Fig. 118.—Equipment, in rack, used at The Manhattan Maternity Hospital in bathing perineum. A, pitcher of lysol, 1%. B, basin of pledgets in lysol. C, sponge-sticks in alcohol.
When the urine is being measured, as it frequently is during the first week, the solution which is used for irrigating the vulva should be measured beforehand and the contents of the bedpan measured after the dressing, in order that the amount of urine passed, if any, may be ascertained.
Another method of bathing the perineum, that employed at Johns Hopkins Hospital, is simply to bathe the perineum with soap and warm water, without separating the labia, using a clean wash cloth and afterwards applying a sterile pad, the pads being changed every four hours, or oftener if necessary. The theory upon which this procedure is based is that the steady outward flow of the lochia constantly carries material, infective and otherwise, away from the generative tract, and that if nothing is introduced between the labia or into the vagina the patient will not be infected.
In caring for the perineum, the nurse must remember also the real danger of the patient infecting herself with her own fingers and should caution her against taking this risk. The patient should be told that if she feels uncomfortable, or thinks she is bleeding, she must lie quietly and summon a nurse, but on no account to try to find out for herself what is wrong. There is little doubt that cases of severe infection have been caused by the introduction of organisms into the vagina by means of the patient’s own fingers, after the most scrupulous precautions had been taken by doctors and nurses to avoid that very disaster.
In most instances the care of the perineum is the same whether or not there are stitches, and in any case the method employed will be specified by the doctor. The nurse’s responsibility is to appreciate the object of the care, whatever form it may take, and bring intelligence to bear in giving it.
When there are perineal stitches, it is a wise and harmless precaution to fasten a towel or bandage about the patient’s knees for a few days, to prevent her pulling apart the uniting edges of the tear as she moves about in bed.
Douches. In connection with perineal dressings, it may be well to caution the nurse against giving douches without explicit orders. Douches are seldom given early in the puerperium, for fear of carrying infective material up into the uterus, except occasionally in cases of hemorrhage, in which case they are given by the doctor.
Sometimes, however, a low vaginal douche is given daily for some time after the patient gets up, with the idea of increasing her comfort and promoting involution. About two quarts of some weak antiseptic solution at 110° F. is given with the nozzle introduced just within the vaginal outlet, and the container of the solution placed only slightly above the level of the patient’s hips, in order that the stream may be very gentle.
Fig. 119.—Sterile gauze held in place over nipples by means of adhesive strips and tapes. (From photograph taken at Bellevue Hospital.)
The Care of the Breasts. There is a wide difference of opinion about the proper care of the breasts, also, but here again, although the details vary, the ultimate objects of the care are always the same, namely: to facilitate the baby’s nursing, promote the mother’s comfort and prevent breast abscesses. These ends are usually accomplished by keeping the nipples clean and intact and by giving support and rest to heavy, painful breasts.
The patient who has cared for her nipples during the latter part of pregnancy will usually have little or no trouble with them during the period of lactation, if the care is continued. But this attention is imperative.
It is very generally customary to have the nipples bathed before and after each nursing with a saturated solution of boracic acid, in either water or alcohol, using sterile pledgets and forceps, and to keep them clean between nursings by applying sterile gauze. This gauze may be held in place by means of a breast binder or by tapes tied through the ends of narrow strips of adhesive plaster, four being applied to each breast. (Fig. 119.) Strips of adhesive plaster about five inches long are folded over at one end, two adhesive surfaces being in contact for about an inch. Through a hole in the folded end a narrow tape or bobbin is tied and the strips applied to the breast, beginning at the margin of the areola and extending outward. The free ends of the tapes are tied over squares of sterile gauze, between nursings, and untied to expose the nipple at nursing time.
Lead shields are sometimes used to protect the healthy nipple and not infrequently are applied to cracked nipples, being held in place by means of a breast binder. The secretion of milk which escapes into the shield is acted upon by the metal and the result is a lead wash which continuously bathes the nipple. The shields should be scrubbed with sapolio and boiled once daily.
Another method, and one widely employed, is to anoint the nipple after nursing with sterile albolene or a paste of sterile bismuth and castor oil, and apply squares of sterile paraffin paper. These bits of paper are pressed into place and held for a moment by the nurse’s hand, the warmth of which softens and moulds them to the breast after which they remain in place. In some instances the bismuth and castor oil paste is wiped off, with a sterile pledget, before nursing and in others it is not.
In some hospitals, neither gauze nor paper is used, the nipples being protected by putting sterile night-gowns on the patients.
