4. Cotton pledgets. These are cotton balls, made as you would a light biscuit with the twist of the cotton to hold it in shape. They should be about the size of the bottom of a teacup. These are thrown in a couple of pillow slips and wrapped and marked.
5. The Bobbin. Cut the bobbin or tape into four nine-inch lengths and wrap and mark.
6. The tooth picks are left in the original package and do not require sterilization.
7. Sterilization. Before steaming and baking, wrap each bundle in another wrapping of cloth and pin again securely. Mark each package plainly in large letters or initials. These packages may be sent to the hospital for sterilization in the autoclave or they may be steamed for one hour in the large wash boiler, by placing them loosely into a hammock-like arrangement made by suspending a firm piece of muslin from one handle of the boiler to the other. The center of the hammock should come to within five inches of the bottom of the boiler which contains three inches of boiling water. The cover of the boiler is now securely weighed down and the water boils hard for one hour, at the end of which time they are removed and placed in a warm oven to dry out. The outer wrapping may be slightly tinged with brown by this baking. After a thorough drying they are allowed to remain in the same wrappings into which they were first placed and put away in a clean drawer awaiting the "Natal Day."
Each hospital has its own methods and regulations for caring for obstetrical patients and it is well for the expectant mother to visit the obstetrical section, the delivery-room and the baby's room, that she may personally know more about the place where she is to spend from ten days to two weeks. Here she may ascertain from the superintendent just what she will need to bring for the baby. Many of the hospitals furnish all the clothes needed for the baby while in the hospital; in such instances, the hospital also launders them. Other hospitals require the baby's clothes to be brought in, in which case the mother looks after the laundry. The mother always takes her toilet articles, a warm bed jacket with long sleeves, several night dresses and a large loose kimono or wrapper to wear to the roof garden or porch in the wheel chair. Warm bedroom slippers and a scarf for the head completes the outfit.
Baby's basket on the day of confinement should contain:
By special preparation, the ordinary bedroom may be fashioned into a delivery-room. Carpets, hangings and upholstered furniture must be removed. Clean walls, clean floors, and a scrupulously clean bed must be maintained throughout the puerperium. Bathroom, and if possible, a porch should be near by. In the wealthy home, a bedroom, bathroom and the nursery adjoining is ideal; but I find that real life is always filled with anything but the ideal.
The dispensary doctor is compelled to depend upon clean newspapers to cover everything in the room he finds his patient in. The only sterile things he uses he brings with him, and should he have to spend the night, the floor is his only bed. A student who was in my service told me that there was not one article in the entire home, which consisted of but one room, that could be used for the baby. He wrapped his own coat about it and laid it carefully in a market basket and placed it on the floor at the side of the pallet on which the mother lay and by the aid of a nearby telephone secured clothes from the dispensary for the babe.
Always select the best room in the house for a home confinement. If the parlor is the one sunny room, take it; remove all draperies, carpet, etc., and make it as near surgically clean as possible. While sunshine is desirable, ample shades must be supplied, as the eyes of both mother and babe must be protected.
A three-quarter bed is more desirable than a double bed. If it is low, four-inch blocks should be placed under each leg, the casters having been removed to prevent slipping. The bed should be so placed that it can be reached from either side by the nurse and physician. The mattress may be reenforced by the placing of a board under it if there is a tendency to sag in the middle. Over this mattress is securely pinned the strip of rubber sheeting or table oilcloth. A clean sheet covers mattress and rubber cloth and at the spot where the hips are to lie may be placed the large sterile pad to absorb the escaping fluids. The floor about the bed is protected by newspapers or oilcloth. Good lighting should always be provided. Much trouble and possible infection may be avoided by clean bedding, plenty of clean dressings, boiled water, rubber gloves, and clean hands.
As the two hundred and seventy-three days come to a close, our expectant mother approaches the day of labor with joy and gladness. The long, long waiting days so full of varied experiences, so full of the consciousness that she, the waiting mother, is to bring into the world a being which may have so many possibilities—well, even the anticipated pangs of approaching labor are welcomed as marking the close of the long vigil. These days have brought many unpleasant symptoms, they have been days of tears and smiles, of clouds and sunshine.
