The Mother and Her Child

This chapter has been devoted to "twilight sleep;" the following chapter will consider "nitrous oxid" and other methods of anesthesia in connection with labor, and should be read along with the foregoing discussion in order to obtain an intelligent view of the whole subject of "painless labor."

Since the public has already been told so much about obstetric anesthesia, we deem it best to go into the whole subject thoroughly, so that the expectant mothers who read this book will be able to form an intelligent opinion regarding the question, and thus be in a position to give hearty cooperation to the decision of their physician to employ, or not to employ, any special form of anesthesia or analgesia in their particular case. In order to give the reader a complete understanding of "painless labor," it will be necessary to give attention to that newer and more safe method of obstetric anesthesia called "sunrise slumber." This method of anesthesia consists in the employment of nitrous oxid or "laughing gas," and will be fully considered in this chapter.

OBSTETRIC FEAR

In this connection we desire to reiterate and further emphasize some statements made in the preceding chapter concerning the unnatural fear and abnormal dread of childbirth.

We feel that it is very important in connection with this new movement in obstetrics to reduce the woman's pain and suffering to the lowest possible minimum, that the trials of labor should not be overdrawn and the pangs of confinement overestimated. We must not educate the normal woman to look upon labor as a terrible ordeal—something like a major surgical operation—which, since it cannot be escaped, must be endured with the aid of a deep anesthesia.

The facts are that a very small per cent of healthy women suffer any considerable degree of severe pain—at least not after the first child. We often observe that judicious mental suggestion on the part of the physician or nurse in the form of encouraging words and supporting assurances tends to exert a marked influence in controlling nervousness and subduing the sufferings of the earlier labor pains.

We must not allow the efforts of medical science to lessen the sufferings of child-bearing, to rob womankind of their natural and commendable courage, endurance, and self-reliance.

We do not mean to perpetuate the old superstition that pain and suffering are the necessary and inevitable accompaniments of child-bearing—that the pangs of labor are a divine sentence pronounced upon womankind—and that, therefore, nothing should be done to lessen the sufferings of confinement. Severe and unnatural pain is not at all necessary to childbirth, and there exists no reason under the sun why women should suffer and endure it, any more than they should suffer the horrors of a very painful surgical operation without an anesthetic. In this connection, it should be recalled that analgesic drugs have been introduced into obstetric practice only during the last fifty years, while such methods of relieving pain have been used in general surgery for a much longer period. It is now only sixty-nine years since Simpson first employed anesthetic in obstetrics, while six years afterwards Queen Victoria gave her seal of approval to the use of chloroform in labor cases.

Thirty years ago, in speaking of the expectant mothers, Lusk warned us:

NITROUS OXID—"LAUGHING GAS"

Nitrous oxid, or "laughing gas," was first used in labor cases in 1880 by a Russian physician. During the last twenty-five years it has been used off and on by numerous practitioners in connection with confinement, but not until the last few years has this method of relieving labor pain come into prominent notice.

While the "laughing gas" method of obstetric anesthesia did not gain notoriety and publicity from being exploited in magazines and other lay publications, it did get its initial boost in a very unique and unusual manner. A gentleman who manufactured and sold a "laughing gas" and oxygen mixing machine for the use of dentists, insisted that this method of anesthesia should be used in the case of his daughter, who was about to be confined. This patient was kept under this nitrous oxid anesthetic for six hours—came out fine—no accidents or other undesirable complications affecting either mother or child, and thus another and safe method of reducing the sufferings of childbirth has been fully demonstrated and confirmed, although it had previously been known and used in labor cases to some extent.

Starting from this particular case in 1913, many obstetricians began experimental work with "gas" in labor cases; and, at the time of this writing, it has come to occupy a permanent place in the management of labor, alongside of chloroform, ether, and "twilight sleep."

ANALGESIA VS. ANESTHESIA

The reader should understand the difference between analgesia and anesthesia. Anesthesia refers to the condition in which the patient is more or less unconscious—wholly or partially oblivious to what is going on, and, of course, entirely insensible to all pain. Analgesia is a term applied to the loss of pain sensation. The patient may not be wholly or even partially unconscious—merely under the influence of some agent which dulls, deadens, or otherwise destroys the realization of pain. This is the condition aimed at by the proper administration of any form of "twilight sleep," whether by the scopolamin-morphin method, or by the nitrous oxid ("sunrise slumber") method.

Any method of treatment which can more or less destroy the pain of labor without in any way interfering with its progress, and which in no way complicates its course or leaves behind any bad effects on either mother or child, must certainly be hailed with joy by both the patient and the physician. While chloroform has served these purposes fairly well, there have been numerous drawbacks and certain dangers; and it was the knowledge of these limitations in the use of both chloroform and ether, that has led to further experimentation and the development of these newer methods of producing satisfactory analgesia—freedom from pain—without bringing about such a state of profound anesthesia as accompanies the administration of the older methods.