The purpose of all of these methods is to keep the nipples clean, and here again the patient must be cautioned against infecting herself. No amount of care on the nurse’s part will protect the patient if she touches her nipples with her fingers.
The nurse will appreciate the reason for all of this painstaking care if she calls to mind the fact that the breast tissues are highly vascular and excessively active at this time and therefore very susceptible to infection, and also that the baby’s suckling is often very vigorous and accompanied by a good deal of chewing and gnawing of the nipples. Unless the nipples have been toughened, and sometimes even when they have, the skin becomes abraded or cracked as a result of the baby’s suckling, thus creating a portal of entry for infecting organisms, in addition to the milk ducts which lead back into the breast tissues. Unless the nipples are kept clean, constantly, they may become infected by organisms from the baby’s mouth or on the patient’s hands, bedding or gown with a breast abscess as a result. The important thing, then, is to keep the nipples clean and not allow anything unsterile, excepting the baby’s mouth, to come in contact with them at any time.
Fig. 120.—Protecting cracked nipples by having the baby nurse through a shield. (From photograph taken at Johns Hopkins Hospital.)
It is sometimes the practice to swab the baby’s mouth with boric soaked cotton or gauze before each nursing, but many doctors hold that this is injurious to the delicate mucous lining of the baby’s mouth. The opinions for and against this routine seem to be about equally prevalent.
Fig. 121.—Nipple shield used in Fig. 120.
If the nipples become painful or cracked, one can easily understand that continued suckling would only aggravate the condition and increase the danger of infection. But the baby must nurse, if possible, and so in the majority of cases a nipple shield is used (Figs. 120–121) as a protection, and after nursing the fissures or abraded areas are painted with bismuth and castor oil paste; compound tincture of benzoin; balsam of Peru; argyrol, silver nitrate or sometimes only alcohol. The application is made with sterile swabs prepared by twisting a wisp of cotton about the end of a toothpick. If the crack or abrasion is extensive enough to cause bleeding, even nursing through a shield is sometimes, but not necessarily discontinued, while the other treatment is the same as for a nipple that does not bleed.
Sound, uninjured nipples, then, are to be kept clean and protected from infection and those which are abraded or cracked are to be kept clean and also protected against further injury.
Lactation. About the third or fourth day after delivery, when milk replaces colostrum, the breasts become swollen, engorged and often very painful, and not infrequently, a hard, sensitive lump or “cake” may be felt. The growing tendency, now, is merely to support these heavy breasts by means of a binder which has straps passing over the shoulders, in order to hold them up without making pressure (Fig. 122) and to apply ice caps or hot compresses to the painful areas. It used to be customary to massage and pump caked breasts, to apply pressure and various kinds of lotions or ointments. Though one, or all of these measures are still employed, in some cases, the general practice is to avoid manipulating the breasts but to empty them regularly by the baby’s nursing; support them and allow Nature to make an adjustment between the amount secreted and the amount withdrawn.
Fig. 122.—A simple method of supporting heavy breasts by means of three folded towels; one fastened about the waist, one over each shoulder, crossing front and back.
Free purging is sometimes employed and the amount of fluids reduced until the engorgement and discomfort subside. This happy issue is practically always reached if the baby nurses regularly and satisfactorily, as there is a spontaneous adjustment between the amount secreted by the mother and that withdrawn by the baby. But as abscesses may follow in the wake of caked breasts, particularly if the nipples are sore, it is of great importance that the nurse watch closely for the first evidence of painful lumps. The prompt application of a supporting bandage and ice bags (Fig. 123) or hot compresses will, in the majority of cases, give speedy and complete relief. So widely is this believed that many doctors regard the care of the breasts, including the prevention of breast abscesses, as a nursing question, entirely, and conversely are likely to regard the occurrence of a breast abscess as an evidence of careless nursing.
Fig. 123.—Ice caps held in place on painful breasts by straight binder with darts pinned in under breasts and supported by shoulder straps of muslin bandage.
Certain it is that breast abscesses are almost never seen where the nurses have this sense of responsibility, and habitually watch the breasts closely and promptly use support and either heat or cold when the breasts become heavy and sensitive.
There are innumerable bandages and methods for supporting heavy breasts, any one of which is efficacious so long as it meets the two chief requirements: to lift the breasts, suspending their weight from the shoulders, and, while fitting snugly below to avoid making pressure at any point, particularly over the nipples. One of the most satisfactory and widely used supports is the Y-bandage, (Figs. 124, 125, 126), another, the Indian binder (Fig. 127.)
