547. If the doctor has not arrived, cheerfulness, quietness, and presence of mind must be observed by all around; otherwise, the patient may become excited and alarmed, and dangerous consequences might ensue.
548. If the infant should be born apparently dead, a few smart blows must be given on the buttocks and on the back; a smelling-bottle ought to be applied to the nostrils, or rag should be singed under the nose, taking care that the burning tinder does not touch the skin; and cold water must be freely sprinkled on the face. The navel-string, as long as there is pulsation in it, ought not to be tied.
549. The limbs, the back, and the chest of the child ought to be well rubbed with the warm hand. The face should not be smothered up in the clothes. If pulsation has ceased in the navel-string (the above rules having been strictly followed, and having failed), let the navel-string be tied and divided,[102] and then let the child be plunged into warm water—98° Fahr. If the sudden plunge does not rouse respiration into action, let him be taken out of the warm bath, as the keeping him for any length of time in the water will be of no avail.
550. If these simple means should not quickly succeed, although they generally will, Dr. Marshall Hall’s Ready Method ought in the following manner to be tried: “Place the infant on his face; turn the body gently but completely on the side and a little beyond, and then on the face, alternately; repeating these measures deliberately, efficiently, and perseveringly, fifteen times in the minute only.”
551. Another plan of restoring suspended animation is by artificial respiration, which should be employed in the following manner: Let the nurse (in the absence of the doctor) squeeze, with her left hand, the child’s nose, to prevent any passage of air through the nostrils; then let her apply her mouth to the child’s mouth, and breathe into it, in order to inflate the lungs; as soon as they are inflated, the air ought, with the right hand, to be pressed out again, so as to imitate natural breathing. Again and again, for several minutes, and for about fifteen times a minute, should the above process be repeated; and the operator will frequently be rewarded by hearing a convulsive sob, which will be the harbinger of renewed life.
552. Until animation be restored, the navel-string, provided there be pulsation in it, ought not to be tied. If it be tied before the child has breathed, and before he has cried, he will have but a slight chance of recovery. While the navel-string is left entire, provided there be still pulsation in it, the infant has the advantage of the mother’s circulation and support.
553. If Dr. Marshall Hall’s Ready Method and if artificial respiration should not succeed, he must be immersed up to his neck in a warm bath of 98° Fahrenheit. A plentiful supply of warm water ought always to be in readiness, more especially if the labor be either hard or lingering.
554. Should the child have been born for some time before the doctor has arrived, it may be necessary to tie and to divide the navel-string. The manner of performing it is as follows: A ligature, composed of four or five whity-brown threads, nearly a foot in length and with a knot at each end, ought, by a double knot, to be tightly tied, at about two inches from the body of the child, around the navel-string. A second ligature must, in a similar manner, be applied about three inches from the first, and the navel-string should be carefully divided midway between the two ligatures. Of course, if the medical man should shortly be expected, any interference would not be advisable, as such matters ought always to be left entirely to him.
555. The after birth must never be brought away by the nurse: if the doctor has not yet arrived, it should be allowed to come away (which, if left alone in the generality of cases, it generally will) of its own accord. The only treatment that the nurse ought in such a case to adopt is, that she apply, by means of her right hand, firm pressure over the region of the womb: this will have the effect of encouraging the contraction of the womb, of throwing off the after birth, and of preventing violent flooding.
556. If the after birth does not soon come away, say in an hour, or if there be flooding, another medical man ought to be sent for; but on no account should the nurse be allowed to interfere with it further than by applying firm pressure over the region of the womb, and not touching the navel-string at all; as I have known dangerous, and in some cases even fatal, consequences to ensue from such meddling.
557. A lady ought never to be disturbed for at least an hour after the delivery; if she be, violent flooding might be produced. The doctor, of course, will make her comfortable by removing the soiled napkins, and by applying clean ones in their place.
558. Her head ought to be made easy; she must still lie on her side; indeed, for the first hour let her remain nearly in the same position as that in which she was confined—with this only difference, that if her feet have been pressing against the bedpost, they should be removed from that position.
