Others collapse at once; they go to pieces under the slightest excuse, and frequently without as much as an excuse. As soon as the pain begins, they willfully ignore all the instructions given and desperately and foolishly try to escape what they cannot escape. In this unreasonable selfishness they resent advice, and at the same time they implore you to "do something"

for them. There is absolutely no excuse for this kind of conduct; and any prospective mother who, because of a willful trait in her disposition, refuses to profit by the kindly professional advice of her physician or nurse, should at least have some consideration for her unborn babe. It may seem unkind to criticise the conduct of any woman at such a time. It is not prompted by a lack of patience or justice however. These women permit, in spite of every a.s.surance to the contrary, an unreasonable fear to overwhelm them; and because of this fear they refuse to be guided into a path of conduct that will save them suffering and shorten the pains which they complain of. It is our conviction that if a woman would try to follow the advice of the physician at this time, at least half of all the seeming suffering would be avoided. We are glad to be able to truthfully state that this type of woman is vastly in the minority.

When the second stage has advanced far enough, the patient will decide to go to bed. It may be necessary to put her in bed earlier, if her pains are very strong, as there is always a possibility of suddenly expelling the child under the influence of a strong pain. She will, as previously stated, discard all clothing, except her night gown, which can be folded up to her waist line and let down as far as necessary after the confinement is over.

The obvious advantage of this arrangement is that the gown remains [99]

unsoiled, and saves what would be needless trouble if it proved necessary to change the night gown at a time when the tired-out patient needs rest.

Much aid may be afforded the woman at this stage by twisting an ordinary bed sheet and putting it around one of the posts or bars of the foot of the bed. The patient may then pull on the ends during the pain; she may also find much comfort and aid by bracing her feet on the foot of the bed while pulling. It is desirable to instruct the nurse to press on the small of the back during these pains. Some women appreciate a hot water bottle in this region. If the pains are hard the patient may perspire freely; it is always refreshing occasionally to wipe the face and brow off with a cloth wrung out of cold water. Cramps of the limbs may be relieved by forcibly stretching the leg and pulling the foot up toward the knee. From this time until the child and after-birth are born the physician will take active charge of the case.

THE MANAGEMENT OF THE ACTUAL BIRTH OF THE CHILD.--Near the end of the second stage of labor it will be observed that the pains have grown strong, expulsive, and more frequent. Very soon the advancing head will begin to push outward the s.p.a.ce between the front and back pa.s.sage; the r.e.c.t.u.m is pushed outward and the lips of the v.a.g.i.n.a open. If an anesthetic is to be used these are the pains that call for it. A few drops may be dropped singly on a small clean handkerchief held up by the middle over the nose, its ends falling over the face. A few drops will just take the edge off the pains, and render them quite bearable. As soon as the pain is over the patient should rest, relax completely, and not fret and exhaust herself worrying about the pains to come. It is astonishing how much actual rest a woman can get between pains if she will only try; and it is astonishing how much concentrated mischief a willful, unreasonable woman can do in the same time. She will not try to rest, but cries and moans and pleads for chloroform, until she succeeds in giving everyone except the physician and nurse the impression that she is suffering unnecessarily. Her husband or her mother, whichever is present, gets nervous; they begin to wonder [100]

if the physician is really trying to help; a.s.sume a long, sad, serious face! forget their promise to look cheerful, and mayhap offer sympathy to the woman. It is a trying moment and needs infinite patience and tact. The physician attends strictly to his duty, which will now be to guard the woman against exerting too great a force during the last few pains. About this time, or before it in many instances, the "waters will break." This means simply that the bag or membrane in the contents of which the child floated burst because of the pressure of a pain. This is a perfectly natural procedure and should not cause any worry: simply ignore it as if it had no bearing on the labor in any way. As soon as the oncoming head has dilated the pa.s.sage sufficiently, so that the edges of the entrance to the v.a.g.i.n.a will slip over the head without tearing, the physician allows the head to be born. It takes some time to do this, and he must hold the head back until just the right moment. It is best not to let the head slip through at the height of a pain, or rupture is sure to occur. Wait till it will slip through as a pain is dying out, and if you have waited long enough and handled the head skillfully, the conditions will be just right at a certain moment to permit this without tearing the parts. There are some cases where a tear, and a good tear, is impossible to guard against.

