to the sore
nipple every time after the child is through nursing. Should the nipple
be too sensitive and the suction of the child too painful, then a
breast pump had better be used for a few days and the child not applied
until the teat has sufficiently improved.
Abscess of the breast constitutes a distressing complication of the
puerperal condition, inflicting upon the patient intense suffering,
and very often leading to a long delay in recovery. It may be due to
cold, and in one case it developed from this cause two months before
confinement, but this is an exception. Sore nipples are a fruitful
cause, for the soreness of nursing makes the mother reluctant to have
the child draw all the milk out, hence, the breast cakes and hardens
with the above result. It also is due to neglect in not having the
nipple properly drawn out; or to a foolish custom, derived from remote
ancestry not to allow the infant to be put to the breast for two or
three days after its birth. In this way the milk ducts become greatly
distended, inflammation sets in, which, if not properly arrested will
terminate in an abscess. If gentle friction of camphorated oil and
hot, moist compresses or poultices do not enable the child to draw
out the secretion, a young pup should be obtained, for he draws with
a gentleness and activity which surpasses the most perfect machine.
The patient must drink sparingly of fluids and properly support the
breasts by means of handkerchiefs placed under them and made to cross
the shoulders, and the bowels should be thoroughly opened. Should an
abscess form it should be opened by a free incision, and the poultice
discontinued, but instead a wad of absorbent cotton should be applied
and the breast tightly bandaged with the handkerchief.