The prospective mother has thought many times, "Will my baby ever come?" But nature is very faithful, prompt, and resourceful. She ushers in this harvest time under great stress and strain, for actual labor is before us—downright, hard labor—just about the hardest work that womankind ever experiences—and, as a rule, she needs but little help—good direction as to the proper method of work and the economical expenditure of energy. In the case of the average mother this is about all that is needed, and if these suggestions come from a wise and sympathetic physician—one who understands and appreciates asepsis—she may count herself as fortunately situated for the oncoming ordeal.
In the days of our grandmothers it was almost the exception rather than the rule to escape "child-bed fever," "milk leg," etc.; but in these enlightened days of asepsis, rubber gloves, and the various antiseptics, puerperal infection is the exception, while a normal puerperium is the rule; and this work of prevention lies in the scrupulous care taken by anyone and everyone concerned in any way with the events of the day of labor.
On this day of labor, the mother, who has gone through the long tedious days of waiting, should see to it that nothing unclean—hands, sponges, forcep, water, cloth—is allowed to touch her. Above all things do not employ a physician who has earned the reputation of being a "dirty doctor." Puerperal infection is almost wholly a preventable disease and every patient has a right to insist upon protection against it.
In a former chapter will be found a detailed description of the "delivery bed." Beside this bed, or near by, are to be found the rack on which are airing the necessary garments for the baby's reception—the receiving blanket and other requisites for the first bath—together with numerous other articles essential to safety and comfort.
There should be an easy chair in the room for the mother to rest in between her walking excursions during the first stages of labor. The sterilized pads and necessary articles mentioned in an earlier chapter are, of course, close at hand.
Regular, cramp-like pains in the lower portion of the abdomen which are frequently mistaken for intestinal colic, often beginning in the lower part of the back, and extending to the front and down the thigh, are often the first symptoms of the approaching event. With each cramp or pain the abdomen gets very hard and as the pain passes away the abdomen again assumes its normal condition. These regular cramp-like pains are the result of the early dilation of the cervix—the first opening of the door to the uterine room which has housed our little citizen through the developmental stages of embryonic life—and as a result of this stretching and dilating there soon appears that special blood-tinged mucus flow commonly known as "the show."
At this time a very thorough-going colonic flushing should be administered. The patient takes the "knee-chest" position, or the "lying-down" position, and there should flow into the lower bowel three pints of soapy water; this should be retained for a few moments; and after its expulsion, a short, plain water injection should be given. Now follows the preliminary general bath.
Just prior to the bath, the pubic hair should be clipped closely, or better shaved. Then should follow a thorough soap wash, with patient standing up in the tub, using plenty of soap, applied with a shampoo brush or rough turkish mit. The rinsing now takes place by either a shower or pail pour. Do not sit down in the tub. This is a rule that must not be broken, because of the danger of infection in those cases where the bag of waters may have broken early in the labor.
A weak antiseptic solution, prepared by putting two small antiseptic tablets into one pint and a half of warm water, is now applied to the body from the breasts to the knee. Put on a freshly laundered gown, clean stockings and wrapper. The head should be cleansed and hair braided in two braids.
If all the mothers who read this volume could bear children with the comfort Mrs. C. does, I should be happy, indeed.
At four o'clock one morning a very much excited father telephoned me, "Hurry, quick, Doctor, it's almost here." It was well that we did hurry, for the first sign the little mother had was the deluge of the waters—at this point the husband ran to telephone for the doctor—no more pains for thirty-eight minutes (just as we entered the door) and the baby was there. But such is not usually the case, nor will it be, as labor usually progresses along the lines of conscious dilating pains, occurring at intervals twenty minutes apart at first, later drawing nearer together until they are three to five minutes apart. This "first stage of labor" lasts from one to fifteen hours—during which time the tiny door to the uterine room which was originally about one-eighth of an inch open—dilates sufficiently to allow the passage of the head, shoulders and body of the fully developed child.
