Prospective Mother — 12 - Chapter 9, part 2 - The Preparations for Confinement

THE CHOICE AND ARRANGEMENT OF A ROOM.

--An old-fashioned custom, which relegated obstetrical patients to the most secluded part of the house, with little regard for comfort and still less for hygiene, has now few, if any, adherents.

There is an advantage, to be sure, in having a quiet room; but this qualification may be secured in a room well located with regard to other essentials.

Selection of a suitable room is not a trivial point.

In most cases, since patients ordinarily remain for convalescence in the same room in which the infant is born, the chamber must serve a two-fold purpose.

A number of requirements, therefore, must be met, and they must all be kept in mind when the room is chosen.

We have seen that the act of birth, natural as it is, may have a very unnatural sequel if precautions against infection are treated lightly.

It is proper, therefore, that the delivery-room should be as clean as care can make it.

Such radical measures as may be employed in sterilizing the dressings are here out of the question; if possible, they would be absurd.

Infection usually develops because harmful bacteria come in contact with the patient.

For that reason, an infection is more likely to be communicated by the dressings than by articles about the room, which only become a source of danger when the dirt upon them is transferred by an attendant.

An acceptable delivery-room may be arranged in any home; it is by no means necessary to duplicate the equipment of a modern hospital.

To choose a room convenient to the bathroom will be found advantageous not only at the time of birth but throughout the lying-in period.

The furnishing should be simple and scrupulously clean; indeed, it is improbable that one of these good points can be secured without the other.

Furthermore, the preparation of the room should be completed well in advance of the date of confinement.

A large collection of furniture interferes with the nursing, and also increases the difficulty of keeping the room free of dust.

It is sound advice, therefore, to remove everything which will not serve some good purpose during the delivery.

Should any article be wanted later, it can be brought back to its accustomed place.

The furniture may be conveniently limited to a bed, a bureau, a washstand, a table, and several chairs, one of them a large, comfortable rocker, which will prove invaluable during the early part of labor.

To approach perfect conditions, bric-a-brac, needless hangings, and everything that might collect dust should be temporarily removed.

A

profusion of pictures does not accord with the best sanitation of a room devoted to the treatment of obstetrical patients; those which are to be left upon the wall ought to be taken down and wiped carefully with a damp cloth.

Other desirable preparations would be instinctively undertaken by the modern housekeeper, and it may seem presumption to mention that the room itself ought to be subjected to most thorough cleaning.

It is well to leave the floor bare or merely covered with freshly cleaned rugs.

Carpeting is difficult to protect against soiling and is not sanitary.

If left down, the carpet should be covered with some suitable material, firmly stretched and tacked in place.

We know that the air in most households does not contain disease- producing bacteria; but the presence of any contagious disease materially alters the situation, and may imperil the convalescence of an obstetrical patient.

Preferably, one should never select a room in which there has lately been sickness, and under no circumstances may such a room be used until carefully fumigated.

The more conspicuous diseases which for at least several months absolutely disqualify an apartment for obstetrical purposes are diphtheria, pneumonia, pleurisy, erysipelas, scarlet fever, typhoid fever, tuberculosis of all varieties, and every sort of discharging sore.

When possible, two adjoining rooms should be given over to the mother and the infant; if this is impracticable, the single room should be large, easily ventilated, well lighted, and heated in such a way as to permit a change of temperature without difficulty.

All these features help to make convalescence comfortable and free from petty annoyances.

A room which has a southern or eastern exposure proves grateful for those who must remain indoors; frequently, this will be beyond reach, but a room getting the sun's rays directly during part of the day will always be available, and the selection should be made with that requirement in mind.

At the time of birth and for the first few days which follow, a patient may not appreciate this feature;

ultimately she will understand the need of sunlight better than the need for the more technical, and therefore the more impressive, preparations.

THE BED.

--Now that housekeepers recognize how easily such furniture can be kept clean, few homes are without a brass or an iron bedstead;

they are equally sanitary.

Undoubtedly, this kind of bedstead fulfills the needs of an obstetrical patient much better than any other; and, if at hand, it should be used.

The single bedstead is the most acceptable, and the mattress ought to be at least twenty inches above the floor.

A low, wide bed interferes with proper management of the delivery and later handicaps the nurse in taking care of the patient.

Wooden blocks may be used to raise a bed which otherwise would be too low.

It is well worth while to provide them if one desires good nursing, for no attendant can do her best when she must continuously bend over a very low bed.

The location of the bed at the time of delivery is not an unimportant matter; it must always be placed so that the brightest possible light will shine over the foot.

Since birth often occurs at night, one should make certain that the artificial lighting of the room is good, and place the bed most advantageously in reference to it; at the same time the necessity of a good light from the windows, when delivery occurs during the day, should not be forgotten.