Fig. 124.—Modified Richardson “Y” binder made of two strips of soft muslin, full width of material and 44 inches long, folded into strips of same width as distance from margin of patient’s breast to outer part of areola. One strip is folded in the middle at right angles and pinned to one end of the other strip as indicated. (Figs. 124, 125, 126, with captions, are from The Maternity Hospital, Cleveland, by courtesy of Miss Calvin MacDonald.)
The nurse must on no account massage or pump engorged breasts on her own responsibility, for there is a good deal of evidence to show that any such manipulation tends to increase the amount of the secretion and this in turn increases the engorgement and pain. It is possible, too, that massage may bruise the breasts and thus make them more susceptible to infection.
Mastitis. When infection occurs, the swollen, painful breasts may grow hot and red, the patient may complain of chilliness and have a slight fever, with or without there being an abscess. Even then the general treatment is most frequently found to consist of support; ice or heat; catharsis and restricted fluids, though in some cases the breasts are pumped and nursing is discontinued.
Fig. 125.—Bandage in Fig. 124 applied. The long arm of binder is placed under patient’s shoulders, one end of the Y being brought around the top of the breasts and the other around the lower part, toward the nurse, crossed at right angles under the arm and pinned to long arm of bandage as indicated in Fig. 126. The nipples are covered with sterile gauze and the upper and lower parts of the Y fastened with a safety pin between the breasts. The remaining length of the long arm is brought across the breasts and fastened with a safety-pin to the opposite side. When the baby nurses this pin is removed as well as the one between the breasts. The entire binder should be snug and held in place by means of shoulder straps, pinned front and back.
When the inflammation so far progresses as to require that the breast be opened and drained, the subsequent nursing care will be outlined by the doctor to meet the needs of each case. It is a painful operation and often a serious one, for the destruction of breast tissue may be extensive enough to render the breasts valueless as milk-producing organs. The healing is slow and altogether the occurrence is a most lamentable one.
Fig. 126.—Y bandage in Fig. 125 seen from the opposite side.
The nurse’s part in preventing this complication is cleanliness and gentleness in her attentions; unremitting watchfulness; immediate application of a suspensory bandage and either heat or cold, upon the first sign of engorgement and prompt reporting to the doctor.
Fig. 127.—Indian Binder used at The Montreal Maternity Hospital for supporting heavy breasts. The tapering ends tie in a knot in front.
If the patient’s nipples have not been toughened during pregnancy or if flat or retracted nipples have not been satisfactorily brought out, it may be necessary for the nurse to employ the treatment to these ends which were described in the chapter on pre-natal care. In the meantime the baby may have to nurse through a shield until the nipple is brought out prominently enough for him to grasp it well.
Stripping. Sometimes in cases of depressed nipples, which the baby cannot grasp, or when the baby is too feeble, to nurse at the breast, milk is withdrawn from the breast by means of so-called “stripping.” The nurse should scrub her hands thoroughly with hot water and soap and dry them on a sterile towel before beginning. The breast is grasped by placing the thumb and forefinger of the right hand on the areola on opposite sides of the nipple but well below it. The nipple is then raised from the breast by a quick, lifting and rolling motion of the thumb and finger, accompanied by slight pressure. A sterile medicine glass should be held in position to receive the milk which spurts from the nipple, but the glass should not touch the breast. (Fig. 128.)
Fig. 128.—Position of thumb and finger below nipple on areola, in stripping breasts. (From photograph taken at The Long Island College Hospital.)
There is a knack about stripping and it requires practice, but those doctors who advocate it feel that it empties the breast, when this is necessary, with less disturbance than that caused by pumping, and as the milk is projected directly from the nipple into the sterile glass, without any of it running over the nipple or breast as may happen in pumping, it has the additional advantage of always being sterile.
Extreme gentleness must be used; the openings of the milk ducts must not be touched by the fingers, and the thumb and finger must not press deeply enough to reach the glandular tissue itself. If done properly stripping neither stimulates nor bruises the breast tissue nor does it cause the patient even temporary discomfort.
Abdominal Binders and Bed Exercises. There is considerable difference of opinion about the advantage of using abdominal binders upon the puerperal patient while she is in bed, and the nurse will accordingly care for the patients of some doctors who use them and for those of others who do not.
The application of a moderately snug binder for the first day or two is a fairly common practice, for multiparæ, particularly, are often made very uncomfortable by the sudden release of tension on their flabby abdominal walls; a discomfort which a binder will relieve. And during the first few days after the patient gets up and walks about, she is sometimes given great comfort by a binder that is put on as she lies on her back, and is adjusted snugly about her hips and the lower part of her abdomen.