About this time the bag of waters usually bursts, and, as a rule, this marks the beginning of the "second stage of labor." The amount of water passed varies in amount. Should the rupture take place before the door is fully open, then labor proceeds with difficulty and the condition is known as "dry labor."
The head after proper rotation now begins the descent; and here the pains begin to change from the sharp, lancinating, cramp-like pains which begin in the back and move around to the front, to those of the "bearing down" variety, while at the same time there begins to appear the bulging at the perineum, which means that the head is about to be born. At this time great stress is brought to bear upon the perineum and often, in spite of anything that can be done to prevent it, the perineum is more or less lacerated.
As soon as the baby is born the "second stage of labor" has passed and within thirty to fifty minutes the close of the third stage of labor is marked by the passage of the placenta or "afterbirth."
Sometimes, as long as two weeks before the birth of the child, certain irregular, heavy, cramp-like pains occur in the abdomen and back. For a half-dozen pains they may show some signs of regularity; but they usually die down only to start up again at irregular intervals. These are known as "false pains."
When the pains begin to take on regularity and gradually grow heavier and it is near the appointed time for the labor, the patient should prepare to start for the hospital; or, if it is to be a home delivery, the physician should be called. As noted above, the first subjective symptom may be the rupture of the bag of waters, and it is imperative to prepare at once for the labor. It is far better to spend the day at the hospital, or even two days waiting, rather than to run the risk of giving birth to the child in a taxicab or street car; or, in the event of a home labor, to have the child born before the doctor arrives.
It is often the case that when we need our physician the most, he is busy with another patient and cannot come, or perhaps an automobile accident detains the man of the hour. The hospital delivery always possesses this advantage over the home—physicians are always on hand. We deem it wise to relate in detail the method of procedure during the rapid birth of a child; that the husband or nurse may give intelligent and clean service.
After the patient has been given the enema and has been shaved and the bath has been administered as previously directed, the helper most vigorously "scrubs up." There are three distinct phases to the "scrubbing up": First, the three-minute scrubbing of the hands and forearms with a clean brush and green soap; to be followed by, second, the trimming and cleaning of the finger nails, for it is here, under the nails, that the micro-organism lives and thrives that causes child-bed fever or septicemia; and, third, the final five-minute scrubbing of the fingers, hands, and forearms. An ordinary towel is not used to dry the well-cleansed hands, but they are now dipped in alcohol and allowed to dry in the air.
And now if the pains are returning every three to five minutes or if the bag of waters has broken, the patient should go to bed. She will lie down on her back with the knees drawn up and spread apart. The patient, having had the cleansing bath, is now washed with the disinfectant bath (2 antiseptic tablets to 1½ pints of water), from the breasts to the knees. Another member of the family takes the outer wrappings off the sterilized delivery pad and the "clean" helper places the sterile delivery pad under the expectant mother, who is directed to "bear down" when her pains come. She may be supported during these pains by pulling on a sheet that has been fastened to the foot of the bed.
The clean, helper then sits by her constantly until the baby is born but under no circumstances should touch her until after the head appears. Immediately after the birth of the head, the shoulders usually follow with the next pain, which ought to occur within two or three minutes. Occasionally the face turns blue, in such an instance, the mother is directed to strain vigorously and presses down heavily on the abdomen with both her hands, this usually hurries matters materially, and the body of the child follows quickly. The baby should cry at once. If the child does not show signs of life, quick, brisk slapping on the back usually brings relief. During the birth of the head it is imperative that, in the event of liquid passing at the same time, no water or blood be sucked into the mouth by the baby. Great care must be exercised in this matter. Should the baby remain blue, lay it quickly upon its right side near the mother, and after the pulse of the cord has stopped beating the clean helper ties the cord twice, two inches from the child and again two inches from this tying toward the mother, and then the cord is cut between the two tyings with scissors that have been boiled twenty minutes.
Should there be more difficulty with the breathing of the new born child, if slapping it on the back brings no relief, its back (with face well protected) may be dipped first in good warm water, then cold, again in the warm, again in the cold—this seldom fails. The child should then be kept very warm, lying on its right side.