The head of the bed may be placed against the wall, but both sides must remain freely accessible not only at the time of delivery but also throughout the lying-in period.

A smooth, firm mattress, made in one piece, should be provided.

One which has been used several years and possibly worn in a hollow will require renovation to be made comfortable.

A feather bed should not be used under any circumstances.

The mattress must be protected; and protection is best secured by means of a large piece of rubber sheeting.

The regulation household sheet covering the rubber should be tucked well under the mattress at the ends and sides; in that way the rubber sheeting will be held firmly.

Since the part of the bed where the hips rest will be most exposed to soiling, the protection of this area is usually reinforced by a "draw sheet."

To arrange this, a cotton sheet is doubled so as to make a strip about one yard wide and two yards long; the smaller piece of rubber sheeting is laid between the folds.

The draw sheet will reach from the middle of the back to the knees; its ends should be tucked under the sides of the mattress, to which it is fastened by means of large safety pins.

After delivery, the draw sheet may be removed without disturbing the mother, who will thus be assured a clean, dry, and comfortable bed.

The bed-clothes covering the patient during labor will vary with the season of the year, but should always be light; in summer a single sheet will suffice, and in winter a blanket will likely be needed.

For sanitary reasons, a freshly laundered sheet should also be placed outside the blanket until the delivery has been completed; later, it may be replaced with a light spread.

Two pillows will be needed, and it is very convenient to have one of hair, the other of feathers.

While there is no necessity for sterilizing the bed-clothes, it is advisable to use linen which has been recently laundered and kept well protected from dust.

Among the poor, infection from soiled bed- linen is not uncommon.

THE PRELIMINARY VISIT OF THE DOCTOR.

--No teaching of medical science has been given greater prominence of late than the principle of prevention.

In obstetrics it finds a particularly wide field of application, and its practice is responsible for removing many of the former terrors of childbirth.

We have just learned that preventive measures effectually reduce the frequency of puerperal infection, and in an earlier chapter we saw the value of routine examination of the urine as a means of anticipating other complications.

Moreover, the benefit of promptly reporting to the physician anything that does not seem to be as it should has been urged constantly, for in this way is afforded the earliest opportunity to treat complications.

Similarly a visit from the doctor about four weeks before the expected date of confinement is indispensable to skillful management of the delivery;

neglect of this precaution is sometimes responsible for bad results.

At this visit the physician not only becomes familiar with the general health of his patient, but he also notes certain facts which will have a direct bearing upon the course of labor.

By means of a few simple measurements he may accurately determine the character of the pelvis, the bony structure through which the fetus passes.

When they are compared with what we know as the normal measurements, a very good idea is gained as to whether the birth-canal will present any obstacle to the passage of the child; and, if it will, there is opportunity to deliberate what treatment may be necessary.

Since another factor in the problem, namely, the size of the child, cannot be accurately predicted, occasionally the physician may hesitate to express as definite an opinion as the patient may wish.

Nevertheless, though it may be impossible to learn every detail, the available information well repays the time and trouble expended.

In nine out of ten cases nothing whatever is found out of the way; the result is an assurance which always justifies the examination.

During this examination the position of the child is also ascertained.

By means of a series of painless manipulations through the abdominal wall of the mother, the head, the body, and the extremities of the child may be mapped out, and the conclusions verified by locating the fetal heart-sounds.

In this regard, also, the physician usually finds normal conditions.

The most favorable presentation, that in which the head is the part to be born first, occurs in ninety-seven of every hundred cases.

When less favorable conditions are recognized, they may frequently be corrected at once;

but should that prove impossible, with foreknowledge of the presentation, the physician will be more competent to conduct the delivery.

With a clear understanding of the character and value of the information gathered at the preliminary examination, patients are not likely to refuse it.

If they do, the risks should be fully explained to them.

Some physicians decline to assume the responsibility of a patient who will not permit these observations.

Such a decision is rarely necessary, for in my experience the patient's consent has never been difficult to obtain.

Many women now regard the visit as part of the routine attention, and inquire when it will be made.

The appropriate time for this examination, as I have indicated, is approximately one month prior to the calculated date of confinement.

Before this period, we have no assurance that the presentation which is found will continue until the time of birth.

The fetus frequently alters its position as long as it is not large enough to fill out the cavity of the womb, consequently it is only during the last month of pregnancy that the final presentation can be determined.

But to defer the examination after the period I have specified is unsafe since we lack an exact method of fixing the day of confinement, and too long a delay might render a preliminary examination impossible.

Aside from its relation to the observations just outlined, the preliminary visit provides an opportunity for the physician to criticize the preparations which have been made, and for the patient to inquire about the personal preparation advisable at the beginning of labor.