It is not a question of patience, or tact, or skill; it is a combination of conditions which patience, tact, and skill are powerless against.

POSITION OF WOMAN DURING BIRTH OF CHILD.--The position of the woman is a matter of choice and is not contributory to the results at all. She can lie on her back, which is the ordinary way, or on her side, as the physician or the patient prefer. As soon as the head is born the physician should see that the cord is not round the child's neck; if it is, release it. The shoulders will most likely be born with the next or succeeding pain. The physician will permit the lower shoulder to slip over the soft parts first; this is done by r.e.t.a.r.ding the upper shoulder by pushing it gently behind the pubic bone of the mother. When the shoulders are through, the rest[101]

of the body of the child slips out without effort.

DUTY OF NURSE IMMEDIATELY FOLLOWING BIRTH OF CHILD.--As soon as the child is born the nurse should sit by the side of the mother and hold the womb until the after-birth is expelled. The womb can be easily felt in the lower part of the woman's abdomen as a hard ma.s.s. It feels about the size of an extra large orange. The object of holding it is to prevent the possibility of an internal hemorrhage. It can be readily appreciated that the interior of a womb, immediately after a child is born, is simply a large bleeding wound. So long as the womb remains firmly contracted there is very little chance for an extensive bleeding to take place. As a rule the womb remains sufficiently contracted to preclude a hemorrhage until the after-birth is out. After the after-birth is expelled, the womb usually closes down firmly and the liability to bleed is very much reduced. Because there is a distinct chance or tendency for the womb to bleed freely during the time the after-birth remains in, it is customary, as stated above, to watch it closely and to hold it securely. It is best held with the right hand. The fingers should surround the top of the womb and exert a slight downward pressure. Should it show any tendency to dilate or fill with blood, get it between the fingers and the thumb and squeeze it, pushing downward at the same time.

EXPULSION OF AFTER-BIRTH.--The after-birth is usually expelled in about twenty minutes after the child is born. Great care should be experienced in its expulsion. It should not be pulled at any stage of its expulsion. If it does not come easily give it a longer time,--it takes time for the womb to detach itself from the after-birth; and some after-births are very firmly attached. Eventually it will come out with a little encouragement in the way of frictional ma.s.sage of the womb through the abdominal walls. If the membranes remain in the womb after the body of the after-birth is out, do not pull on them. Take the after-birth up in the palm of your hand and turn or twist it around, and keep turning it around gently, thereby loosening the membranes from the womb instead of pulling them, which would surely break them, leaving the broken ends in the womb, and, as a result, the[102]

chance of developing serious trouble.

The patient should now be given one teaspoonful of the fluid extract of ergot, which should be repeated in an hour. Should there be an excessive flow of blood after this period it may be again repeated at the third hour.

CUTTING THE CORD.--As soon as the child is born, and of course long before the after-birth is expelled, the physician will tie the cord. This is best done at two places, one about two inches from the child, and the other two or three inches nearer the mother. Cut the cord about one-half inch beyond the first ligature, which will be between the two ligatures. The cord should be tied with sterile tape made for the purpose, or heavy twisted ligature silk, or a narrow, ordinary, strong tape, previously boiled. It should be tied firmly and inspected a number of times within one hour of its birth. It is possible for a baby to lose enough blood from a cord badly tied to cause its death. A very good way to ensure against such an accident is to cut the cord one inch from the ligature nearest the baby, then turn this inch backward and retie with the same ligature, thus making a double tie at the same spot. Cut the cord with scissors that have been boiled and reserved for this purpose.

WASHING BABY'S EYES AND MOUTH IMMEDIATELY AFTER BIRTH.--As soon after birth as is practicable, wash the baby's eyes with a saturated solution of boracic acid.

Immediately after the eyes have been washed the physician will drop into them a solution of silver nitrate, three drops of a two per cent. solution in each eye, or argyrol, three drops 20 per cent. solution. This precaution is taken against possible infection during labor and, as explained elsewhere, it is a preventive against certain diseased conditions which, if present, would result in blindness.