All this time, a member of the family has been firmly grasping the mother's abdomen, and within an hour the afterbirth passes out through the birth canal. If the physician has not yet arrived, all dressings, the pad, the afterbirth, must all be saved for his inspection.
The inside of the thighs and the region about the vagina is now washed with bichloride solution, the soiled delivery pad removed, a clean delivery pad is placed under her; an abdominal binder is applied and two sterile vulva pads are placed between the legs, and hot water bottles are put to her feet, as usually at this stage there is a slight tendency toward chilliness. She should now settle down for rest. Fresh air should be admitted into the room. There may be some hemorrhage, and if it is excessive, grasp the lower abdomen and begin to knead it until you distinctly feel a change in the uterus from the soft mass to a hard ball about the size of a large grape fruit; thus contraction has been brought about which causes the hemorrhage to decrease. If the doctor has not yet arrived put the baby to the breast, and place an ice bag for ten or fifteen minutes on the abdomen just over the uterus. Should there be lacerations, the doctor will attend to their repair when he comes. One teaspoonful of the fluid extract of ergot is usually given at this time, if possible get in touch with the physician before it is administered.
After the mother is comfortable, your attention is directed to the baby; the condition of the cord is noted; should it be bleeding, do not disturb the tying, but tie again, more tightly just below the former tying, and with the long ends of the tape, tie on a sterile gauze sponge or a piece of clean untouched medicated cotton, thus efficiently protecting the severed end of the cord. No further dressing is needed until the doctor arrives.
Grave disorders have arisen from infection through the freshly cut umbilical cord.
Should the doctor be longer delayed, one drop of twenty per cent argyrol should be dropped in each of the infant's eyes and separate pieces of cotton should be used for each eye to wipe the surplus medicine away.
This application must not be long neglected, for a very large per cent of all the blindness in this world might have been avoided had this medicine been placed in each eye soon after birth.
The warmed albolene is now swabbed over the entire body of the infant (this is done with a piece of cotton), the arm pits, the groins, behind the ears, between the thighs, the bend of the elbow, etc, must all receive the albolene swabbing. In a few minutes, this is gently rubbed off with a piece of gauze or an old soft towel, and the baby comes forth as clean and as smooth as a lily and as sweet as a rose.
The garments are now placed on the child—first the band, then shirt, diaper, stockings, flannel skirt, and outing flannel gown—and it is put to rest after the administration of one teaspoonful of cooled, boiled water. In six to eight hours it will be put to the breast.
In recent years much has appeared in both the popular magazines and the medical press concerning the so-called "twilight sleep" and other methods of producing "painless childbirth." Many of these popular articles in the lay press cannot be regarded in any other light than as being in bad taste and wholly unfortunate in their method and manner of presenting the subject; nevertheless, these writings have served to arouse such a general public interest in the subject of obstetric anesthetics, that we deem it advisable to devote two chapters to the brief and concise consideration of the subjects of pain and anesthetics in relation to the day of labor.
First, let us briefly consider the question of pain in connection with childbirth. Many women—normal, natural, and healthy women—suffer but comparatively little in giving birth to an average-sized baby during an average and uncomplicated labor. Like the Indian squaw, they suffer a minimum of pain at childbirth—at least this is largely true after the birth of the first baby; and so there is little need of discussing any sort of anesthesia for this group of fortunate women; for at most, all that would ever be employed in the nature of an anesthetic in such cases, would be a trifle of chloroform to take the edge off the suffering at the height or conclusion of labor.
But the vast majority of American mothers do not belong to this fortunate and normal class of women who suffer so little during childbirth; they rather belong to that large and growing class of women who have dressed wrong; who have lived unhealthful and sometimes indolent lives; who are more or less physically and temperamentally unfitted to pass through the experiences of pregnancy and the trials of labor.
The average American woman shrinks from the thought and prospect of suffering pain; she is quite intolerant with the idea of undergoing even the few brief moments of physical suffering attendant upon childbirth. She refuses to contemplate the day of labor in any other light than that which insures her against all possible pain and other physical suffering.
And it is just this unnatural and abnormal fear of labor-pains—this unwomanly dread of the slightest degree of physical suffering—that has indirectly led up to so much discussion regarding the employment of "twilight sleep" and other forms of obstetric anesthesia.