But the continued use of a binder after the first day or two, while the patient is still in bed, is not as general as it formerly was. Many women ask for binders in the belief that they help to “get the figure back” to its original outline, and some doctors feel that the use of the binder is helpful in restoring the tone to the abdominal muscles, which amounts to about the same thing. Both the straight swathe and the Scultetus binder are used for this purpose and they are put on in the usual manner; snugly and with even pressure, but not tight enough to bind.
Those doctors who disapprove of the binder believe that it interferes with involution and, by making pressure, tends to push the uterus back and cause a retro-position, in addition to retarding instead of promoting a return of normal tone to the abdominal muscles.
Accordingly, they instruct their patients to take exercises, instead of wearing binders, and they have these exercises started while the patient is still in bed. Their adoption, and the rate at which they are increased, are entirely dependent upon the individual patient’s condition, for they must never be continued to the point of fatigue. There are, therefore, no definite rules laid down, concerning these exercises, beyond a description of the positions and movements themselves, and their sequence.
Those which are taught to the patients at the Long Island College Hospital are so simple, and evidently productive of such happy results that they offer excellent examples of this form of treatment. They are, of course, taken only by the doctor’s order, but the nurse’s intelligent supervision increases their effectiveness.
The general purpose of these exercises is to strengthen the abdominal muscles, thus helping to prevent a large, pendulous abdomen; to increase the patient’s general strength and tone, just as exercise benefits the average person; to promote involution; to prevent retro-version and in a measure, increase intestinal tone and thus relieve constipation. To accomplish these much to be desired ends the exercises must be taken with moderation and judgment; started slowly; increased very gradually and constantly adapted to the strength of the individual patient. Otherwise they may do more harm than good. In the average, uncomplicated case in which the patient is doing well, she usually starts the chin-to-chest exercise from twelve to twenty-four hours after delivery. She should lie flat on her back and raise her head until her chin rests upon her chest. (Fig. 129.) If she rests her hand upon her abdomen, she will feel for herself that the abdominal muscles contract, and accordingly will be disposed to continue the exercises with more interest and confidence than she otherwise might. The movement is repeated twenty-five times, morning and evening, every day, and continued as long as the patient is in bed.
Fig. 130.
Fig. 131.
The familiar, deep-breathing exercise is ordinarily started on the third or fourth day. The patient should lie flat, with her arms at her sides, then extend them straight out from the shoulders (Fig. 130), raise them above her head (Fig. 131) and return them to the original position. This is repeated ten times morning and evening, daily, as long as the patient is in bed.
Fig. 132.
The one-leg-flexion exercises are not done by patients with perineal stitches, but in other cases they are usually started about the fifth day. The thigh is flexed sharply on the abdomen and leg on thigh (Fig. 132), then extended and lowered to the bed. This is repeated ten times, with each leg, morning and evening for one, or possibly two days.
The next exercise replaces the one-leg-flexion and is started after the latter has been done for one or two days, according to the strength of the patient, and it in turn is continued for only one or two days. Both thighs are sharply flexed on abdomen and legs on thighs (Fig. 133), then extended and lowered but not far enough for the heels to rest upon the bed before being flexed again. This is repeated ten times morning and evening.
Fig. 133.
Fig. 134.
Next is the exercise for which the leg-flexion exercises prepare the patient, and which are discontinued when this one is adopted. It is started, as a rule, about the seventh day, or three or four days before the patient gets up. Both legs are slowly lifted to a position at right angles to the body (Fig. 134) and slowly lowered, but not far enough for the heels to touch the bed (Fig. 135), and the movement repeated. As this exercise requires a good deal of effort, it must be taken up very gradually, as follows: The legs should be raised on the first day, once in the morning and twice in the evening; second day, three times in the morning and four times in the evening; third day, five times in the morning and six times in the evening and so on, if the patient is not fatigued, until the exercise is repeated ten times each morning and evening. It is continued for several months.
Fig. 135.
The knee chest position (Fig. 136) is intended to counteract the tendency toward retroversion, from which so many women suffer after childbirth. It is usually started about the seventh day and the patient begins by remaining in that position for a moment or two, gradually lengthening the time to about five minutes each morning and evening for about two months.
Fig. 136.—Knee chest position.
Fig. 137.—Walking on all fours. (From a photograph taken at the Long Island College Hospital.)