The physician should then wind a little sterile cotton round his moistened little finger, dip it in the boracic solution, and holding the baby up by the feet head down, insert this finger into the throat, thus clearing it of mucus. The tongue and mouth may be gently washed with the same [103]

solution.

After the baby has cried l.u.s.tily as an evidence of life and strength, he should be wrapped up in a warm blanket quickly, and immediately put in a cozy basket in a warm place, and left there undisturbed, with his eyes shaded from the light until the nurse is ready to attend to him. The baby should be laid on his right side.

CONDUCT IMMEDIATELY FOLLOWING LABOR.--As soon as the physician is satisfied that the patient is well enough to be left in care of the nurse or attendant, every effort should be made to favor a long, refreshing sleep.

Nothing will contribute to the patient's well-being so much as a quiet, restful sleep after labor. The nurse will therefore take the baby into another room, fix the mother comfortably, and give her a gla.s.s of warm milk,--draw the shades or lower the light and tell the tired-out mother to go to sleep. As a rule she will sleep easily, as she is sore and exhausted.

AFTER-PAINS.--In women who have had children the womb does not as a rule contract down as firmly as after the first confinement. This condition permits of slight relaxation of the muscular wall, at which times there is a slight oozing of blood. This blood collects and forms clots in the uterine cavity which acts as irritants, exciting contractions in the effort to expel them. These contractions cause what are commonly known as "after-pains." These pains last until the womb is free from blood-clots.

They may be severe the first twenty-four hours and then gradually die out during the following two or three days. Ordinarily in uncomplicated confinements they rarely annoy the patient longer than a few hours. It is a rare exception to observe them after the first confinement.

REST AND QUIET AFTER LABOR.--Sometimes the birth chamber is the rendezvous for all the inquisitive ladies in the neighborhood. No one should be permitted in the lying-in chamber until the patient is sitting up, except the husband and the mother. This should be made an absolute rule in every confinement. This is a period that demands the maximum of uninterrupted rest and repose. The world and all its concerns should remain a blank to a woman during the whole period of her confinement. This is the only successful means of obtaining mental rest. The husband and mother [104]

should be instructed to present themselves just often enough to demonstrate their interest in the welfare of the patient and the baby.

POSITION OF THE PATIENT AFTER LABOR.--After delivery a woman should be instructed to lie on her back, without a pillow, for the first night. On the following morning she may have a pillow, but she must remain on her back for the first week. Sometimes an exception may be made to this rule by letting the patient move around on the side, with a pillow supporting the back, on the fourth day. These exceptional cases are those whose womb has contracted firmly, as shown by the quick change in the amount and color of the lochia. Women should be told why they must remain on their backs as explained in the chapter: "How long should a woman remain in bed?"

THE LOCHIA.--The discharge which occurs after every labor is called the lochia. Its color is red for the first four or five days; for the succeeding two or three days it is yellow; for the remainder of its existence it is of a whitish color. It lasts from ten days to three weeks.

The odor of the lochia is at first that of fresh blood; later it has the odor peculiar to these parts. If at any time the odor should become foul or putrid it is a danger signal to which the nurse should immediately draw the physician's attention.

If the amount of the lochia should be excessive it should be investigated.

THE EVENTS OF THE DAY FOLLOWING LABOR.--We will a.s.sume that the patient enjoyed a long sleep and wakes up refreshed, and with a thankful feeling that all is over and that baby is safely here. She will want to see and caress baby, of course. Lay the baby down in bed beside her and let her love and mother it. Tell her not to lift it, for the strain might injure her, then quietly steal away for ten or fifteen minutes, for these are precious, sacred moments. Motherhood--that angel spirit, whose influence every human heart has felt--that guards and guides the world in its sheltering arms--is born in its divine sense, into the heart of every woman for the first time, as she gazes in ecstasy and wonder at her [105]

first-born. She feels that she has begotten a trust,--a trust direct from her Creator, and she makes a silent resolve, as she gently and timidly feels the softness of baby's cheek, that she will watch over it, and guide it, and do all a mother can for it, with G.o.d's help. It is good for the race that mothers do feel this way: and it is good for all concerned that they be given the opportunity to be so inspired.