While the authors recognize the great blessing of anesthesia to the woman in labor—and almost unfailingly make use of it in some form—nevertheless, we also recognize that it would be a fine form of mental discipline and mighty good moral gymnastics, if a great many self-centered and pampered women would "spunk right up" and face the ordeal of labor with natural courage and normal fortitude. It would be "the making of them," it would make new women out of them, it would start them out on the road to real living. At the same time we do not mean to advocate that women should suffer unnecessary pain in childbirth any more than we allow them to suffer in connection with surgery.
While so much is being written about "twilight sleep" and "painless labor," it might be well to remind the American mother that much can be done to lessen the sufferings of the day of labor by one's method of living prior to the confinement.
We believe that child-bearing is a perfectly normal physical function for a healthy and normal woman—that it is even essential to her complete physical health, mental happiness, and moral well-being. Theoretically, child-bearing ought to be but little more painful than the functionating of numerous other vital organs—stomach, heart, bladder, bowels, etc.—and, indeed, it is not in the case of certain savage tribes and other aboriginal people, such as our own North American Indian.
But we must face the facts. The average American woman does suffer at childbirth; and she suffers more than we are disposed to allow her, or more than she, as a general rule, is willing to suffer. So, while we discuss appropriate methods of lessening the pain of labor and the pangs of childbirth by the scientific use of anesthetics, let us also call attention to certain things which may aid in decreasing the amount of pain which may reasonably be expected to attend child bearing.
To assist in bringing about this preparation for decreased pain at childbirth, mothers should teach their daughters how to develop, strengthen, and preserve their physical, mental, and moral resistance. The young mother should be taught by both her mother and her physician how to dress, how to work, and how to eat. Every care should be given to the hygiene of pregnancy and labor.
The expectant mother should have plenty of fruits and fruit juices, and if not physically well endowed to give birth to a large babe, she should have her diet restricted in meat, bread and milk, as well as the cereals. Overeating during pregnancy should be carefully guarded against, as emphasized in an earlier chapter. Deformities of the pelvis, etc., should rule out a consideration of pregnancy.
While artificial painless childbirth by means of "twilight sleep" and other similar methods all have their place; nevertheless, these procedures should not lead to the neglect of those natural methods and preventive practices which aid in preparing the normal expectant mother for nature's relatively painless labor. When so much anesthesia has to be used in a normal labor, it cannot but strongly suggest that both patient and physician have neglected those common but efficient methods which contribute indirectly to lessening the pangs of child bearing.
"Twilight sleep" is a recent term which has become associated in the public mind with "painless labor." The reader should understand that "twilight sleep" is not a new method of obstetric anesthesia. While this method of inducing "painless labor" has been brought prominently before the public mind in recent years by much discussion and by numerous magazine articles—being often presented in such a way as sometimes to lead the uninstructed layman to infer that a new method of obstetric anesthesia had just been discovered—it has, nevertheless, been known and more or less used since 1903. Later known as the "Freiburg Method," and as the "Dammerschlaf" of Gauss, and still later popularized as "twilight sleep," this "scopolamin-morphin" method of obstetric anesthesia, has gained wide attention and acquired many zealous advocates.
"Twilight sleep" is, therefore, nothing new—it is simply a revival of the old combination of scopolamin and morphin anesthesia. While many different methods of administering "twilight sleep" have been devised, the following general plan will serve to inform the reader sufficiently regarding the technic of this much-talked-of procedure.
The scopolamin must always be fresh, although different forms of the drug are used. It tends quickly to decompose—forming a toxic by-product—and, according to some authorities, this decomposed scopolamin is responsible for many undesirable results which have attended some cases of "twilight sleep." Various forms of morphin are also used, as also is narcophin.
The "twilight-sleep" injections are not started until the patient is in the stage of active labor. The initial injection consists of the proper dose of scopolamin and morphin (or some of their derivatives), while the patient's pupils, pulse, and respiration are carefully noted, as also are the character of the uterine contractions and the character of the fetal heart action.