It should be borne in mind that in using "sunrise slumber" (nitrous oxid) for labor pains, the gas is so administered that the patient is just kept on the "borderline"—in a typical "twilight" state—and not in the condition of deep anesthesia which is developed when nitrous oxid is employed by physicians and dentists as an anesthetic for major and minor surgical operations.

Analgesia is the first stage of anesthesia—the "twilight zone" of approaching unconsciousness—in which the sense of pain is greatly dulled or entirely lost, while even that which is experienced is not remembered. It seems to the authors that "gas" is the ideal drug for producing this condition whenever it is necessary, as nitrous oxid is the most volatile of anaesthetics, acts most quickly, and its effects pass away most rapidly, while its administration is under the most perfect control—it may be administered with any desired proportion of oxygen—and may be discontinued on a moment's notice. It is practically free from danger even when continued as an analgesic for several hours. Nitrous oxid never causes any serious disturbance in the unborn child, as chloroform sometimes does when used too liberally.

EFFECTS OF NITROUS OXID

It will not be necessary to compare the favorable and unfavorable claims for nitrous oxid as we did the contentions for and against "twilight sleep." Whatever service "laughing gas" or "sunrise slumber" can render the cause of obstetrics we can accept, knowing full well that, in competent hands, it can do little or no harm; and this we know from the facts herewith recited and from the further fact that we have gained a wide experience with this agent in the practice of both dentistry and surgery. In a general way, the influence of "sunrise slumber" on mother and child may be summarized as follows:

1. It can accomplish its purpose—can quite satisfactorily relieve the mother of severe pain—when employed as an analgesic. It is not necessary to administer the gas to the point of anesthesia except at the height of suffering at the end of the second stage of labor, when the head of the child is passing through the birth canal.

2. This method can be stopped at any moment—the patient ran be brought out from under its influence entirely and almost instantaneously. It is not like a hypodermic injection of a drug which may exert a varying and unknown influence upon the patient, and which, when once given, cannot be recalled.

3. It is a method which may be used in the patient's home just as safely as in a hospital; the only drawback being the inconvenience of transporting the gas-containing cylinders back and forth. This is even now partially overcome by the improved combination gas and oxygen form of apparatus which has been devised.

4. The administration of nitrous oxid analgesia or anesthesia does not interfere with or lessen the uterine contractions or expulsive efforts on the part of the mother—at least not to any appreciable extent.

5. Just as soon as a severe uterine contraction—attended by its severe pain—begins to subside, the gas inhaler is immediately removed, and in a few seconds the patient is again conscious. It is not necessary to keep the patient continuously under the influence of the drug, as in the case of the scopolamin-morphin method of "twilight sleep."

6. This method ("sunrise slumber") is certainly far more safe in ordinary and unskilled hands than the "twilight sleep" procedure. The patient is more safe with this method in the hands of the average doctor or trained nurse.

7. It has been our experience that nitrous oxid in the smaller, interrupted and analgesic doses, actually tends to stimulate the uterine pains and contractions, while at the same time rendering the patient quite oblivious to their presence. When properly administered, the freedom from pain is perfect.

8. Under the influence of "gas," patients often appear to "bear down" with increased energy. It certainly does not lessen their cooperation in this respect.

9. We have not observed, nor have we learned of, any cases of inertia (weak and delayed contractions), post partum hemorrhage, or shock, as a result of "laughing gas" or "sunrise slumber" analgesia.

10. This method lends itself to perfect control—it may be decreased, increased, or discontinued, at will; it may be given light now and heavy at another time; while, at the height of labor, it may be pushed to the point of complete anesthesia, if desired.

11. We have found "sunrise slumber" (nitrous oxid) analgesia to be the ideal obstetric anaesthetic, and have adopted it quite to the exclusion of both chloroform and "twilight sleep." We find that this form of analgesia has all the advantages of "twilight sleep" without any of its dangers or disadvantages.

12. A possible objection to the nitrous-oxid method is the cost, especially in the private home. The average cost in the hospitals where we are using this method runs about $2.00 for the first hour and $1.50 for each hour thereafter. This is the cost when using large tanks of gas, and is, of course, somewhat increased when the smaller tanks are used in the patient's home.

METHOD OF ADMINISTRATION

Since it was thought best to give the reader some idea of the technic for the administration of "twilight sleep," it may not be amiss to explain how "sunrise slumber" is usually employed in labor cases. The technic is very simple. The administration of the gas is generally begun about the time the patient begins seriously to complain of the severity of the second stage pains; although, of course, the gas can be given during the first stage pains if desired. In the vast majority of cases, however, we think it is best to encourage the patient to endure these earlier and lighter pains without resorting to analgesic procedures.