Walking on all fours is violent exercise and has to be taken up very gradually. Some patients are able to attempt it on the first day out of bed, if they have been taking the other exercises, but as a rule it is not started until the second or third day. The patient’s clothes should be free from all constrictions; the knees should be held stiff and straight with the feet widely separated, to allow a rush of air into the vagina, and the entire palmar surface of the hands should rest flat on the floor. (Fig. 137.) The patient should start by taking only a few steps each morning and evening, gradually lengthening the walk to five minutes twice daily and continuing it for about two months.
It is believed that as the patient walks in this position the uterus and rectum rub against each other producing something the same result as would be obtained by massage. The effect of the exercise is to promote involution and diminish the tendency toward constipation and retroversion, apparently preventing malposition entirely in a large percentage of cases. Though not widely used, its beneficial effects are unquestioned by those doctors who employ it.
In taking a general survey of the young mother and her needs, we realize that in a broad sense she is not ill, in so far as no pathological condition exists. But she is in a transitional state and may become acutely or chronically ill if not carefully watched and nursed. In general her mental, physical and nervous forces must be conserved and increased, and this requires thoughtful and devoted attention from the nurse. She must be scrupulously clean in her care of the nipples and perineum, and in order to be able promptly to inform the doctor of any departure from the normal in the patient’s condition, the nurse’s watchfulness should embrace regular observations upon the following:
If all goes well and there are no complications, the patient will usually be able to assume full charge of her baby by the sixth or eighth week, and practically return to her customary mode of living, with the difference that she now has the care of a baby which she did not have before. The care of that baby requires certain, definite care of herself, as a nursing mother, which will be described in detail in the next chapter.
To sum up the general principles of nursing the young mother during the puerperium, we find that just as during pregnancy and labor, the nurse must first be familiar with the normal changes that occur in order that she may recognize the abnormal. Then, as before, the nurse’s care of the individual patient must rest unfailingly upon a foundation of cleanliness in order to prevent infection; watchfulness, which implies ability to recognize normal changes and unfavorable symptoms; adjustment to the methods of the attending physician and to all of the circumstances surrounding the patient, and the wisest and tenderest consideration for her patient as an individual.
Not infrequently the nurse remains with her patient after the end of the puerperium, and therefore she may have the care of the mother and baby for several weeks, or even months. The most valuable single service which she can perform in this capacity is to help in making it possible for the mother to nurse her baby at the breast. For both the nurse and the mother must realize that the breast-fed baby is much more likely to live through the difficult first year, and is markedly less susceptible to disease and infection than is the bottle-fed baby.
The first step is to convince the young mother of what it means to her baby and her obligation to try to nurse him, since, excepting under very rare and unusual conditions, she can nurse him if she wants to enough to make the necessary effort and sacrifice.
The important contra-indications for attempting breast-feeding are retracted nipples, tuberculosis, eclampsia, severe heart or kidney disease and certain acute infectious diseases such as typhoid fever.
It seldom happens that the mother who has had average prenatal care, followed by good care during and after delivery, is unable to nurse her baby if she orders her life in the way that is known to be necessary to promote and maintain lactation. The first essential is her real desire to nurse her baby; next, her appreciation of the continuous care of herself that is necessary and third, her whole-hearted willingness to take this care for her baby’s sake.
It is safe to say that if the doctor and the nurse and the patient all want the baby to nurse at the breast, and all do everything in their power to make this possible, they will almost invariably succeed. This assertion can scarcely be made too positively, and the nurse should never lose sight of the fact that if the baby is not breast-fed he is being defrauded, and in the vast majority of cases, because of insufficient effort on the part of the doctor, nurse or patient, or all three.
A favorable frame of mind and state of good nutrition in the mother are the two indispensable factors in establishing breast-feeding and in maintaining the secretion of an adequate supply of breast-milk. These conditions, in turn, are both affected by her general mode of living, as long as the baby nurses.
Women with happy, cheerful dispositions usually nurse their babies satisfactorily, while those who worry and fret are likely to have an insufficient supply of milk, or milk of a poor quality. And in addition to this sustained influence, the temporary effect of a fit of temper; of fright; grief; anxiety or any marked emotional disturbance is frequently injurious to the quality of milk that previously has been satisfactory. Actual poisons are created by such emotions and may affect the baby so unfavorably as to make it advisable to give him artificial food, for the time being, and empty the breasts by stripping or pumping, before he resumes breast feeding.