She will also learn the signs which indicate that labor has begun and will be told what to do when they appear.

Although physicians may not agree in all these directions, there can be no difference of opinion relative to the essential points.

At least, the rules given here will serve to bring the patient and the doctor to a definite understanding as to the course he desires her to follow.

WHEN TO CALL THE DOCTOR.

--During the last two or three weeks of pregnancy not a few patients are more comfortable than they have been for several months.

About this time the womb usually drops somewhat and relieves the pressure which has interfered with breathing.

These changes, however, do not promote comfort in every direction; more freedom for the organs of the chest means compression of the structures below the womb; consequently, the inclination to empty the bladder and for the bowels to move becomes more frequent.

Patients complain also of cramps in the legs and experience difficulty on walking.

This order of events enables some women to recognize the approach of delivery.

Of course there is other evidence when labor actually begins.

Its onset may be indicated in one of three ways, namely, by periodic pains, by a gush of water from the vagina, or by a discharge of blood as though the patient were taken unwell.

Each of these unmistakable signs is a sufficient reason for notifying the doctor.

At the onset of labor, dragging pains are usually felt at the back, but sometimes in the lower part of the abdomen.

The rhythm with which they come and go identifies them more certainly than any other feature, though this indication is not entirely reliable, for intestinal colic also causes rhythmical pain.

At first the uterine contractions which occasion the discomfort are weak and appear at long intervals.

Gradually they become stronger and closer together.

When the interval between them has been shortened to half an hour or less their significance is fairly certain, provided the abdomen becomes tense and hard with each pain, remaining comparatively soft between them.

When contractions begin during the day or early evening, the physician will be glad to have immediate notification in order that he may arrange his appointments and thus be free to attend the patient when she needs his services.

On the other hand, if they begin between 11 P. M.

and 7 A. M.

the nurse, who will always be summoned with the very first warning, should be allowed to decide when the doctor is to be called.

Unless other instructions have been given, she will usually wait until the interval between the contractions is five to ten minutes.

Usually the symptoms make it clear that labor has begun, but occasionally the greatest difficulty will be experienced in deciding whether the discomfort has not some other origin.

Uncertainty may prevail not only because of the similar effects of colic, but also from the fact that uterine contractions do not always have the same value.

Preliminary pains may appear several days, or even weeks, before the actual onset of labor.

Now and then the "false" pains cease, and after a period of comfort efficient contractions are established.

There is never difficulty in recognizing the latter;

doubt always relates to the preliminary pains, which may subside or may pass into the efficient type.

We lack a method of foretelling which turn they will take; developments may be calmly awaited, with the assurance that ample warning will precede the birth.

A slight mucous discharge from the vagina is frequently seen toward the end of pregnancy and may be disregarded, but a gush of watery fluid always means that the sac which contains the fetus has ruptured.

Uterine contractions generally follow within a few hours, though in a few instances they will not appear for a number of days.

Under any circumstances the event ought to be promptly reported to the doctor.

Similarly, he should be notified whenever bleeding from the vagina occurs, since it is important to have him determine its significance.

Anyone who supposes that patients are more likely to be infected when delivery occurs so quickly that there is not time for the doctor to arrive overlooks the leading factor in the production of this complication.

Unless harmful bacteria are introduced into the birth- canal and lodge there, infection is impossible.

Bacteria never enter of their own accord; they are usually carried into the vagina by means of an examining finger or some other foreign body.

Accordingly, with the exception of those instances in which local inflammation already exists, there is no reason to fear infection when delivery proceeds so rapidly that internal examinations are not required.

PERSONAL PREPARATIONS.

--Ordinarily, if the nurse is not already in the house, she will arrive in time to assist the patient in making the final arrangements for delivery.

Should the nurse be delayed, the patient herself may make certain preparations to insure personal cleanliness, another very important factor in the prevention of infection.

The presence of hair and the folding of the skin about the outlet to the birth-canal render the disinfection of this area somewhat difficult.

It is advisable, therefore, to clip the hair as short as possible and, while bathing the whole body, to scrub the region in question with especial thoroughness.

Before the bath an enema of soap-suds should be taken to clear the rectum of material which otherwise might be expelled during the birth and contaminate the field of delivery.

The bath-towels and the gown which are used should have been freshly laundered.

Other especial preparation of the delivery-field will be made later by the nurse.

But whenever labor progresses so rapidly that neither the nurse nor the doctor arrives before the child is born, such preparations as I have indicated will be sufficient, for more minute precautions are unnecessary unless an internal examination must be made.

THE CARE OF OBSTETRICAL PATIENTS AT THE HOSPITAL.

--The majority of obstetrical patients are attended at home, and there is no reason why this should not be.