The form of apparatus used is the same as that employed by dentists and contains both nitrous oxid and oxygen cylinders. A small nasal inhaler is best, although the ordinary mouthpiece will do very well. The gasbag attached to the tank should be kept under low pressure and, as a pain begins, the patient is told to breathe quietly, keeping the mouth closed. As a rule this sort of light inhalation serves to produce the desired analgesic effect. It is not necessary to put the patient deeply under in order to relieve the pain.

It is our custom to begin "sunrise slumber" as soon as the uterine contractions become painful. The earlier the gas is started, the more oxygen should be used. Two or three inhalations will suffice to take the "edge" off the earlier and lighter pains. When the pains grow heavier we use less oxygen and permit three or four deep inhalations just before a bearing-down pain. At the first suggestion of a contraction, the patient must begin to inhale the gas; while after the patient has pulled hard on the traction strops—just as the contraction pain is passing—she is given an inhalation containing a larger percentage of oxygen.

At the beginning of a pain, pure nitrous oxid is administered, and the patient is instructed to breathe deeply and rapidly through the nose. The gasbags should be about half filled. The mixture of gas and oxygen must be determined by the severity of the pains and individual behavior of the patient.

Four to six inhalations of the gas are sufficient to produce the required analgesia in the average case. Following the first few deep inspirations through the nose, the patient can be instructed to breathe through the mouth, while the gas is well diluted with oxygen and continued until the end of the pain. In this way a satisfactory analgesia is maintained throughout the "pain" with a minimum of "gas." The proportion of oxygen used will run from nothing up to ten per cent. This procedure is repeated with the occurrence of each pain.

The use of the "mask" is just as effective as a nasal inhaler, but wastes more gas and so is more costly.

When the head is passing the perineum the gas should be pushed to the point of anesthesia, while the patient's color will suggest the amount of oxygen to be used as well as serve to control the administration of the nitrous oxid.

CHLOROFORM AND ETHER

For many years chloroform and ether have been used to alleviate the pains of women in labor. Valuable as these agents are when deep anesthesia is required for the carrying out of operative procedures, they have not proved satisfactory as analgesic agents. If administered in small quantities at the commencement of a strong uterine contraction, the patient does not usually inhale sufficient to abolish pain. She is then apt to be irritated and is certain to insist on being given a larger quantity. If a sufficient amount be administered to satisfy the woman, the continued repetition gradually inhibits the power both of the uterus and of the accessory muscles, so that labor is unnecessarily prolonged, and, possibly, the life of the fetus endangered. Physicians have, therefore, been accustomed to employ these drugs very sparingly, restricting their use to the very end of the second stage, during the painful passage of the head through the vulva. The results of the administration at this time are also uncertain. If delivery be rapid the woman may not be able to inhale sufficient to abolish her consciousness of pain. If it be slow she may take too much and weaken the muscular powers, thereby prolonging labor and, often, necessitating forceps delivery. It is not surprising, therefore, that the medical profession has long been hoping that a more satisfactory method of relieving the pain of labor would be found.

CONCLUSIONS

In summing up our conclusions regarding analgesia and anesthesia in labor cases, the authors would state their present position as follows:

1. That anesthetics or analgesics are a necessary accompaniment of confinement in this day and age; that the average labor case demands some sort of pain-relieving agent at some time during its progress; but that intelligent efforts should be put forth to limit and otherwise control their use. While we recognize the necessity for avoiding needless suffering, at the same time we must also avoid turning our women into spineless weaklings and timid babies.

2. That we should seek to develop, strengthen, and train our girls for a normal and natural maternity; that we should study to attain something of the naturalness and the painlessness of the labors of Indian tribes; and, even if we partially fail in this effort, we shall at least leave our women with ennobled characters and strengthened wills.

3. That the scopolamin-morphin method of inducing "twilight sleep" has its place—in the hands of experts—and in the hospital; and that in many cases it probably represents the best method of obstetric anesthesia which can be employed.

4. That as a general rule and in general practice, the safest and best method of inducing the "twilight" state of freedom from severe pain, is by the use of nitrous oxid or "laughing gas"—the "sunrise slumber" method. It has been our practice to start all general ether anesthetics with "gas" for a number of years, while we have been doing an increasing number of both minor and major operations with "gas" alone.

5. That we still employ general ether or chloroform anesthesia in Cesarean sections and other major obstetric operations, although several operators are beginning to use "gas" in even these heavy cases.

6. That the intelligent and careful use of pituitary extract in certain cases of labor serves greatly to shorten the second stage; that it is of great value in certain "slow cases," and serves greatly to reduce the use of low forceps.