A mother’s lack of faith in her ability to nurse is so detrimental in its effect that she must be assured over and over, that she can nurse her baby if she will persevere. If the nursing does not go well at first she must not give up, but must continue to put the baby to the breasts regularly, as this is the best means of stimulating them to activity. His feeding should be supplemented with modified cow’s milk, if the breast milk is inadequate, either in amount or quality.
Method of Nursing. The baby should be put to the breast for the first time between eight and twelve hours after he is born. This gives the tired mother an opportunity to rest and sleep, and the baby, too, is benefited by being kept warm and quiet during this interval. His need for food is not great as yet, nor is there much if any nourishment available for him.
In preparing to nurse her baby, the mother should turn slightly to one side, and hold the baby in the curve of her arm so that he may easily grasp the nipple on that side. She should hold her breast from the baby’s face with her free hand by placing the thumb above and fingers below the nipple, thus leaving his nose uncovered, to permit his breathing freely. (Fig. 138.) The mother and baby should lie in such positions that both will be comfortable and relaxed, and the baby will be able to take into his mouth, not only the nipple but the areola as well, so as to compress the base of the nipple with his jaws as he extracts the milk by suction.
Fig. 138.—Position of mother and baby for nursing in bed.
The nurse may have to resort to a number of expedients in persuading the baby to begin to nurse, for he does not always take the breast eagerly at first. He must be kept awake and sometimes suckling will be encouraged by patting or stroking his cheek. Or if his head is drawn away from the breast, a little, he will sometimes take a firmer hold and begin to nurse. Moistening the nipple by expressing a few drops of colostrum or with sweetened water may stimulate the baby’s appetite and thus prompt him to nurse.
The young mother must be prepared to find very discouraging the early attempts to induce the baby to nurse, but if the nurse will help her to persevere in making regular attempts she will almost certainly succeed.
During the first two or three days the baby obtains only colostrum, while nursing, but the regular suckling is extremely important, not alone for the sake of getting him into the habit of nursing but for the sake of stimulating the breasts to secrete milk.
Moreover, the irritation of the nipples so definitely promotes involution of the uterus that this process goes on more rapidly in women who nurse their babies than in those who do not. If the nipples are not sufficiently prominent for the baby to grasp them, a shield will have to be used while they are being brought out. But the shield should be discarded as soon as possible for it is the baby’s suckling that produces the physiological effects. If a shield is used, it should be washed and boiled after each use and kept, between nursings, in a sterile jar or a solution of boracic acid.
The length of the nursing periods and the intervals between them have to be adjusted to the needs and condition of each baby; his weight, vigor, the rapidity with which he nurses, the character of his stools and his general condition, all of which will be considered in connection with the care of the baby. The intervals between nursings are measured from the beginning of one feeding to the beginning of the next, and are fairly uniform for babies of the same age and weight. The length of the nursing period itself is usually from ten to twenty minutes.
Fig. 139.—The Nursing Mother. (By permission from a pastel by Gari Melchers.)
The average baby nurses about every six hours during the first two days, or four times in twenty-four hours. According to one schedule he will nurse every three hours during the day for about three months, beginning with the third day, and at 10 p.m. and 2 a.m., or seven times in twenty four hours. From the third to the sixth month he nurses every three hours during the day and at ten o’clock at night, or six times in twenty-four hours, and from that time until he is weaned he should nurse at four hour intervals during the day and at ten o’clock at night, or five times daily, as follows:
| Day | Night | ||||||
|---|---|---|---|---|---|---|---|
| First and second days | 6 | 12 | 6 | 12 | |||
| First three months | 6 | 9 | 12 | 3 | 6 | 10 | 2 a. m. |
| Third to sixth month | 6 | 9 | 12 | 3 | 6 | 10 | |
| After the sixth month | 6 | 10 | 2 | 6 | 10 | ||
It is becoming more and more common to omit night feedings after 10 p.m., even during the first three months, with the average baby who is in good condition. When this practice is adopted the baby not only seems to do as well as he normally should, but to benefit by the long digestive rest during the night. Certainly the mother profits by the unbroken sleep which this makes possible.
As a rule the baby should nurse from one side, only, at each nursing, emptying the breasts alternately, but if there is not enough milk in one breast for a complete feeding both breasts may be used at one nursing. Neither the mother nor the baby should be permitted to sleep while he is at the breast, but he should pause every four or five minutes to keep from feeding too rapidly.
