For the first week or two after the baby comes, you will be in bed, of course; your doctor will come in often and you will doubtless be cared for by a nurse devoted exclusively to you, or by a visiting nurse aided by members of your family. You will find that it is money well spent to keep the nurse, or someone else, to care for and help you, for six or eight weeks after the baby’s birth, or longer if possible.

Adequate care after childbirth accomplishes two important ends. It practically always averts such immediate complications as hemorrhage and infection and it prevents more or less chronic invalidism. Infection is prevented by the scrupulously clean care which is given to your breasts and perineum, while hemorrhage is avoided by keeping you quiet and closely watching the condition of the uterus. Later invalidism is prevented by the many precautions which enter into your general care. These relate to your position in bed, diet, fresh air, rest, exercise, bathing, attention to your bowels; observance of symptoms and conserving all of your forces while increasing your strength.

All of these details are important, for during the five or six weeks after confinement certain changes take place in your body which return it very nearly to its pre-pregnant state, and lack of watchful care while these changes are in progress may retard them and result in your being more or less permanently wretched.

Make every effort, therefore, to secure the care that you need during this transitional period of five or six weeks called the puerperium.

You will doubtless feel a little tired and nervous at first, for you have been through something of an ordeal, but when one considers the great things that your body has accomplished, your recovery and return to a normal condition will be surprisingly rapid. During the first few days you are likely to have little or no appetite but be very thirsty; be constipated; perspire freely and have an increased amount of urine, which you may have difficulty in passing; but these conditions are only temporary.

In the beginning you will probably be nursed just about as anyone would be after a slight operation, with the addition of special attention to your breasts and perineum to prevent infection, and the toning up of abdominal muscles. In order to prevent bleeding and hasten your recovery you will be kept very quiet for a day or two, perhaps flat on your back; you may not be allowed to have any visitors and your diet, at first consisting of liquids, will finally be made up of light, easily digestible but nourishing food.

About the sixth or eighth day you will probably begin to sit up in bed and about the ninth or tenth day you may be allowed to sit up in a chair for a little while. Some young mothers are able to sit up for an hour the first time, without fatigue, while others can sit up for only a few moments, morning and afternoon, on the first day, gradually lengthening the period each time that they get up. You will probably be able to sit up an hour or so longer on each successive day and walk a few steps on the third or fourth day after getting up.

These first few days of being up and trying to walk are often tiring, and a little discouraging in consequence, but of course you will gain steadily, even though it be slowly, do a little more each day and gradually feel more and more like your old self.

The mother who has stitches, because of the perineum having been torn at the time of the baby’s birth, does not usually sit up in bed until the ninth or tenth day, when the stitches are removed, sitting up in a chair for an hour, two or three days later. In connection with tears it may be well for you to know that in spite of the most skillful and careful efforts to prevent them, tears of some degree usually occur when the first baby is born and in about half of the confinements that follow.

But as most tears are very slight and are immediately repaired they have little or no effect upon one’s comfort or general health.

It is ordinarily considered a safe precaution to avoid going up and down stairs until the baby is about four weeks old and not wholly to resume normal activities within six or eight weeks after his birth. A pinkish or red discharge or backache, after the mother gets up are regarded as indications that she is not quite ready to do much standing or walking and that she still needs a good deal of rest.

The whole question of the time for sitting up, of getting up and of walking about varies so with different individuals, as you see, that it is not possible to describe a definite routine, for some women recover slowly and would be injured by getting up and about at a period which would be entirely safe and normal for the majority. The doctor has to decide what is best in each case.

While you are being actually nursed as a bed patient, especial attention is given to the bathing of the perineum, as has been stated; the care of the breasts and restoring tone to your abdominal muscles, so we may well have a word of explanation about each of these details.