559. She ought, after the lapse of an hour or two, to be moved from one side of the bed to the other. It ought to be done in the most tender and cautious manner. She must not, on any account whatever, be allowed to sit erect in the bed. While being moved, she herself should be passive—that is to say, she ought to use no exertion, no effort, but should, by two attendants, be removed from side to side; one must take hold of her shoulders, the other of her hips.
560. A patient, after delivery, usually feels shivering and starved; it will therefore be necessary to throw additional clothing, such as a blanket or two, over her, which ought to envelop the body, and should be well tucked around her; but the nurse ought to be careful not to overload her with clothes, or it might produce flooding, fainting, etc.; as soon, therefore, as she is warmer, let the extra clothing be gradually removed. If the feet be cold, let them be wrapped in a warm flannel petticoat, over which a pillow should be placed.
561. A frequent change of linen after confinement is desirable. Nothing is more conducive to health than cleanliness. Great care should be taken to have the sheets and linen well aired.
562. A cup of cool, black tea, directly after a patient is confined, ought to be given. I say cool, not cold, as cold tea might chill her. Hot tea would be improper, as it might induce flooding.
563. As soon as she is settled in bed, there is nothing better than a small basin of warm gruel.
564. Brandy ought never, unless ordered by the medical man, to be given after a confinement. Warm beer is also objectionable; indeed, stimulants of all kinds must, unless advised by the doctor, be carefully avoided, as they would only produce fever, and probably inflammation. Caudle is now seldom given; but still, some old-fashioned people are fond of recommending it after a labor. Caudle ought to be banished the lying-in room; it caused in former times the death of thousands.
565. (1) This consists of thick linen, similar to sheeting, about a yard and a half long, and sufficiently broad to comfortably support the belly. It ought to be put on moderately tight; and should be retightened every night and morning, or oftener, if it become slack. (2) Salmon’s Obstetric Binder is admirably adapted to give support after a confinement, and may be obtained of any respectable surgical-instrument-maker.
566. If there be not either a proper bandage or binder at hand—(3) a yard and a half of unbleached calico, folded double, will answer the purpose. The best pins to fasten the bandages are the patent safety nursery-pins. The binder requires no pins.
567. A support to the belly after labor is important: in the first place, it is a great comfort; in the second, it induces the belly to return to its original size; and lastly, it prevents flooding. Those ladies, more especially if they have had large families, who have neglected proper bandaging after their confinements, frequently suffer from enlarged and pendulous bellies, which give them an unwieldy and ungainly appearance.
568. The way of placing the patient in bed.—She ought not, immediately after a labor, under any pretext or pretense whatever, to be allowed to raise herself in bed. If she be dressed, as recommended at paragraph 508, her soiled linen may readily be removed; and she may be drawn up by two assistants—one being at the shoulders and the other at the legs—to the proper place, as she herself must not be allowed to use the slightest exertion.
569. Inattention to the above recommendation has caused violent flooding, fainting, bearing down of the womb, etc., and in some cases even fatal consequences.
570. The room to be kept cool and well ventilated.—A nurse is too apt, after the confinement is over, to keep a large fire. Nothing is more injurious than to have the temperature of a lying-in room high. A little fire, provided the weather be cold, to dress the baby by, and to encourage a circulation of the air, is desirable. A fire-guard ought to be attached to the grate of the lying-in room. The door must occasionally be left ajar, in order to change the air of the apartment; a lying-in woman requires pure air as much as any other person; but how frequently does the nurse fancy that it is dangerous for her to breathe it!
571. After the affair is over, the blinds ought to be put down, and the window curtains should be drawn, in order to induce the patient to have a sleep, and thus to rest herself after her hard work. Perfect stillness must reign both in the room and in the house.
572. It is really surprising, in this present enlightened age, how much misconception and prejudice there still is among the attendants of a lying-in room; they fancy labor to be a disease, instead of being what it really is—a natural process; and that old-fashioned notions, and not common sense, ought to guide them.