After the mother sits up, she may occupy a low, comfortable chair while nursing the baby. She should lean slightly forward and raise the knee upon which the baby rests by placing her foot on a stool, supporting his head in the curve of her arm, and holding her breast from his face, just as she did while in bed. (Fig. 139.) She should nurse him in a quiet room where she will not be disturbed nor interrupted and where the baby and her breasts will be protected from drafts or from being chilled. Many women prefer always to lie down when nursing the baby.
Before the nurse leaves her patient she should teach her how to care for her nipples, including the preparation of boric solution; the importance of washing her hands before bathing her nipples, and of keeping the breasts covered with clean gauze between nursings.
The personal hygiene of the nursing mother should be virtually a continuation of that which is advisable during the latter part of the puerperium; a normal, tranquil kind of life which is unfailingly regular in its daily routine.
But this is not quite as easy as it sounds, for during the puerperium the young mother is still something of a patient and is regarded as such, while during the months that follow she is simply a nursing mother, who must live sanely and moderately for her baby’s sake, and at the same time take her place among people who are not under compulsion to place any special restrictions upon their daily lives. It is much easier to take precautions and follow directions for a few days or weeks, while the situation is novel, than it is to persist month after month without help or encouragement. The young mother’s family often fails to appreciate the difficulty of her problem and for this reason she is sometimes unable to care for herself, as she should, with the result that she cannot nurse her baby successfully.
As long as the nurse remains with her patient, therefore, she must try to impress upon both the patient and the members of her household that the most important single factor in the care of the new baby is the sustained and regular care which the nursing mother should take of herself. For it must be remembered constantly that it is not alone breast feeding, but satisfactory breast feeding that nourishes and builds and protects the baby. Unsatisfactory breast milk may be positively injurious, and irregularity and thoughtlessness in the mother’s mode of living will usually produce milk of this character.
Therefore, for ten or twelve months after the baby is born, the mother should discharge her responsibility and obligation to him by regulating her own life to meet his needs.
Diet. Throughout the entire nursing period the mother’s diet must be such that it will nourish her and also aid in producing milk which will meet the baby’s needs. His needs are that the daily demands of his growing body shall be supplied and that he shall be given those materials which will build a sound body, with resistance against disease and infection.
So important is this matter of nutrition, and the principles upon which it rests, that it is discussed at considerable length in the succeeding chapter. At this point, however, it may be stated briefly that the most valuable article in the nursing mother’s dietary is milk, and that to this should be added eggs and the vegetables which are designated as “leafy,” and fresh fruits, particularly oranges. These foods are rich in the materials which are essential to the baby’s nutrition, good health, and resistance.
She should have a generous, simple, nourishing mixed diet, then, consisting largely of milk, eggs, and leafy vegetables. She must steadily guard against indigestion for if her digestion is deranged the baby is almost sure to suffer. Rich and highly seasoned foods must be avoided, as well as alcohol, strong tea and coffee or any articles of food or drink that might upset her.
It becomes apparent that although the expectant mother does not have to “eat for two,” the nursing mother does, in certain respects. She should augment the nourishment provided by her three regular meals, by taking a glass of milk, cocoa or some beverage made of milk, during the morning, afternoon and before retiring.
The morning and afternoon lunches had better be taken about an hour and a half after breakfast and luncheon, respectively, in order not to impair the appetite for the meals which follow.
It is very important that the nursing mother shall take her meals with clock-like regularity and enjoy them, but at the same time she must guard against overeating, for fear of deranging her digestion. She must drink water freely, partly for the sake of promoting intestinal activity.
Bowels. The nursing mother’s bowels must move freely and regularly every day, but she should not take cathartics nor even enemata without a doctor’s order.
She will usually be able to establish the habit of a daily movement by taking exercise, eating bulky fruit and vegetables, drinking an abundance of water and regularly attempting to empty her bowels, every day, preferably immediately after breakfast.
Rest and Exercise. The nursing mother will not thrive, nor will the baby, unless she has adequate rest and sleep and takes at least a moderate amount of daily exercise in the open air. She should have eight hours sleep, out of the twenty-four, in a room with open windows, and as fatigue has an injurious effect upon the character of the milk, the average mother should lie down for a while every afternoon.
Her exercise will have to be adjusted to her tastes, customary habits, circumstances and physical endurance, for it must always be stopped before she is tired. Walking is often the best form of exercise that the nursing mother can take, though she may engage in any mild sports that she enjoys. Violent exercise is inadvisable because of the exhaustion that may follow.