Just as gently take the baby away at the expiration of the allotted time.

Take it with a cheerful, smiling word, and do not comment upon mother's happy, thoughtful face, she will quickly collect herself and enter into the spirit of quiet congratulation that should now permeate the home.

THE FIRST BREAKFAST AFTER LABOR.--If the patient has pa.s.sed a comfortable night, feels well, and is free from temperature, and has a normal pulse, breakfast will consist of a cup of warm milk, or a cup of cocoa made with milk, a piece of toasted bread, and a light boiled egg; or if preferred a cereal with milk and toasted bread. This will be the breakfast for the two following days also. The milk, or the cocoa (whichever is taken), must be sipped, while the attendant supports the patient's head. The cereal, or the egg (whichever is taken), must be fed to the patient out of a spoon. The patient must not make any physical effort to help herself; she must remain relaxed. Even when she sips her milk, or cocoa, she must not make any effort to raise her head; the nurse must support its entire weight. This will be the absolute routine of every meal until the physician gives permission to change the procedure. It is a waste of time to formulate rules only to disobey them.

Shortly after breakfast the patient's toilet should be attended to. She should have her hair combed, and her face and hands washed. The hair on the right half of her head should be combed while the head rests on the left side, and vice versa. The water used for washing the hands and face should be slightly warmed. It is best to keep the hair braided and to consult the wishes of the patient as to the frequency of combing it. [Page 106]

THE IMPORTANCE OF EMPTYING THE BLADDER AFTER LABOR.--An effort should be made now to have the patient urinate. This is very important at this time, as it is not an uncommon experience to find that the abdominal muscles are so worn out and overstrained with the fatigue of labor that they refuse to act when an effort is made to urinate. As a consequence the bladder becomes distended and may have to be emptied by other means. This condition is a temporary and a painless one, and will rectify itself in a day or two; meantime, if this accident has occurred, it is essential that the bladder should be emptied from time to time until the patient can do it herself. To test this function place the patient on the bed pan into which a pint of hot water has been put, and give her a reasonable time to make the effort to pa.s.s her water. Should she fail, take an ordinary small bath towel and wring it out of very hot water, just as hot as she can tolerate, and spread it over the region of the bladder and genitals: if there is running water in the room, turn it on full and let it run while the towel is in position as above. If the bladder is full, there is a peculiar, irresistible desire to urinate when one hears running water. If this effort fails, report the fact to the physician when he makes his daily call; he will draw the urine and it will be part of his daily duty to give specific instructions regarding this function until nature reestablishes it.

No particular attention need be paid to the bowels for the first two days.

On the morning of the third day, if they have not acted of their own accord, the physician will give the necessary instructions to move them.

The means necessary to accomplish the first movement after a confinement is a matter of choice. The old-time idea was to use castor oil, and while other remedies are now more or less fashionable, castor oil is still an excellent agent. Enemas are frequently used, but their use is questionable in this instance, inasmuch as a movement has not taken place for three days, the object is to clean out the whole length of the intestinal tract, and an enema is limited to part of the large intestine only,--according to how it is given. If the small intestines are not thoroughly emptied, [107]

particles of food may remain there, and if so, they will putrify and the patient runs the risk of developing gas,--sometimes to an enormous extent.

This affliction is painful, and dangerous, and nearly always unnecessary.

It is always, therefore, more safe, and more desirable, to use some agent by the mouth, and we know of no better one than castor oil; and as castor oil can be so masked as to be practically tasteless at any drug-store soda fountain there can be small objection to it. My custom is to send the nurse or husband with an empty gla.s.s to the drug store to have the mixture made there and brought back ready for use. We have frequently obtained it in this way and given it to the patient without her knowing what it was. The best time to give castor oil is two hours after a meal, and two hours before the next meal--i.e., on an empty stomach. It works quicker and does not nauseate when the stomach is empty.