Usually within an hour, a second dose of scopolamin is given, while the application of so-called "memory tests" serves to indicate whether it is advisable to administer additional injections. Some leading advocates of this method claim that the majority of the unfavorable results attendant upon "twilight sleep" are the direct result of failure to control the dosage of the drug by these "memory tests;" and they call attention to the large percentage of "painlessness" as proof of probable overdosing. If the patient's memory is clear and she is not yet under the influence of the drug, a third dose is soon given. If, however, the patient is in a state of amnesia (lack of memory), this third injection is not commonly given until about one hour after the second injection. The amount of amnesia present is used as a guide for repeated injections at intervals of one to one and a half hours. As a rule, the morphin is not repeated.
It must be evident that the success of such a method of anesthesia must depend entirely upon thoroughgoing personal supervision of the individual patient by a properly trained and experienced physician; and it is for just these reasons that "twilight sleep" is destined to remain largely a hospital procedure for a long time to come.
Experience has shown that those cases of "twilight sleep" that are not under the influence of scopolamin over five or six hours do vastly better than those under a longer time. When employed too long before labor this method seems to favor inertia and thus tends to increase the number of forceps deliveries.
The number of injections may run from one to a dozen or more, and patients have come through without accident with fifteen or more doses, running over a period of twenty-four hours.
While "twilight sleep" as a method of anesthesia is not altogether new, many of the claims made for it by recent advocates are more or less new; and, to enable the reader clearly to comprehend both the advantages and disadvantages of this method, both the favorable and unfavorable facts and contentions will be summarized in this connection. The favorable claims made for "twilight sleep" are:
1. That eighty to ninety per cent of all women who use this method can be carried through a practically painless labor.
2. That there is practically no danger to the mother (some degree of danger to the child is admitted by most of its champions) other than those commonly attendant on the older and better known methods in general use.
3. That "twilight sleep," being almost exclusively a hospital procedure, would result in more women going to the hospital for their confinement—if it were used more; and would, therefore, tend to bring about more careful supervision and individual care on the part of the attending obstetrician.
4. That by lessening the dread of labor and the fear of painful childbirth, there will probably occur an increase in the birth rate of the so-called "higher classes of society"—the social circles which now show the lowest birth rates.
5. That it is of special value in the cases of certain neurotic women and those of low vital resistance; especially those patients suffering from certain forms of heart, respiratory, kidney, and other organic diseases.
6. Some authorities maintain that "twilight sleep" is of value even in threatened eclampsia, although they admit it tends to produce a rise in blood-pressure.
7. It is supposed to shorten the first stage of labor—by facilitating the dilation of the cervix—owing to the painless stretching; although the majority of its special advocates admit that it lengthens the second stage of labor, during which the patient must be very closely watched.
8. That even in those cases where the sense of pain is not entirely destroyed, the patient seems to possess little or no subsequent memory of any physical suffering or other disagreeable sensations.
9. That the method is of special value in sensitive, high-strung, nervous women of the "higher classes," who so habitually shun the rigors of child bearing—especially in the instance of their first child.
10. That the action of scopolamin is chiefly upon the central nervous system—the cerebrum—that it diminishes the perception of pain without apparently decreasing the contractile power of the uterus; labor may, therefore, proceed with little or no interruption, while the patient is quite oblivious to the accompanying pains.
11. That the physical and nervous exhaustion is quite entirely eliminated—especially in the case of the first labor—that patients who have had this method of anesthesia appear refreshed and quite themselves even the first day after labor.
12. That there is decidedly less "trauma" (appreciable injury) to the nervous system and therefore less "shock;" and that all this saving of nervous strain tends greatly to hasten convalescence.
13. And, finally, that "twilight sleep" does not interfere with the carrying out of any other therapeutic measures which may be deemed necessary for a successful termination of the labor.
While we are recounting the real and supposed advantages of "twilight sleep"—especially in certain selected cases—it will be wise to pause long enough to give the same careful consideration to the known and reputed dangers and drawbacks which are thought to attend this method of anesthesia in connection with labor cases.