We have treated the subject of obstetric anesthesia in this full manner, because of the fact that so much has appeared in the public press on these subjects, and, further, because we desired that our readers should have placed before them the facts on all sides of the question just as fully as a work of this scope would permit.

Popularly spoken of as the "lying-in period," and medically known as the puerperium, this time of convalescence immediately following childbirth is usually occupied by two important things: the restoration of the pelvic organs to their normal condition before pregnancy, and the starting of that wonderfully adaptative mechanism concerned with the production of the varying and daily changing food supply of the offspring.

The uterus, now more than fifteen times its normal size and weight, begins gradually to contract and assume its normal weight of about two ounces; and it requires anywhere from four to eight weeks to accomplish this involution. In view of all this it is obvious that there can be no fixed time to "get up." It may be at the end of two weeks, or it may not be until the close of four or five weeks, in the case of the mother who cannot nurse her child; for the nursing of the breast greatly facilitates the shrinking of the uterus. Extensive lacerations may hinder the involution as well as other accidents of childbirth, so it must be left with the physician to decide in each individual case when the mother may enter into the activities of life and assume the responsibilities of the care of the baby and the management of her home.

THE NURSE

During this period of the puerperium a member of the family, a neighbor, a visiting nurse, a practical nurse, or a trained nurse, looks after the mother and gives to the babe its first care; whoever it may be, certain laws of cleanliness must be carried out if infection is to be guarded against. If there are daily or semi-daily calls made by the physician, a member of the family may be trained to care for the mother with proper cleanliness and asepsis; but it is far better for the mother, if possible, to secure the services of a trained nurse, or the visiting nurse, in which instance she will call each day, wash and dress the baby, clean up the mother and care for the breasts. She is not supposed to clean the room, make the bed or prepare the food. If a trained nurse can be in charge, the convalescing time is usually shortened as the responsibilities are taken from the mother, her mind freed from care and it is her's to improve, rest, and wait for the restoration of the pelvic organs, when she may again go forth among her family.

The nurse may have to sleep in the same room; but, if it be possible, she should occupy an adjoining room, she should have a regular time each day for an hour's walk in the fresh air, she should be served regular meals, and be allowed some time out of the twenty-four hours for unbroken slumber. In return she will intelligently cooperate with the physician in bringing about the restoration of body and upbuilding of the mother's nerves.

REST AND EXERCISE

From a monetary standpoint there can be nothing so wasteful or extravagantly expensive in the home as to allow the mother to drag about from day to day and week to week with chronic weakness or invalidism because she did not have proper care during her already too short puerperium, or because she got up too soon.

Having a baby is a perfectly normal, physiological procedure. It is also, usually, downright hard work; and, beside the hard laborious work, there is not only a wearied and severely shocked nervous system to be restored, but there is also a certain amount of uterine shrinkage which must take place—and this requires from four to eight weeks; and so our mother must be allowed weeks or even a month or two to rest, to enjoy a certain amount of well-directed exercise, to have an abundance of fresh air, to be wheeled or lifted out of doors if possible into the sunshine, that she may be the better prepared for the additional duties and responsibilities the little new comer entails. Sunshine and fresh air are wonderful health restorers as is also a well-directed cold water friction bath administered near the close of the second week of a normal puerperium. During the second week a few carefully selected exercises such as the following are not only beneficial, but tend to increase circulation and thus to promote the secretion of milk and the shrinking of the uterus.

1. Head raising, body straight and stiffened.
2. Arm raising, well extended.
3. Leg stretching, with knees stretched and toe extended.
4. Massage, administered by the nurse.

A splendid tonic circulatory bath may be administered at the close of the second week (in normal puerperium), known as the "cold mitten friction," which is administered as follows: The patient is wrapped in a warm blanket, hot water bottle at feet, and each part of the body—first one arm then the other; the chest, the legs, one at a time—is briskly rubbed with a coarse mit dipped in ice water. As one part is dried it is warmly covered, while the next part is taken, and so on until the entire body has been treated. The body is now all aglow, the blood tingling through the veins, and the patient refreshed by this wide-a-wake bath. Properly given, the cold-mitten friction bath is one of the most enjoyable treatments known and under ordinary conditions, if intelligently administered, may be given as early as the eighth day.

AFTER PAINS

After the birth of the first baby the uterus usually is in a state of constant contraction, hence there are no "after pains;" but after the birth of the second or third child, the uterine muscle has lost some of the tone of earlier days—there is a tendency toward relaxation—so that when the uterine muscle does make renewed efforts at contraction, these "after pains" are produced. They usually disappear by the third day. Nothing should be done for them, indeed they should be welcomed, for their presence means good involution (contraction) of the uterus.