Recreation. Part of the value of exercise lies in the pleasure and diversion which it gives, for a happy, contented frame of mind is practically indispensable to the production of good milk. In addition to some regular and enjoyable exercise, therefore, the mother needs a certain amount of recreation and change of thought and environment. If her life is monotonous and colorless, the average woman is likely to become irritable and depressed; to lose her poise and perspective; to worry and fret, and then, no matter what she eats nor how much she sleeps, her digestion will suffer, her milk will be affected and the baby will pay. This, of course, goes back to the question of her mental state and the condition of her nerves as being determining factors in the young mother’s ability to nurse her baby successfully.
For the sake of giving her an opportunity to go out, mingle with her friends or enjoy some music or a play, it is often a very good plan to replace one breast feeding, some time in the course of each day, with a bottle feeding. The freedom which this long interval between two nursings gives the mother for diversion and amusement, will usually affect her general condition so favorably that the quality of her milk is better than it otherwise would be, and the baby is benefited as a result. This single supplementary feeding cannot be regarded lightly, however, for it must be prepared with the same cleanliness and accuracy as an artificial diet.
Weaning. One advantage in giving the baby a supplementary bottle, once a day, is that it paves the way for weaning, when the time comes to make this change. Under ordinary conditions, the mother begins to wean her baby about the eighth or tenth month. Having started by replacing one breast feeding, daily, with a bottle feeding, she should gradually increase the number of daily artificial feedings until all of the breast feedings are discontinued by the time the baby is eleven or twelve months old. There are exceptions to this general rule, of course, and under any conditions the weaning should always be directed by a doctor, for the baby will suffer unless it is skillfully done.
If the mother’s milk is satisfactory and the baby is doing well, it is often considered wiser not to discontinue the breast feeding entirely, during the hot summer months, even though the weaning falls due at this time.
It was formerly deemed advisable to wean the baby for any one of several reasons, but at present the only indications for this step which are generally accepted by the medical profession, are: pulmonary tuberculosis, acute infectious diseases in the mother, and pregnancy. Menstruation, which is normally suspended during lactation, was long regarded as incompatible with satisfactory nursing, but it is now known that if the mother is taking proper care of herself and is in generally good condition, the effect of menstruation upon the milk is usually for the duration of the periods only. It may be necessary to supplement the breast feeding with suitably modified cow’s milk during menstruation, but the baby should be put to the breast regularly, just the same, for if the stimulation of the baby’s suckling is discontinued, the temporary reduction in the amount of milk secreted will probably be permanent.
The state of pregnancy, however, is different, for though some women nurse the baby satisfactorily for some months after becoming pregnant, it is not considered advisable to subject a woman to the combined strain of pregnancy and nursing. Moreover, the mother’s milk is usually impoverished during pregnancy and the nursing baby suffers in consequence.
Drying up the Breasts used to be a great bugbear. Lotions, ointments and binders were employed and often a breast pump as well. Various drugs were given by mouth and the patient was more or less rigidly dieted. It is true that some of these measures are still employed and are followed by a disappearance of the milk. But at the same time, the breasts dry up quite as satisfactorily when none of these things is done, provided the baby does not nurse. It is not known what starts the secretion of milk in the mother’s breasts but certain it is that absence of the baby’s suckling prevents it.
If the drying up of the breasts is left to the nurse, as it so frequently is, her wisest course will be to do nothing beyond applying a supporting bandage if the breasts are heavy enough to be uncomfortable. She may rely absolutely upon the fact that the baby’s suckling is the most important stimulation in promoting the activity of the breasts and if this stimulation is not given, or is removed, the secretion of milk will invariably subside in the course of a few days. It is true, that the breasts may be engorged and very uncomfortable for a day or two, and in addition to a supporting bandage the doctor may order sedatives, but the discomfort subsides as the secretion disappears. This is true whether the reason for drying up the breasts is that the baby is still born or has died, or a live baby’s nursing is discontinued.
Naturally, the nurse will not press her patient to drink an extra amount of milk if it is not desirable to promote the activity of the breasts, but, unless otherwise ordered, there is no necessity for placing any other restrictions upon her patient’s diet.
In thinking over the period of lactation, as a whole, it is apparent that the most valuable service which the nurse can offer to the nursing mother, is assistance in planning and living a simple, normal, tranquil life; helping her to eat, sleep, bathe, and exercise and to nurse her baby with unfailing regularity—all for the sake of providing her baby with adequate nourishment. This must be the chief end and aim of her existence.
Normal breast-milk is the ideal baby food and there is no entirely satisfactory substitute. It greatly increases the baby’s chances of living through the first year, and protects him from many diseases.
Quite evidently, breast-feeding is every baby’s right and the nurse can and should help him to secure it.