573. The patient should, after the labor, be strictly prohibited from talking; and noisy conversation ought not to be allowed; indeed, she cannot be kept too quiet, as she may then be induced to fall into a sweet sleep, which would recruit her wasted strength. As soon as the baby is washed and dressed, and the mother is made comfortable in bed, the nurse ought alone to remain; let every one else be banished the lying-in room. Visitors should on no account, until the medical man gives permission, be allowed to see the patient.
574. Ought a patient to go to sleep before she has made water?—There is not the least danger in her doing so (although some old-fashioned person might tell her that there is); nevertheless, before she goes to sleep, if she have the slightest inclination she should respond to it, as it would make her feel more comfortable and sleep more sweetly.
575. Let me urge the importance of the patient, immediately after childbirth, making water while she is in a lying position. I have known violent flooding to arise from a lying-in woman being allowed, soon after delivery, to sit up while passing her water.
576. The “female slipper”[103] (previously warmed by dipping it in very hot water and then quickly drying it) ought, at these times, and for some days after a confinement, to be used. It is admirably adapted for the purpose, as it takes up but little room and is conveniently shaped, and readily slips under the patient, and enables her to make water comfortably, she being perfectly passive the while. It should be passed under her in front, and not at the side of the body.
577. If there be any difficulty in her making water, the medical man must, through the nurse, be immediately informed of it. False delicacy ought never to stand in the way of this advice. It should be borne in mind that, after either a very lingering or a severe labor, there is frequently retention of urine,—that is to say, that although the bladder may be full of water, the patient is, without assistance, unable to make it.
578. After the patient, while lying down, trying several times to pass her water, and after, allowing twelve or fifteen hours to elapse, and not being able to do so, it will be well for her to try the following method: Let the pot de chambre be well warmed, let the rim be covered with flannel, let her, supported the while by the nurse, kneel on the bed, her shoulders being covered with a warm shawl; then let her, with the pot de chambre properly placed between her knees on the bed, try to make water, and the chances are that she will now succeed.
579. If she does not, twenty-four hours having elapsed, the doctor must be informed of the fact; and it will then be necessary, absolutely necessary, for him, by means of a catheter, to draw off the water. It might be well to state that the passing of a catheter is unattended with either the slightest danger or pain; and that it is done without exposing her, and thus without shocking her modesty.
580. The bowels are usually costive after a confinement. This confined state of the bowels after labor is doubtless a wise provision of nature, in order to give repose to the surrounding parts—especially to the womb; it is well, therefore, not to interfere with them, but to let them have perfect rest for three days. Sometimes before the expiration of the third day the bowels are relieved, either without medicine or merely by the taking of a cupful of warm coffee. If such be the case, all well and good; as it is much better that the bowels should be relieved without medicine than by medicine; but if, having taken the coffee, at the end of the third day they are not opened, then early on the following—the fourth—morning, a dose of castor oil should be given in the manner recommended at paragraph 281. Either a teaspoonful or a dessertspoonful, according to the constitution of the patient, will be a proper dose. If, in the course of twelve hours, it should not have the desired effect, it must be repeated. The old-fashioned custom was to give castor oil on the morning after the confinement; this, as I have before proved, was a mistaken plan.
581. After a lying-in, and when the bowels are not opened either naturally or by the taking of a cupful of warm coffee, if medicine be given by the mouth, castor oil is the best medicine, as it does not irritate either the patient’s bowels, or, through the mother’s milk, gripe the infant. Aperient pills, as they most of them contain either colocynth or aloes, or both, frequently give great pain to the babe, and purge him much more than they do the mother herself; aperient pills, therefore, after a confinement ought never to be taken.
582. If the patient object to the taking of castor oil, let the nurse, by means of an enema apparatus, administer an enema. This is an excellent, indeed the best, method of opening the bowels, as it neither interferes with the appetite nor with the digestion; it does away with the nauseousness of castor oil, and does not, in the administration, give the slightest pain. If the first enema should not have the desired effect, let one be given every quarter of an hour until relief be obtained. One of the best for the purpose is the following:
To make a clyster.
Another capital enema for the purpose is one made of Castile soap dissolved in warm water.