THE TEMPERATURE

Careful notations of the temperature should be made during the first week. A temperature chart should be accurately kept and if the temperature should rise above 100° the physician should be notified at once. The third day temperature is watched with expectancy, for if an accidental infection occurred at the time of labor, it is usually announced by a chill and sudden rise of temperature on the third day. This may be as good a place as any to mention the commonly met night sweating. This is due to a marked accentuation of the function of the skin. It is not at all unusual for a sleeping mother in the early puerperium to wake up in a sweat with night gown very nearly drenched. The gown should be changed underneath the bedding, while alcohol is rubbed over the moistened skin surface.

These sweats will disappear as soon as the mother begins to regain her strength. A vinegar rub administered on going to bed may often prevent these sweats.

THE TOILET OF THE VULVA

Immediately after the birth of the baby and the expulsion of the afterbirth, the thighs and vulva are cleansed as follows: Into a basin of warm, boiled water are dropped four small antiseptic tablets of bichlorid of mercury; this gives a proper antiseptic wash. Into this solution are placed four pieces of sterile cotton Two of these are used, one at a time, without being returned to the solution to wash each inside of the thigh, the remaining two to cleanse the vulva. Without drying the vulva, two sterile pads are applied and pinned to the binder. These pads are changed every hour during the first day or two because of the profuse lochial flow.

After each urination and bowel movement, a lysol solution (prepared by putting one teaspoonful of lysol in a quart of sterile water) is poured from a clean pitcher over the vulva into the bed pan, and fresh pads applied. This toilet continues until the close of the second week or longer, if there is a lochial flow.

These sterile pads not only absorb the lochia but also, among ignorant or thoughtless mothers, prevent contamination by the patient's hands.

URINATION

The patient should be encouraged to urinate during the first few hours after labor; catheterization should not take place until every effort has been made to bring about normal urination; or, until there is a well marked tumor above the bony arch of the pelvis in the lower part of the abdomen. It is far less harmful to the patient for her to sit up on the jar placed on the edge of the bed, than to undergo the risk of inflammation of the bladder which so often follows catheterization.

THE LOCHIA

The first few days the lochia is very red because of the large amount of blood which it contains. After the third or fourth day it is paler and after the tenth it assumes a whitish or yellowish color. During the three changes it should always smell like fresh blood. Any foul, putrifying odor should be promptly reported to the physician.

If on getting up at the close of the second week the lochia should resume its red color, the patient should return to bed and notify her physician.

THE ABDOMINAL BINDER

After the tenth day, the abdominal binder may be pinned as tightly as the patient desires, but prior to the tenth day many physicians believe the exceedingly tight binder causes misplacements of the enlarged, softened, and boggy uterus. It should be pinned snugly; but not drawn as tight as possible with the idea of keeping the uterus from relaxing, for at best, it does not do it; while tight constriction may produce a serious turning or flexion of the uterus. The breast binder is applied during the first twenty-four hours to support the filling breasts, loosely at first, and as they increase in size, as the glands become engorged, the binder is drawn more tightly. A sterile piece of gauze is placed over the nipples.

THE BOWELS

On the morning of the second day a cathartic is usually given—say one ounce of castor oil or one-half bottle of citrate of magnesia. The bowels should move at least once during each twenty-four hours; if they are obstinate, a simple laxative may be nightly administered. Certain constipation biscuits, sterilized dry bran, or agar-agar may be eaten with the breakfast cereal. Prunes and figs should be used abundantly. Bran bread should be substituted for white bread. The enema habit is a bad one and should not be encouraged; however, the enema is probably less harmful than the laxative-drug habit. Mineral oil is useful as a mild laxative, and does not produce any bad after results.

CARE OF THE NIPPLES

Fissures of the nipples should be reported to the physician at once. There are many good remedies which the physician may suggest; in his absence, Balsam Peru may be advantageously applied. Boracic acid solution should be applied before and after each nursing from the very first day; in this way much nipple trouble may be prevented through cleanliness and care. The nipples should be kept thoroughly dry between nursings Nipple shields should be used where fissures persist.

THE DIET

For the first three days a liquid and soft diet is followed such as hot or cold milk, gruels, soups, thin cereals, eggnog (without whiskey), eggs, cocoa, dry toast, dipped toast, or cream toast. There should be three meals with a glass of hot milk at five in the morning (if awake) and late at night; nothing between meals except plenty of good cold water. After the third day, if temperature is normal, a semi-solid diet may be taken, such as baked, mashed, or creamed potatoes, soups thickened with rice, barley or flour, vegetables (peas, corn, asparagus, celery, spinach, etc.); eggs, light meats, stale breads, toast, bland or subacid fruits (sweet apples, prunes, figs, dates, pears, etc.); macaroni, browned rice (parched before steaming), etc.; ice cream, custards, and rice puddings for desserts after the seventh day. Three good meals a day, at eight and one and six, with a couple of glasses of hot milk or cocoa or an eggnog at five a. m., to be repeated at 9 or 10 p. m., with plenty of cold water between the meals, will abundantly supply the necessary milk for the growing babe. Tea and coffee are not of any special value in encouraging a flow of milk.