Generally it is unfair to urge a woman to go to a hospital if she has already passed through a normal confinement and there is no reason to anticipate trouble in the approaching one; on the other hand, if any complication whatever is anticipated, the patient should certainly enter a hospital.

Furthermore, it frequently proves advantageous to do so where the pregnancy is the first, though no complication is expected and none develops.

The average labor with the first child lasts somewhat longer than with subsequent ones, and in consequence there is greater opportunity for the patient's family or friends to interfere with the management of the case, which never benefits a patient, and is sometimes a serious handicap.

Then again, the cramped apartments, so common in these days, are poorly adapted to the treatment of sickness of any sort and should induce many obstetrical patients to choose the hospital.

There are, besides, other features which favor this course, such as economy, convenience, and safety.

From my own experience, which includes the care of patients both at home and at the hospital, I am convinced that, as a rule, the latter is much more satisfactory.

Most cities now have institutions which provide a room and all the essential care, exclusive of the doctor's services, at approximately the cost of a trained nurse at home; luxuries will naturally add to the expense in hospitals as quickly as elsewhere.

If one considers the various items connected with attention at home, such as the maintenance of the nurse and of the patient, the cost of the equipment necessary for confinement, the additional household laundry, and the sundry other details, it is clear that hospital treatment becomes distinctly economical.

Moreover, the uncertainty of the date of confinement may necessitate paying a nurse for a longer or shorter period before the birth.

Expense at the hospital, on the contrary, usually begins when the patient enters; and if she lives in the city it is rarely advisable for her to leave home until the beginning of labor.

Even aside from the matter of expense some women prefer the hospital, since in this way they avoid the technical preparations for the birth.

Much more vital, however, is the care patients receive in the hospital, for rigid adherence to surgical cleanliness is exemplified in the hospital as it can be nowhere else.

Infections rarely develop there.

Formerly these accidents were more common in the hospital than in the home, but conditions are now reversed and fatalities predominate among those delivered in private houses.

The modern theory of asepsis has, to be sure, been widely accepted and is practiced so far as possible wherever obstetrical patients are attended, but only in the hospital can the underlying principles be applied with complete thoroughness and persistence.

The hospital is constantly alert, whereas in private houses carelessness or ignorance, or both, often lead to lax technique.

As a result, statistical evidence indicates that two to three infections occur among those delivered at home for one at the hospital.

In the event of an emergency during labor, the hospital affords another distinct advantage in its staff of trained attendants.

Of course they may be brought to one's home, yet not without some delay and extra expense; whereas in the hospital their assistance is instantly available.

In institutions charity patients are often delivered under more favorable auspices than are the wealthy at their homes.

Convalescence likewise is favored at the hospital, since the rules which control the admission of visitors guard the mother from exhaustion and annoyance.

Moreover, isolation such as can only be secured in a hospital is conducive to a well-trained baby.

Patients debating what course to follow often ask when they must leave home, what they should take with them, and how long they ought to remain at the hospital.

The attending circumstances will alter the answers to these questions, but in a general way the following directions will serve as a guide.

Ordinarily, the patient may remain at home until the first warning of labor.

Departure from this rule is justified if the patient becomes unduly anxious about reaching the hospital in time, especially when she lives some distance from the institution, or if there is any doubt of securing accommodations.

In either event, she should go to the hospital at least one week before the confinement is expected.

There is no danger in riding to the hospital after labor has begun;

frequently, the ride exerts a helpful influence and shortens the labor.

Whatever is to be taken to the hospital should be packed in a bag several weeks before the predicted date of confinement and put in a convenient place so that one may be spared the trouble of gathering it at the last minute.

Beside her usual toilet articles, the mother will require several gowns, a dressing-robe, and bedroom slippers.

Clothing for the child will also be needed since most institutions stipulate that the infant use its own wearing apparel.

If impracticable to transport the entire wardrobe when the mother enters the hospital, so much may be taken as will be needed during the first few days, and other articles may be brought as the need of them arises.

The personal laundry of both mother and infant is usually done outside the institution.

Surgical dressings of every description are provided by the hospital.

Those who intend to enter a hospital, therefore, may disregard the list of articles necessary for confinement.

Similarly, the sterilization, the preparations of the room and of the bed, and personal preparations will be of interest only to the patient who intends to stay at home.

It is not always possible for the physician to say how long a patient should remain at the hospital; the rapidity of the mother's convalescence and the progress of the child, both important factors, cannot be accurately foretold.

Frequently, it is a good plan to remain until the infant is four weeks old, but the majority of patients are dismissed at a somewhat earlier date.

In no instance, however, should the mother be allowed to leave before the infant is two weeks old.

Even when given the privilege of leaving so early she will always understand that competent assistance must be provided at home, for the mother should not resume her routine duties until six weeks after the birth.

CHAPTER X