INSTRUCTING THE NURSE IN DETAILS.--The nurse will attend to the patient's discharges by changing the napkins frequently. The bruised parts should be washed twice daily, for the first three or four days. If the nurse is a trained graduate nurse a few directions will suffice. If she is not a trained nurse the physician should be explicit in his instructions. It would be better if he actually showed her just how he wanted this work done. The best way to cleanse the v.u.l.v.ae or privates is to take an ordinary douche bag at the proper height (about three feet) and allow the solution (1 to 2,000 bichlorid) to run over the parts into the douche pan, but do not touch any part of the patient with the nozzle of the douche bag. While she is directing the water with the left hand she should have a piece of sterile cotton in the right hand with which she will gently mop the parts.

This method ensures disengaging any clotted blood and is aseptic. Dry the parts afterwards with a soft sterile piece of gauze and apply a clean sterile napkin.

DOUCHING AFTER LABOR.--A nurse should never give a v.a.g.i.n.al douche without instructions from the physician. Douches are not necessary in the convalescence of ordinary uncomplicated confinement cases. When it is [108]

necessary to give v.a.g.i.n.al douches after a confinement, there are good reasons why they should be given, and it is therefore absolutely essential that they should be given properly, and with the highest degree of aseptic precautions. If these rules are not observed, the danger of causing serious trouble is very great, and as the physician is directly responsible for the conduct of the case, he should in justice to himself and his patient, do the douching himself.

HOW TO GIVE A DOUCHE.--The proper way to give a v.a.g.i.n.al douche after a confinement, when the parts are bruised and lacerated, and when, as a consequence, the possibility of infection is very great, is as follows:

Instruct the nurse to boil and cool about two quarts of water and have another kettle of water boiling. Boil the douche bag and its rubber tubing and the gla.s.s douche tube (do not use the hard rubber nozzle that comes with the ordinary douche bag). Drain off the water after it has boiled for ten minutes, but instruct the nurse not to touch the bag or tube, to leave them in the pan, covered, till the physician uses them. When the physician calls, place the patient on a clean warm douche pan while he is sterilizing his hands and making the solution ready. While he is douching the patient the nurse will hold the bag. The bag should not be held higher than two feet above the level of the patient.

ADVANTAGES OF PUTTING BABY TO THE BREAST EARLY AFTER BIRTH.--The patient can now take, and will likely be ready for, an hour's nap. After the rest it is desirable to put the baby to the nipple, first carefully cleaning the nipple with a soft piece of sterile gauze dipped in a saturated solution of boracic acid. The reasons for this are as follows:

1st. There is in the b.r.e.a.s.t.s of every woman after confinement a secretion known as "colostrum" which has the property of acting as a laxative to the child, in addition to being a food.

2nd. It is advisable that the child's bowels should move during the first twenty-four hours and the colostrum was put there partly for that purpose.

3rd. The act of suckling has a well-known influence on the womb, in [109]

that it distinctly aids in contracting it, and thereby expelling blood-clots and small shreds of the after-birth which might cause trouble if left in.

4th. By nursing the colostrum out of the b.r.e.a.s.t.s, it will favor and hasten the secretion of milk.

5th. It is frequently easier for the baby to get the nipple before the breast is full of milk, and having once had the nipple it will be easier to induce him to take it again when it is more difficult to get.

THE FIRST LUNCH AFTER LABOR.--Lunch will be next in order, and that should consist of a clear soup,--chicken broth, mutton broth, beef broth with a few Graham wafers or biscuits, and a cup of custard or rice pudding. This will be the lunch for the two following days also. The same precautions are to be observed in giving this as were observed with breakfast and as will be observed with all other meals as clearly stated before, and repeated again, so that no mistake may be made. In the middle of the afternoon the patient can take a cup of beef tea or a cup of warm milk.

THE FIRST DINNER AFTER LABOR.--Dinner will consist of more broth, or a plate of clear consomme with a dropped egg, or a cereal, a little boiled rice with milk, and stewed prunes, or a baked apple.

After the bowels have moved, on the third day, and provided the temperature and pulse have been normal since the confinement, the patient can be put on an ordinary mixed diet, particulars regarding which are given on page 121 under the heading "Diet for the nursing mother."