The Perineum. The nurse will bathe the area between your thighs very carefully, at regular intervals, using pledgets soaked in some kind of antiseptic solution, and put on a fresh one of the sterile pads that you made and sterilized some weeks back. This attention is partly to promote your comfort and partly to remove any infective material that may be present, thus preventing fever. After the care that you have had up to this time, it will scarcely be possible for you to have childbed fever if all infective material is kept away from the vaginal outlet. I speak of this in order that you may realize how important it is for you to avoid touching these parts with your fingers, upon which there are almost certain to be germs. There is little doubt that women sometimes seriously infect themselves after the doctor and nurse have taken the most scrupulous care to protect them from this very complication.

Your breasts will be given painstaking care in order that the baby may nurse satisfactorily and to prevent both sore nipples and breast abscesses. If you cared for your breasts during the latter part of pregnancy as was advised in Chapter V and will continue to observe ordinary precautions while the baby is nursing, it is not at all likely that you will have any trouble with your breasts.

The main features of the care of your breasts, now, are keeping the nipples clean and supporting the breasts themselves if they grow heavy enough to be uncomfortable. This latter condition is not uncommon about the third or fourth day after the baby is born, when the colostrum is replaced by what one might call almost a rush of milk. The breasts may then become hard, swollen and uncomfortable and sometimes a sensitive lump or “cake” may be felt. The usual course, nowadays is simply to support those swollen breasts and to apply ice bags or hot compresses to the painful areas.

There are innumerable bandages and methods for supporting heavy breasts, any one of which is satisfactory 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 may take a towel for example, or a straight strip of muslin, fasten it around the chest, pin in darts below the breasts with safety-pins, and provide support by means of shoulder straps, attached with safety-pins to the front and back of the binder. Fig. 25 shows such a binder being used to hold ice bags in place, for which also it is satisfactory and very easily devised.

Three folded towels or folded bands of muslin will provide a comfortable support if applied in the sling-like manner indicated in Fig. 26; the Indian binder shown in Fig. 27, made of cheesecloth or any soft material is cool, light and very comfortable, and in addition to these improvised binders there are several entirely satisfactory brassières, opening down the front, to be bought in the shops. Happily the discomfort from swollen breasts lasts only a day or two, for in some mysterious way Nature makes an adjustment between the amount of milk produced by the mother and that withdrawn by the baby. So as he comes to nurse regularly and satisfactorily, the excessive supply of milk disappears, and with it the discomfort.

The care of the nipples practically resolves itself into keeping them clean in order to avoid infection. Notice that I say keeping them clean, for merely bathing them, no matter how regularly, is not enough. The nurse will probably bathe your nipples with boracic acid solution and sterile cotton pledgets before and after each time that the baby nurses, and keep them covered, during the intervals, with sterile gauze or cotton.

Here again you may undo all of the nurse’s careful precautions against infection, which might cause an abscess, if you touch your nipples with your fingers or anything else that is not sterile, except the baby’s mouth. The gauze squares or sponges or the cotton pledgets that you sterilized will serve excellently to protect your nipples between nursings. These may be held in place by a binder or by tapes tied through the ends of narrow strips of adhesive plaster, four being applied to each breast as shown in Fig. 28. Strips of adhesive plaster about five inches long are folded back at one end so that two adhesive surfaces stick together for about an inch. Through a hole cut in this folded end a narrow tape or bobbin is tied, and the strips are applied to the breast, beginning at the margin of the darkened area and extending outward. The free ends of the tapes are tied over pads of gauze or cotton between nursings, and untied to expose the nipple at nursing time.

Lead shields are sometimes used to protect the nipples, being held in place by means of a binder. These shields should be scoured and boiled daily.

Method of Nursing. One important reason for all of this scrupulous care is that it favors the baby’s nursing satisfactorily and without interruption, so now you will want to know about the actual details of nursing him.

The baby is usually put to the breast for the first time, between eight and twelve hours after he is born. This gives the mother an opportunity to rest, and the baby too profits by being quiet and undisturbed during this interval. His need for food is not great as yet, nor is there much if any nourishment available for him. There is no hard and fast rule for the mother’s position in bed, while nursing her baby, beyond the fact that both she and the infant should be in a relation that makes the nursing easy. One very natural and satisfactory method is for her to 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. If you take this position you should hold your breast from the baby’s face with your free hand by placing the thumb above and the fingers below the nipple, thus leaving his nose uncovered to permit free breathing, as shown in Fig. 29. You and the 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 much of the dark circle as well, so as to compress the base of the nipple with his jaws and extract the milk by suction.

The comfort of this position is sometimes increased by laying the baby on a small pillow placed close to the mother’s side, thus raising his body to the level of his head as it rests upon her arm.

You and 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, first and foremost, and sometimes suckling will be encouraged by patting or stroking his cheek or chin or lightly spanking his buttocks. If his head is drawn away from the breast a little, as he holds the nipple in his mouth, 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 whet the baby’s appetite and thus prompt him to nurse.

You must be prepared to find the early attempts to nurse your baby far from satisfactory, but if you persevere in making attempts regularly, you 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 because his suckling is the best and surest means of stimulating your breasts to produce milk. And, as we shall see in a moment, the irritation of the nipples in this manner so definitely promotes desirable changes in the uterus that these go on more rapidly in women who nurse their babies than in those who do not.

If your nipples are not sufficiently prominent for the baby to grasp them, or if they become sore, you may have to use a shield for a while as shown in Figs. 30 and 31, but the shield should be discarded as soon as possible for it is the baby’s suckling that produces the desired effects. If a shield is used, it should be washed and boiled after each nursing and kept in a sterile jar or solution of boracic acid, between times.

The length of the nursing periods, and the intervals between them, are decided upon by the doctor according 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. The length of the nursing periods themselves, is usually from ten to twenty minutes, the intervals between them being 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 average baby nurses about every six hours during the first two days, or four times in twenty-four hours. After this, according to one schedule, he will nurse every three hours during the day for about three months 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 nurses at four-hour intervals during the day and at ten o’clock at night, or five times daily. Such a feeding schedule may be arranged in a table as follows:

It is becoming more and more common to omit night feedings after ten o ’clock with the average baby who is in good condition even during the first three months. When this practice is adopted the baby seems not only to do as well as he normally should, but to profit by the long digestive rest during the night. Certainly the mother is benefited by the unbroken sleep thus made possible.

As a rule the baby nurses 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 you nor the baby should go to sleep while he is at the breast, but he should pause every four or five minutes to keep him from feeding too rapidly.

After you sit up you will find it a good plan to occupy a low, comfortable chair while nursing the baby. Lean slightly forward and raise the knee upon which the baby rests by placing your foot on a stool; support his head in the curve of your arm and hold your breast from his face though slightly above it, just as you did while nursing him in bed. Nurse him in a quiet room where you will not be disturbed and where neither your breasts nor the baby will be exposed to drafts or the possibility of being chilled.

Some mothers like to lie down while nursing the baby, for in addition to finding the position comfortable they are glad to have these regular, though short periods of rest.

Abdominal Binders and Bed-Exercises. Most women are interested in this question as it concerns the restoration or preservation of the “figure.”

The application of a snug binder for the first day or two after the baby comes, is a fairly common practice, for many women are very uncomfortable as a result of the sudden release of tension on their abdominal walls, a discomfort which a binder relieves. And during the first few days after the mother gets up and walks about she is sometimes given great comfort by a binder that is put on and snugly adjusted about her hips and the lower part of her abdomen, as she lies on her back.

In addition to this, some doctors like to have the young mother wear a snug binder throughout her entire stay in bed, while others instruct their patients to take bed exercises. If the binder is your portion, you have nothing to do but wear it, for some one else must put it on you. But if bed exercises are in order, the following descriptions and pictures of the exercises taken by young mothers at the Long Island College Hospital may be helpful.

The day upon which the exercises are started, the rate at which they are increased and the length of time during which they are continued, are, of course, entirely regulated by the doctor according to the strength and needs of each patient, for they are never continued to the point of fatigue. Quite evidently, then, there can be no definite directions for these exercises; one can give only a description of the positions and movements that are frequently used and the order in which they are adopted.

The average mother who is recovering normally begins the chin-to-chest exercise from twelve to twenty-four hours after the baby’s birth. She lies flat on her back and raises her head until the chin rests upon her chest. (See Fig. 32.) By resting her hand upon the abdomen she feels for herself that the abdominal muscles contract as she lifts her head and accordingly realizes that she is actually exercising them. The movement is usually repeated twenty-five times, morning and evening, every day and continued as long as the patient is in bed.

The familiar deep-breathing exercise comes next and is ordinarily started on the third or fourth day. The mother lies flat, with her arms at her sides, then extends them straight out from the shoulders (Fig. 33), raises them above her head, as in Fig. 34, and returns them to their original position. She repeats this exercise ten times morning and evening as long as she is in bed.

The one-leg flexion exercises are not taken by mothers who have stitches, but in other cases they are usually started about the fifth day. One thigh is flexed sharply on the abdomen and the foot brought down to the buttocks as in Fig. 35. The leg is then straightened out and lowered to the bed. This is repeated ten times, with each leg, morning and evening, for two or three days.

The next exercise sometimes replaces the one-leg-flexion and sometimes it is taken up in addition to it, being started after the former has been done for a day or two, according to the strength of the mother. Both thighs are brought up on the abdomen in this one, as in Fig. 36, but when the legs are straightened the feet are lowered not quite to the bed, as in Fig. 37, before being raised again. This is repeated ten times morning and evening.

Then comes the exercise for which the leg-flexions prepare the mother and which are sometimes discontinued when this one is adopted. It is started, as a rule, about the seventh day, or two or three days before the mother gets up. Both legs are slowly raised to a position at right angles to the body, as in Fig. 38, and slowly lowered but not far enough for the heels to touch the bed (see Fig. 37), and the movement repeated. As this exercise requires a good deal of effort it is taken up very gradually, somewhat as follows: The legs are raised once in the morning and twice in the evening of the first day; 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 mother is not fatigued, until the exercise is repeated ten times or more each morning and evening for several months.

The knee chest position shown in Fig. 39 is intended to prevent a misplacement of the uterus, from which so many women suffer after childbirth. It is usually started about the seventh day and the patient begins by being assisted to that position and keeping it for a moment or two, gradually lengthening the time to about five minutes each morning and evening; this is often continued for two months or more.

Walking on all fours is violent exercise and is taken up very gradually. Some women are able to attempt it on the first day out of bed, if they have been taking the other exercises regularly, but as a rule it is not started until the second, third or fourth day after getting up. The clothes are free from all constrictions, pajamas being very satisfactory; the knees are 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 rests flat on the floor. (See Fig. 40.) The patient starts 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 young mother walks in this position the uterus and rectum rub against each other, producing something the same result as would be obtained if it were possible to massage them, the effect of this being to promote involution, which will be explained later, and lessen the tendency toward constipation and uterine misplacement.

The general purpose of these exercises, as a whole, then, is to strengthen the abdominal muscles, thus helping to prevent a large, pendulous abdomen; to increase the convalescing mother’s general strength and tone just as exercise benefits the average person; to promote involution (See page 134); to prevent misplacement of the uterus and in a measure to relieve constipation. In order that the exercises may accomplish these much-to-be-desired ends, the doctors who advise them feel that it is important for them to be taken with moderation and judgment; started slowly; increased gradually and constantly adjusted to the strength of the individual mother.

Otherwise they may do more harm than good.

Concerning the changes that take place in your body during the puerperium, the ones that will interest you particularly are: (1) the shrinkage in the size of your uterus and its gradual descent into the pelvis where it was before the baby began his life within it; (2) the production of milk by your breasts; (3) a loss of body weight.

The Uterus. Immediately after delivery the uterus weighs about 2 pounds; is from 7 to 8 inches high; about 5 inches across and 4 inches thick. The top of the uterus, or fundus, may be felt just below the navel and the inner surface where the placenta was attached, is raw and bleeding. At the end of six or eight weeks the organ has descended into the pelvic cavity and resumed approximately its original position and size and its former weight of 2 ounces. This return of the uterus to practically its pre-pregnant state is called involution and in the interest of your immediate recovery and future health it is important that this shall progress normally.

There is evidently a close relation between the functions of the breasts and of the uterus and accordingly involution is likely to progress more satisfactorily in women who nurse their babies than in those who do not. The so-called “after-pains,” also, are affected by nursing, being more severe, as a rule, when the baby is at the breast than at other times. These pains are caused by alternate contractions and relaxations of the uterine muscles and are more common in women who have had other children than after the first baby. These pains usually subside after the first twenty-four hours, though they may persist for three or four days.

In connection with the changes that take place in the uterus, the discharge called lochia should be mentioned. This is quite profuse and bloody at first but if the uterus involutes normally the discharge gradually decreases in amount and fades in color, until by the end of the puerperium it has entirely disappeared.

The Production of Milk. During the first two or three days after the baby is born, the breasts secrete a small amount of yellowish fluid called colostrum, which differs somewhat from the milk that comes later. About the third day the meager amount of colostrum is replaced by milk and as this increases rapidly in amount, the breasts usually become tense and swollen and sometimes painful; but this discomfort generally subsides in a day or two.

The production of milk is definitely stimulated by the baby’s suckling and will not continue for more than a few days without this stimulation, a fact to be remembered if, for any reason, it is desirable to dry up the breasts. The end earnestly to be desired is for the breasts to produce a quantity and quality of milk which will adequately nourish the baby during the first eight or ten months of his life, and with proper care and effort this ideal can nearly always be realized. But if the mother becomes pregnant while nursing her baby—and this sometimes occurs as early as a few weeks after childbirth—the quality of her milk is likely to suffer.

The return of menstruation, however, does not necessarily affect the milk unfavorably, as is so generally believed. It is true that in the ideal course of events, the mother does not menstruate while nursing her baby, that is, for eight or ten months, but it is probable that about one-third of all nursing mothers begin to menstruate about two months after confinement and half of those who do not nurse their babies begin to menstruate in six weeks. A nursing mother may menstruate once and then not again for several months or a year; or she may menstruate regularly and still nurse her baby satisfactorily.

Menstruation is more likely to return early after the birth of the first baby than after those born subsequently. Mothers sometimes wonder whether this early discharge is menstrual or lochial, and though they, themselves, cannot possibly distinguish between them, a physician can easily decide by examination, and in the interest of the mother’s future health it is important that this uncertainty be cleared up.

The loss of weight is one of the striking changes which take place during the puerperium, varying in different women from a total loss of from twelve to fifteen pounds. Fat women lose more than thin women and those who nurse their babies lose more than those who do not. This loss may be somewhat controlled, however, by suitable diet and under most conditions the mother returns to not less than her pre-pregnant weight by the end of the sixth or eighth week. You will recall that there was a general gain in weight, over the entire body, during pregnancy, in addition to the increased weight of the uterus.

If all goes well, your doctor may not call to see you regularly after the first couple of weeks, but he will probably want to make a thorough examination, sometime about five or six weeks after the baby’s birth. As this examination is a very influential factor in securing your future health you should be sure to have it made. A slight abnormality, if detected at this time, may usually be corrected with little difficulty, but if allowed to persist may result in chronic invalidism, or necessitate an operation. In case the uterus is not properly involuted, for example, or the perineum is found to be flabby, a little more rest in bed is indicated; while a uterine misplacement, which seems to occur in about a third of all cases, usually may be corrected by the adjustment of a pessary. Quite evidently, then, it rests with the young mother to coöperate with the doctor in guarding against future ill health, or even operations, by having this final examination made and following whatever course he prescribes, as a result of his inspection.

Most of the discussion in this chapter relates to the care that is given to you by others, in preparing you to take up life anew, perhaps unaided, and assume the care of your baby. As we shall see in the next chapter, the care of your baby, for the next few months, is closely associated with the care which you take of yourself and the regulation of your daily life.