We desire to state that these expressions, both for and against "twilight sleep," are not merely representative of our own experience and attitude; but that they also represent, as far as we are able to judge at the time of this writing, the consensus of opinion on the part of the most reliable and experienced observers and practitioners who have used and studied this method in both this country and Europe. The dangers and difficulties of "twilight sleep" may be summarized as follows:
1. That this method tends to weaken the mental resistance of many women; to lessen their natural courage and to decrease that commendable fortitude which is such a valuable feature of the character endowment of the normal woman.
2. That "twilight sleep" is essentially a hospital method and is, therefore, inaccessible to the vast majority of women belonging to the middle and lower classes of society, as well as to those women who live in rural communities.
3. That in fifteen or twenty per cent, the method fails to produce the desired results—at least, when administered in amounts which are deemed safe.
4. That this method does decrease the baby's chances of living; that the second stage of labor is definitely prolonged; that from ten to fifteen per cent of the babies are sufficiently under the influence of the anesthesia when born as to be unable to breathe or cry without artificial stimulus.
5. That it is a method requiring special training and experience; that it will be many years before the average practitioner will become proficient in its use; and that the older methods are probably far safer for the average physician.
6. That the method requires more care in its administration than can be expected outside of the hospital in order to avoid the dangers of fetal asphyxiation—which danger has led not a few obstetricians to abandon it.
7. That a satisfactory technic is almost impossible of development; that every patient must be individualized; that the chief dangers are connected with the over dosage of morphin; that the method is not adaptable to the general practice of the average doctor.
8. That by prolonging the second stage of labor and by sometimes giving too much morphin, the number of forceps deliveries is greatly increased, with their attendant and increased dangers to both mother and child.
9. That the prospects of passing through labor which may be rendered painless by artificial methods, tends to produce an attitude of carelessness and indifference towards those natural methods of living and other hygienic practices which so greatly contribute to naturally painless confinements.
10. That this method as sometimes practiced greatly increases the dangers of a general anesthetic, if such should be found necessary later on during the labor.
11. That "twilight sleep" is contra-indicated (should not be used) in the following conditions: primary inertia (abnormally delayed and slow labor); expected short labor—especially in women who have already borne children; when the fetal head is known to be large and the mother's pelvis small; placenta praevia (abnormal placental attachment); accidental hemorrhage; absent or doubtful fetal heart beat; when labor is already far advanced; and in threatened convulsions and eclampsia.
Having presented the evidence both for and against "twilight sleep," it may be of assistance to the lay reader to have placed before her the personal conclusions and working opinions of the authors. We, therefore, undertake to summarize our present attitude and outline our practice as follows:
1. "Twilight sleep" as a method of obstetric anesthesia in certain selected cases and in well-equipped hospitals, and in the hands of careful and experienced practitioners, has demonstrated that it is a scientific reality—and has probably come to stay—at least until better and safer methods of affecting a relatively painless confinement are discovered; although we are compelled to state that it is not the panacea the lay press has led many of our patients to believe. (That we believe a much better and safer method has been devised, the next chapter will fully disclose.)
2. We do not expect this method ever to become general in its use; we do not look for a chain of special "twilight hospitals" to stretch across the continent and then to overrun the country. We expect much of the recent forced enthusiasm to die down, while scopolamin-morphin anesthesia takes it proper place among other scientific methods of alleviating the pangs of labor.
3. We know that standard and fresh solutions—as already noted—are absolutely essential for the success of this method.
4. We are certain that no routine method or technic can be developed. Each patient must be individualized. The method does not consist in injecting scopolamin every so often. The patient's mental and physical condition—as also that of the unborn child—must control the administration of "twilight sleep."
5. The patient must be in a quiet and partially darkened room. She must not be disturbed; while the physician, or a competent trained nurse, must be in constant attendance. well-appointed hospital, there is no real reason why it cannot be fairly well carried out in a well-regulated private home, provided the necessary preparations have been made, a trained nurse is present, and provided, further, that the physician is willing to remain in the home with the patient the length of time required properly to supervise the treatment.