The constant coaxing of the mother with "Do drink this," and "You must drink this, or you won't have any milk," not only saddens her but seriously upsets digestion and thus indirectly interferes with normal lactation.

GETTING UP

Everybody should stay at home and away from the mother and her new born child until after the seventh day, and then, if our patient is normal, visitors may call, but should not stay longer than five minutes. The convalescing mother will improve faster without the neighborhood gossip, or the tales of woe so often carried by well-meaning, but woefully ignorant acquaintances.

When the hard ball-like mass can no longer be felt in the lower abdomen, when the lochia has passed through the three changes already mentioned, and the flow is whitish or yellowish, scanty and odorless, the patient may sit up in a chair increasingly each day. Such conditions are usually found anywhere from the tenth to the fifteenth day. The patient first sits up a little in a chair—she has already been exercising some in bed—and this enables her to sit up with ease for a half-hour the first day, increasing one-half hour each day during the week following. At the end of three weeks, she may be taken down stairs providing there is ample help to carry her back up stairs. After another week (at the close of the fourth), if the lochia is entirely white or yellow, with no blood, she may begin carefully to go about the house. There should be no lifting, shoving, pulling, wringing, sweeping, washing, ironing, or other heavy exercise for at least another two weeks, better four weeks. Any variance from this program usually means backache, lassitude, diminished milk supply, and frequently a general invalidism for weeks or months—sometimes years.

COMPLICATIONS

Cystitis, or painful urination, is avoided by tardy "getting up;" quietly, slowly moving about; abundant water drinking; and the avoidance of catheterization.

Hemorrhage. Notify the physician if it occurs at any time. The treatment is heavy kneading of the abdomen until the uterus again becomes like a hard ball. Cold compresses over the lower abdomen may sometimes help.

Infection is manifested by chilly sensations or a distinct chill followed by fever, usually on the third day. Take a cathartic; notify the physician at once and follow his directions.

Mastitis, inflammation or caking of the breasts. Very hot fomentations wrung out of boiling water, alternating with ice-cold compress, should be applied to the breast for an hour or more, three or four times a day. Cathartics should be administered, and eliminative measures instituted such as the hot-blanket pack.

Pneumonia. Keeping the arms and chest well protected by a long-sleeved coat of warm texture, should help in preventing this serious complication. Pneumonia complicating labor is usually the result of carelessness and exposure.

PART II

THE BABY

PART II

Happy is the mother and fortunate is the home that possesses the intelligent services of a trained attendant during the early days of the baby's career. A century or more ago skilled nurses were unheard of, and both mothers and babies seemed to thrive on the unskilled but faithful and sympathetic care given by the willing neighbor who "thought I'd just run over and help out." Who of us cannot remember the days when mother was "gone to a neighbor's" to give this same willing but unskilled care at the time of "confinement."

MODERN METHODS

And why are we so concerned today about asepsis, sterilization, etc., when a generation ago they were not? We used to live more slowly than we do now. Then it took the entire day to do the marketing for the week, now we take a receiver from the hook and a telephone wire transmits the verbal message. Our days are literally congested with events that were almost impossibilities a century ago. The ease and leisure of former days are unknown and unheard of today. The artificial way in which we live exerts more or less of a strain upon the present generation; the average woman's nervous system is keyed up to a high pitch; her general vital resistance is running at a low ebb; while child-bearing brings a certain added stress and strain that requires much planning to avoid and overcome.

For many days and ofttimes weeks the mother is unfit—physically unable—properly to care for her child, and so whether it be the trained assistant in constant attendance or the visiting nurse in her daily calls, or the kind, willing, but unskilled neighbor—each helper must acquaint herself, in varying degrees, with the physical, nervous, and mental needs of the child, as well as take into account and anticipate the numerous habits and wants of the new born babe, such as urination, bowel movement, pulse, respiration, temperature, etc.

THE HEAD

At birth, the head is remarkably large as compared to the rest of the body, for, surprising as it may seem, the distance from the crown to the chin is equal to the length of the baby's trunk; and, too, if birth has been prolonged this large head has also been pressed or squeezed somewhat out of shape. This state of affairs, however, need give no cause for either alarm or anxiety, for the head will shape itself to the beautiful rotundity of the normal baby's head within a few days.

The general shape of the baby's head, as seen from above is oval. Just back of the forehead is formed a diamond-shaped soft spot known as the anterior fontanelle which should measure a little more than one inch from side to side. On a line just posterior to this soft spot and to the back of the head, is found another soft spot somewhat smaller than the one in front. Gradual closure of these openings in the bones occurs, until at the end of six or eight months, the posterior fontanelle is entirely closed; while eighteen months are required for the closure of the anterior fontanelle.

These "soft spots" should not be depressed neither should they bulge. The head is usually covered with a growth of soft, silky hair which will soon drop out, to be replaced, however, by a crop of coarser hair in due season. The scalp should always be perfectly smooth. Any rash or crusts or accumulation of any kind on the scalp is due to uncleanliness and neglect, and should be carefully removed by the thorough application of vaseline followed by a soap wash. The vaseline should be applied daily until all signs of the accumulation are entirely removed. The eyes of all babies are generally varying tints of blue, but usually change to a lighter or darker hue by the seventh or eighth week. The whitish fur which often is seen on the baby's tongue is the result of a dry condition of the mouth which disappears as soon as the saliva becomes more abundant.

CHEST, ABDOMEN, AND LEGS

The baby's chest, as compared to the size of the head and abdomen, appears at a disadvantage, while the arms are comparatively short and the legs particularly so, since they measure about the same as the length of the trunk. They naturally "bow in" at birth so that the soles of the feet turn decidedly toward each other. All these apparent deformities, as a rule, right themselves without any help or attention whatsoever.

PULSE AND RESPIRATION

The pulse may be watched at the anterior fontanelle or soft spot on top of the head while the child quietly sleeps and should record, at varying ages, as follows:

The above table is correct for the inactive normal child. Muscular activity, such as crying and sucking, increases the pulse rate from 10 to 20 beats per minute.

The respiration of the baby often gives us no small amount of real concern at the first. The baby may be limp and breathless for some few moments at birth, and this condition calls for quick action on the part of the nurse and doctor.

The utmost care to avoid the "sucking in" of any liquid or blood during its birth must be exercised, for this often seriously interferes with the breathing. Sometimes this condition is not relieved until a soft rubber catheter is placed in the throat and the mucus is removed by quick suction. When you are reasonably sure that there is no more mucus in the throat, then sudden blowing into the baby's lungs (its lips closely in touch with the lips of the nurse or physician) often starts respiration. Slapping it on the back also helps, while the quick dip into first hot then cold water seldom fails to give relief.

A quiet-sleeping infant breathes as shown below at varying ages. An increase of six to ten breaths per minute may be allowed for the time it is awake or otherwise active.

THE WEIGHT

The normal weight of the average baby is seven to seven and one-half pounds. Its length may range anywhere from sixteen to twenty-two inches.

There is an initial loss of weight during the first few days; however, after the milk has been established the child should make a weekly gain of four to eight ounces until it is six months old, after which time the usual gain is from two to four ounces per week.

If the weight has been doubled at six months and the weight at one year is three times the birth weight, the child is said to have gained evenly and normally.

THE SKIN

At birth the skin of the baby is red and very soft owing to the presence of a coating of fine down. A blue-tinged skin may be occasioned by unnecessary exposure or it may be due to an opening in the middle partition of the heart which should close at birth. As soon as the baby is born, it should be placed on its right side while the cord is being tied, as this position facilitates closure of this embryonic heart opening. With the provision for a little additional heat the blue color should disappear, if it is not due to this heart condition. At the close of the first week the red color of the skin changes to a yellow tint due to the presence of a small amount of bile in the blood. This sort of jaundice is very common and is in no wise evidence of disease. The "down" falls off with the peeling of the skin which takes place during the second week; by the end of which time, the skin is smooth and assumes that delightful "baby" character so much admired.

THE CORD DRESSING

The cut end of the tied umbilical cord is swabbed and squeezed with a sterile sponge saturated with pure alcohol. It is then wrapped in a sterile dressing made as follows: Four or five thicknesses of sterile cheese cloth are cut into a four-inch square with a small hole cut in the center and one side cut to this center. This is slipped about the stump of the cord and wrapped around and about in such a manner as entirely to cover the stump of the cord. The wool binder is then applied and sewed on, thus avoiding both pressure and the prick of pins. If it remains dry this dressing is not disturbed until the seventh or eighth day, when the cord ordinarily drops off. Should it become moistened the dressing is removed and the second dressing is applied exactly like the first.

THE EYES

The closed eyes of the newly born child are generally covered with mucus which should be carefully wiped off with a piece of sterile cotton dipped in boracic acid solution, in a manner not to disturb the closed lid. A separate piece of cotton is used for each eye and the swabbing is done from the nose outward. The physician or nurse drops into each opened eye two drops of twenty per cent argyrol, the surplus medicine being carefully wiped off with a separate piece of cotton for each eye. The baby should now be placed in a darkened corner of the room, protected from the cold.

The eyes are washed daily by dropping saturated solution of boracic acid into each eye with a medicine dropper. Separate pieces of gauze or cotton are used for each eye.

THE FIRST OIL BATH

As soon as the cord and the eyes have received the proper attention and the mother has been made comfortable, the baby is given its initial bath of oil. This oil may be lard, olive oil, sweet oil, or liquid vaseline. The oil should be warmed and the baby should be well covered with a warm blanket and placed on a table which is covered with a thick pad or pillow. The temperature of the room should be at least eighty degrees Fahrenheit. Quickly, thoroughly, and carefully the entire body is swabbed with the warmed oil—the head, neck, behind the ears, under the arms, the groin, the folds of the elbow and knee—no part of the body is left untouched, save the cord with its dressing. This oil is then all gently rubbed off with an old soft linen towel.

THE FIRST CLOTHING

After the oil bath, the silk and wool shirt (size No. 2), the diaper and stockings are quickly put on to avoid the least danger of chilling. The band having been applied at the time of the dressing of the cord, our baby is now ready for the flannel skirt. This should hang from the shoulders by a yoke of material adapted to the season, cotton yoke without sleeves if a summer baby, and a woolen yoke with woolen sleeves if a winter baby. The outing-flannel night dress completes the outfit and should be the only style of dress worn for the first two weeks. Loosely wrapped in a warm shawl, the baby is about ready for its first nap, save for a drink of cooled, boiled water.

This cooled, boiled, unsweetened water should be given in increasing amounts every two hours until the child is two or three years of age. It is usually given the child in a nursing bottle. In this way it is taken comfortably, slowly, can be kept clean and warm, and should the babe be robbed of its natural food and transferred to the bottle as a substitute for mother's milk, it will already be acquainted with the bottle and thus one-half of a hard battle has already been fought and won.

BABY'S FIRST NAP

The baby's bed should be separate and apart from the mother's. It may be a well-padded box, a dresser drawer, a clothes basket, or a large market basket. A folded comfortable slipped in a pillow slip makes a good mattress. A most ideal bed may be made out of a clothes basket; the mattress or pad should come up to within two or three inches of the top, so the baby may breathe good fresh air and not the stale air that is always found in a deeply made bed. Into this individual bed the baby is placed as soon as it is dressed; and a good sleep of four to six hours usually follows.

Frequent observations of the cord dressing should be made as occasionally hemorrhage does take place, much to the detriment of the babe. If bleeding is at any time discovered the cord is retied just below the original tying. By the time baby has finished a six- or eight-hour nap the mother is wondrously refreshed and is ready to receive it to her breast.

PUTTING TO THE BREAST

During the first two days the baby draws from the breasts little more than a sweetened watery fluid known as the colostrum; but its intake is essential to the child in that it acts as a good laxative which causes the emptying of the alimentary tract of the dark, tarry appearing stools known as the meconium. On the third day this form of stool disappears and there follows a soft, yellow stool two or three times a day.

The child should be put to the breast regularly every four hours; two things being thus encouraged: an abundant supply of milk on the third day and the early shrinking of the uterus. More than once a mother has missed the blessed privilege of suckling her child because some thoughtless person told her "why trouble yourself with nursing the baby every four hours, there's nothing there, wait until the third day;" and so when the third day came, there was little more than a mere suggestion of a scanty flow of milk, which steadily grew less and less.

THE URINE

The urine of the very young child should be clear, free from odor and should not stain the diaper, nor should it irritate the skin of the babe. Often urination does not take place for several hours, sometimes not at all during the first twenty-four hours. If the infant does not show signs of distress, there is no cause for alarm; the urine should pass, however, within thirty hours. As a rule there are usually between ten and twenty wet diapers during each twenty-four hours. The following table shows about the amounts of urine at different ages:

GENITALS OF THE MALE CHILD

The foreskin of the male child is often long, tight, and adherent, and is often the direct cause of irritability, nervousness, crying, and too frequent urination. It should be closely examined by both physician and nurse and when the foreskin does not readily slip back over the acorn-like head of the organ, circumcision is advised early in the second week. This simple operation will start the child out on his career with at least one moral handicap removed and one desirable possibility established—that of being able to keep himself clean.

POST-OPERATIVE CARE OF CIRCUMCISION

The dressings that are loosely applied at the time of the operation should remain untouched (especially those next to the skin), unless otherwise directed by the physician, until the seventh or eighth day when the babe is placed in a warm soap bath, at which time the dressings all come off together. Clean sterile gauze is so placed as entirely to protect the inflamed skin from the diaper at all times before this bath, and these same dressings should be continued for at least another week. Sterile vaseline (from a tube) should be applied twice a day after the original dressings are removed in the bath at the end of the first week. There should be little or no bleeding following the operation, neither should the penis swell markedly; if either complication should occur, the physician should be promptly notified.