583. If the patient object both to the taking of the castor oil and to the administration of an enema, then the following draught will be found useful; it will act kindly, and will neither gripe the mother nor the child:
To make a draught. To be taken early in the morning.
If in twelve hours the above draught should not have the desired effect (although, if the essence of senna be good, it usually does long before that time), let the draught be repeated. If the bowels be easily moved, half of the above draught is generally sufficient; if it be not so in twelve hours, the remainder should be taken. But let every lying-in woman bear in mind that as soon as her bowels will act, either naturally or by the taking of a cupful of warm coffee, without an aperient, not a particle of opening medicine should be taken.
584. But, after all that can be said on the subject, there is no better method in the world for opening a lying-in patient’s bowels, when costive, than (if the cup of coffee be not sufficiently powerful) by giving her an enema, as advised in a previous paragraph. An enema is safe, speedy, painless, and effectual, and does not induce costiveness afterward, which castor oil, and all other aperients, if repeatedly taken, most assuredly will.
585. An enema, then, is an admirable method of opening costive bowels, both during suckling and during pregnancy, and deserves to be more universally followed than it now is; fortunately, the plan just recommended is making rapid progress, and shortly will, with ladies at such times, entirely supersede the necessity of administering aperients by the mouth.
586. Aperients, after a confinement, were in olden times, as a matter of course, repeatedly given both to the mother and to the babe, to their utter disgust and to their serious detriment! This was only one of the numerous mistakes and follies that formerly prevailed in the lying-in room. Unfortunately, in those days a confinement was looked upon as a disease, and to be physicked accordingly. A better state of things is happily now dawning.
587. When the patient’s bowels, for the first few days after the confinement, require to be opened, she ought to use either the French bed-pan or the bed-pan of the Liverpool Northern Hospital. Either the one or the other of these pans is a great improvement on the old-fashioned bed-pans, as they will readily slip under the patient, and will enable her, while lying down and while she is perfectly passive in bed, to have her bowels relieved, which at these times is very desirable. The French bed-pan or the bed-pan of the Liverpool Northern Hospital is admirably adapted for a lying-in room; indeed, no lying-in room ought to be without either the one or the other of these useful inventions. “A flannel cap for the toe-part, held on by strings round the heel, will afford considerable comfort to the patient.”[104]
588. The “Cleansings.”—This watery discharge occurs directly after a lying-in, and lasts either a week or a fortnight, and sometimes even longer. It is, at first, of a reddish color; this gradually changes to a brownish hue, and afterward to a greenish shade; hence the name of “green waters.” It has in some cases a disagreeable odor. A moderate discharge is necessary; but when it is profuse, it weakens the patient.
589. Some ignorant nurses object to have the parts bathed after delivery; they have the impression that such a proceeding would give cold. Now, warm fomentation twice a day, and even oftener, either if the discharge or if the state of the parts requires it, is absolutely indispensable to health, to cleanliness, and comfort. Ablutions, indeed, at this time are far more necessary than at any other period of a woman’s existence.
590. There is nothing better for the purpose than a soft sponge and warm water, unless the parts be very sore; if they be, a warm fomentation, two or three times a day, of marshmallows and chamomile,[105] will afford great relief, or the parts may be bathed with warm oatmeal gruel, of course without salt. In these cases, too, I have found warm barm (yeast) and water a great comfort, and which will soon take away the soreness. The parts ought, after each fomentation, to be well but quickly dried with warm, dry, soft towels.
591. If the internal parts be very sore, it may be necessary, two or three times a day, to syringe them out, by means of an india-rubber vaginal syringe,[106] with either of the above remedies. Hence the importance of having a good monthly nurse, of having one who thoroughly understands her business.
592. Let the above rules be strictly followed. Let no prejudices and no old-fashioned notions, either of the nurse or of any female friend, stand in the way of the above advice. Ablution of the parts, then, after a confinement, and that frequently, is absolutely required, or evil results will, as a matter of course, ensue.
593. A horizontal—a level—position for either ten days or a fortnight after a labor is important. A lady frequently fancies that if she supports her legs, it is all that is necessary. Now, this is absurd; it is the womb and not the legs that requires rest; and the only way to obtain it is by lying flat either on a bed or on a sofa: for the first five or six days, day and night, on a bed, and then for the next five or six days she ought to be removed for a short period of the day either to another bed or to a sofa; which other bed or sofa should be wheeled to the side of the bed, and she must be placed on it by two assistants, one taking hold of her shoulders and the other of her hips, and thus lifting her on the bed or sofa, she herself being perfectly passive, and not being allowed to sit erect the while. She ought, during the time she is on the sofa, to maintain the level position.
594. She ought, after the first nine days, to sit up for an hour; she should gradually prolong the time of the sitting; but still she must, for the first fortnight, lie down a great part of every day. She should, after the first week, lie either on a sofa or on a horse-hair mattress.
595. The above plan may appear irksome, but my experience tells me that it is necessary, absolutely necessary. The benefit the patient will ultimately reap from it will amply repay the temporary annoyance of so much rest. Where the above rules have not been adopted, I have known flooding, bearing down of the womb, and even “falling” of the womb, frequent miscarriages, and ultimately ruin of the constitution, to ensue.
596. “Falling of the womb” is a disagreeable complaint, and the misfortune of it is, that every additional child increases the infirmity. Now, all this might, in the majority of cases, have been prevented, if the recumbent posture for ten days or a fortnight after delivery had been strictly adopted.
597. If a patient labor under a “falling of the womb,” she ought to apply to a medical man, who will provide her with a proper support, called a pessary, which will prevent the womb from “falling down,” and will effectually keep it in its proper place.
598. It is only a medical man, accustomed to these matters, who can select a pessary suitable for each individual case. A proper kind of, and duly-adjusted, pessary is a great comfort to a patient, and will enable her both to take her proper exercise and to follow her ordinary employments; indeed, if a suitable pessary be used, it is so comfortable that the patient often forgets that she is wearing one at all. Those pessaries ought only to be employed that can be removed every night, as there is not the least necessity for a patient to sleep in one, as the womb does not usually come down when the patient is lying down. Moreover, a pessary ought to be kept perfectly clean, and unless it be daily removed it is utterly impossible to keep it so. It is a great comfort and advantage to a patient to be able both to introduce and to remove the pessary herself, which, if a proper kind be employed, she can, when once taught, readily do.
599. If “falling of the womb” be early and properly treated, there is a good chance of a patient being perfectly cured, and thus of being able to dispense with a pessary altogether.
600. For the first day the diet should consist of nicely made and well-boiled gruel, arrow-root and milk, bread and milk, tea, dry toast and butter, or bread and butter; taking care not to overload the stomach with too much fluid. Therefore, either a cupful of gruel, or of arrow-root, or of tea, at a time, should not be exceeded, otherwise the patient will feel oppressed; she will be liable to violent perspiration, and there will be a too abundant secretion of milk.
601. For the next—the second day.—Breakfast,—either dry toast and butter, or bread and butter, and black tea. Luncheon,—either a breakfast-cupful of strong beef-tea,[107] or of bread and milk, or of arrow-root made with good fresh milk. Dinner,—either chicken or game, mashed potatoes, and bread. Tea, the same as for breakfast. Supper,—a breakfast-cupful of well-boiled and well-made gruel, made either with water or with fresh milk, or with water with a tablespoonful of cream added to it.
602. If beef-tea and arrow-root and milk be distasteful to the patient, or if they do not agree, then for luncheon let her have either a light egg pudding or a little rice pudding instead of either the beef-tea or the arrow-root.
603. On the third and fourth days.—Similar diet to the second day, with this difference, that for her dinner the patient should have mutton—either a mutton-chop or a cut out of a joint of mutton, instead of the chicken or game. The diet ought gradually to be improved, so that at the end of four days she should return to her usual diet, provided it be plain, wholesome, and nourishing.
604. The above, for the generality of cases, is the scale of dietary; but of course every lying-in woman ought not to be treated alike. If she be weak and delicate, she may from the beginning require good nourishment, and instead of giving her gruel, it may, from the very commencement, be necessary to prescribe good strong beef-tea, veal-and-milk broth,[108] chicken-broth, mutton-chops, grilled chicken, game, the yelk and the white of an egg beaten up together in half a teacupful of good fresh milk, etc. Common sense ought to guide us in the treatment of a lying-in as of every other patient. We cannot treat people by rule and compass; we must be guided by circumstances; we can only lay down general rules. There is no universal guide, then, to be followed in the dietary of a lying-in woman; each case may and will demand separate treatment; a delicate woman, as I have just remarked, may, from the very first day, require generous living; while, on the other hand, a strong, robust, inflammatory patient may, for the first few days, require only simple bland nourishment, without a particle of stimulants. “And hence the true secret of success rests in the use of common sense and discretion—common sense to read nature aright, and discretion in making a right use of what the dictates of nature prescribe.”[109]
605. For the first week, either toast and water, or barley-water and milk,[110] with the chill taken off, is the best beverage. Wine, spirits, and beer, during this time, unless the patient be weak and exhausted, or unless ordered by the medical man, ought not to be given. All liquids given during this period should be administered by means of a feeding-cup; this plan I strongly recommend, as it is both a comfort and a benefit to the patient; it prevents her from sitting up in bed every time she has to take fluids, and it keeps her perfectly still and quiet, which, for the first week after confinement, is very desirable.
606. When she is weak, and faint, and low, it may, as early as the first or second day, be necessary to give a stimulant, such as either a tumblerful of home-brewed ale or a glass or two of wine daily; but, as I before remarked, in the generality of cases, either toast and water, or barley-water and milk, for the first week after a confinement, is the best beverage.
607. After a week, either a tumblerful of mild home-brewed ale or of London or Dublin porter, where it agrees, should be taken at dinner; but if ale or porter be given, wine ought not to be allowed. It would be well to keep either to ale or to porter, as may best agree with the patient, and not to mix them, nor to take porter at one meal and ale at another.
608. Barreled, in this case, is superior to bottled porter, as it contains less fixed air. On the whole, however, I should prefer home-brewed ale to porter. Either old, or very new, or very strong ale, ought not, at this time, to be given.
609. Great care is required in the summer, as the warm weather is apt to turn the beer acid. Such beer would not only disagree with the mother, but would disorder the milk, and thus the infant. A nursing mother sometimes endeavors to correct sour porter or beer by putting soda in it. This plan is objectionable, as the constant taking of soda is weakening to the stomach and impoverishing to the blood. Moreover, it is impossible, by any artificial expedient, to make either tart beer or porter sound and wholesome, and fit for a nursing mother. If beer or porter be sour, it is not fit to drink, and ought either to be thrown away or should be given to the pigs.
610. Sometimes neither wine nor malt liquor agrees; then, either new milk and water, or equal parts of fresh milk and barley-water, will generally be found the best beverage. If milk should also disagree, either barley-water, or toast and water, ought to be substituted.
611. The period at which a lying-in woman should leave her room will, of course, depend upon the season, and upon the state of her health. She may, after the first fourteen days, usually change the chamber for the drawing-room, provided it be close at hand; if it be not, she ought, during the day, to remove—be either wheeled or carried in a chair—from one bedroom to another, as change of apartment will then be desirable. The windows, during her absence from the room, ought to be thrown wide open; and the bedclothes, in order that they may be well ventilated, should be thrown back. She should, at the end of three weeks, take her meals with the family; but even then she ought occasionally, during the day, to lie on the sofa to rest her back.
612. The period at which a lady, after her confinement, ought to take exercise in the open air, will, of course, depend upon the season, and upon the state of the wind and weather. In the winter, not until the expiration of a month, and not even then unless the weather be fine for the season. Carriage exercise will at first be the most suitable. In the summer she may, at the end of three weeks, take an airing in a carriage, provided the weather be fine, and the wind be neither in an easterly nor in a northeasterly direction. At the expiration of the month she may, provided the season and weather will allow, go out of doors regularly, and gradually resume her household duties and employments.