6. While this method of treatment is best carried out in the well-appointed hospital, there is no real reason why it cannot be fairly well carried out in a well-regulated private home, provided the necessary preparations have been made, a trained nurse is present, and provided, further, that the physician is willing to remain in the home with the patient the length of time required properly to supervise the treatment.
7. Even when the treatment is not instituted early in labor, it can, in certain selected and appropriate cases, be utilized even in the second stage of labor—thus saving these special cases much unnecessary pain; in fact, some authorities regard it as a valuable adjunct in the management of "borderland contractions" as it allows the patient a full test of labor.
8. In our opinion, this method has little effect on the first stage of labor if properly administered; but it does undoubtedly prolong and tend to complicate the second stage; in fact, we are coming to look upon "twilight sleep" as being more distinctly a first stage procedure; that it bears the same relation to the first stage of labor that chloroform bears to the second stage—relieving the pain but not stopping the progress of labor.
9. That when safe amounts of the drug are used the pain is greatly lessened in all cases—the subsequent memory of pain is absent in the majority of the patients—but the labor is not always entirely painless as is popularly supposed.
10. We do not believe that this method when properly administered increases the number of forceps deliveries—at least not in the case of high forceps operations. It undoubtedly does cover up the symptoms of a threatened rupture of the uterus, and thus increases danger from that source; nevertheless it may be safely stated that this method does not in any way greatly interfere with any other measures which might be found necessary to institute in order to bring about a successful termination of the labor.
11. The baby's heart beat must be carefully and constantly watched; sudden slowing means that the treatment must be discontinued and the child delivered as soon as possible; even then, difficulty may be experienced in getting the baby's breathing started after it is born. In the vast majority of cases where the baby does not cry or breathe at birth, the usual methods employed in such cases serve quickly to establish normal respiration, and the baby seems to be but little the worse for the experience.
12. While altogether too much has been claimed for "twilight sleep" at the same time many false fears have also been suggested, among which may be mentioned the fear of the mother losing her mind after the treatment; the undue fear of asphyxiation on the part of the baby; the fear of post-partum hemorrhage; and the fear that it will lessen the milk supply. We cannot deny that the child's dangers are often increased; but in other respects, this method (in properly selected cases) presents little more to worry us than the older methods of anesthesia.
13. We are inclined to the belief that this method has but little influence on the course of convalescence following labor. Certain nervous and highly excitable women certainly seem to do better, as a result of experiencing less pain and nervous shock; while other cases do not turn out so well. It certainly does not retard repair and recovery during the puerperium.
14. This method seems to have its greatest field of usefulness in those cases of highly intelligent but excessively neurotic women who have an abnormal dread of pain and child bearing; or women who have suffered unusually at the time of a previous confinement—perhaps in the case of the first baby—or from other complications; women such as these, and other special cases, are the ones to benefit most from the employment of "twilight sleep."
15. This method as has already been intimated, is most useful in the case of the first baby, or in the case of women who have established a record of tedious and painful labors. It has no place in normal and short labors; although it may be used to great advantage in certain cases during the first stage of labor—being carefully and lightly administered—while chloroform or gas is utilized at the end of the second stage just as has been our custom for a generation.
16. As noted under the special claims made for this method, it is (as also is nitrous oxid) the ideal procedure in cases of heart, respiratory, kidney, and other organic difficulties, the details of which have already been noted, and their repetition here is not necessary.
17. It must be remembered that scopolamin and morphin are more or less uncertain in their action; scopolamin is variable in its results, often producing such marked nervous excitement in the patient as greatly to interfere with the carrying out of an aseptic technic; while morphin has been shunned by obstetricians for a whole generation, because of its well-known bad effects on the unborn child as well as its interference with muscular activity on the part of the mother.
In Germany, it is said, that a great many damage suits against prominent physicians have resulted because of the alleged ill effects which have followed the use of "twilight sleep."
18. In presenting these facts and opinions regarding "twilight sleep," the reader should bear in mind that we are not only endeavoring to state our own views and experience, but also to give the reader just as clear and fair an idea of what other and experienced physicians think of the method, both favorably and unfavorably; and we will draw these conclusions to a close by citing the opinion of one or two who have had considerable experience with the method and who, in summing up their observations, say: