Prospective Mother — 14 - Chapter 10, part 2 - The Birth of the Child

THE EFFECT OF LABOR UPON THE CHILD.

--Unless the experience of countless generations had taught us otherwise, we should fear the child would be injured by its passage through the birth-canal.

Immediately after the birth evidence of the journey is seldom wanting, but it quickly disappears.

The unusual size of the infant's brain requires the head to be large, and bestows upon it a contour which differs from that of the mother's pelvic cavity.

Since the bones of the pelvis are rigid, while those of the fetal skull are malleable, the head is molded as it descends into the pelvic cavity, so that its passage may be made the easier.

As the result of this process of accommodation the skull becomes relatively longer from crown to chin than in adults.

Within a few weeks, however, the modification vanishes.

If an infant is born with the buttocks first, the head does not linger in the birth-canal, a fact which in such cases explains the pleasing shape of the skull, which emerges with the contour determined by fetal growth.

Whenever a soft swelling appears over that portion of the scalp which was foremost during the birth, the curiosity of the family is aroused; but the swelling is harmless and subsides quickly.

It originates for the same reason that a finger swells if too tight a ring is worn, which, as everyone knows, is because of interference with the circulation.

Just as the swelling of the finger disappears when the constriction is removed, so the swelling of the scalp subsides shortly after the child is born.

Usually no trace of it can be found the next day; but even when more persistent it will always vanish after a short time.

For the child the most notable result of labor relates to the revolutionary changes in its mode of existence.

Up to the time of birth the fetus received nourishment by way of the placenta, but after separation from the mother another source of food must be found.

The health of the tissues, perpetually in need of oxygen, requires that the lungs act very promptly.

Contact with the air, which is cooler than the previous environment of the child, irritates the nerve-endings in the skin; in response to the sensation thus produced breathing is established automatically.

Whenever the temperature stimulus proves insufficient, physicians employ a stronger one, spanking the child until it cries lustily.

Crying not only expands the lungs, but also has a favorable influence upon needful alterations in the fetal circulation.

The lungs, since they must from this time on provide oxygen for the infant, need to receive more blood than formerly.

The vessels leading toward them must be widely opened, and structures which previously diverted the blood-stream to the navel must be closed.

The intricate shifting of forces which produces the change cannot be understood without a knowledge of anatomy; it will suffice for us to know that the blood is drawn into the vessels of the lungs with each inspiration.

Other changes also occur.

On account of some of these, namely, certain alterations in the blood current through the heart, physicians once taught that newly born infants should always be laid upon the right side.

Except in very unusual cases, that precaution is now regarded as unnecessary.

Of all the elements essential to nutrition, oxygen is the only one required immediately after birth; as the child enters the world well stocked with all the others.

Babies are not born hungry, as many people seem to think.

Neither is their crying a proof of it, for, as we have observed, they have other very good reasons for crying; nor is their readiness to suck anything that comes in contact with the mouth, for they will behave in the same way while they are receiving an abundance of nourishment through the umbilical cord.

Many hours pass before a newly born infant can possibly need food.

Indeed, it could survive a week or longer without taking anything, by mouth, except water.

The ability to suckle at birth merely indicates that the infant is prepared to utilize the mechanism which nature will now employ to sustain it.

After the umbilical cord has been severed the blood vessels within it can serve no further purpose.

Consequently the remnant of this structure attached to the child's abdomen begins to shrivel.

Formerly the care of the stump was considered a trivial matter; when cleanliness was neglected decomposition caused more rapid separation than takes place under the treatment which it now receives.

No annoyance should be felt because the cord hangs on a long time;

indeed, such an experience means it has been given exceptionally good care.

Separation rarely occurs before the end of a week.

It may be deferred for two weeks, or even longer, if the stump has been kept perfectly clean.

After the shriveled cord drops off, the skin around the navel contracts, leaving a small raw area which discharges a yellow fluid for two or three days before the healing is complete.

MEDDLING.

--In selecting a physician the patient will almost certainly have been guided by her confidence in his ability.

It may seem strange, therefore, to insist that he be allowed to conduct the delivery as he thinks best.

Nevertheless, suggestions from outsiders are so common, especially if the labor be at all prolonged, that it seems appropriate to warn patients to pay no attention to such advice.

In the heat of excitement well-meaning relatives are sometimes inclined to interfere, and women who are not members of the family occasionally wish to discuss their experiences, irrelevant as they may be.

The patient's intimate friends, quite naturally, have the keenest personal interest in the event, an interest that of itself disqualifies them from reasoning calmly at the time.

Their influence may be positively harmful if they persuade the physician to undertake procedures which his judgment convinces him are inadvisable.

Should he turn a deaf ear, they will think him lacking in sympathy; but should he adopt their suggestions he would assume the full responsibility, and would perhaps be censured later by the very persons whom he sought to please.

There can be no question of the proper course for him to pursue.

Any influence which such entreaties may have will always be in the direction of too early interference, which is fraught with danger to mother and child alike.

The master- word is patience, and it applies alike to the mother herself, to the doctor, and to her friends.

Almost always the whole duty of the doctor consists in watching the progress of labor, so that he may be ready to render assistance should it be needed.

Until the second stage begins there is no real necessity for him to remain in the room.

Indeed, it is better for him not to do so after he has made sure that satisfactory conditions prevail, for his judgment will be less biased if the patient is not continuously under his observation.

JUSTIFIABLE INTERVENTION.

--It is quite true that in the progress of the birth difficulties now and then arise; yet they are far less common than rumor would lead us to believe.

The unusual always attracts attention, often receiving greater emphasis than it merits.

The particulars of confinement provide no exception to this rule; a delivery which requires artificial aid will be talked about, while hundreds that terminate naturally pass without comment.

In this way the public gets an exaggerated notion of the frequency of difficult labors.

Moreover, the nature of the trouble is usually distorted, for reports of medical events are apt to be incorrect, and errors multiply with each rehearsal.

Obstetrical patients who wish, so far as possible, to escape the depressing influence of such inaccurate reports will be most likely to succeed if they follow the advice to select a physician at the beginning of pregnancy.

When this is done the physician will have opportunity to explain or discredit alarming rumors, a task which it is usually necessary for him to perform, for there are always some persons who feel that a prospective mother should listen to everything that they have heard of childbirth.

The most frequent cause for intervention during labor is insufficiency of the muscular contractions to overcome the resistance of the birth-canal.

Unusual resistance of this kind explains the longer labors of women who have passed middle life before becoming pregnant.

They may need to exercise more patience than younger women, though they have no greater reason to apprehend serious difficulties.

Whenever rigidity of the muscles adjacent to the birth-canal arrests delivery the physician may employ the obstetrical forceps, which have been in use since the seventeenth century.

Although it is widely known that physicians sometimes terminate labor in this way, the public estimate of the merits and of the limitations of the instrument is so inexact that the truth about it should be understood.

Obstetrical forceps were devised by one of the Chamberlens, a family of French Huguenots who fled to England in 1569. The invention was long kept a secret; therefore its date cannot be fixed, nor even the inventor clearly identified, though everyone agrees that he was a member of this family.

Clearly the instrument had been in use for some generations prior to Hugh Chamberlen, who translated from French into English the foremost obstetrical textbook of his time.

The book, published in 1672, does not contain a description of the forceps, but in his preface Hugh Chamberlen refers to delay in delivery, saying, "My father, my brothers, and myself (though none else in Europe as I know) have by God's blessing and our own industry attained to and long practiced a way to deliver women without prejudice to them or their infants in this case."

It is not questioned that the forceps was the secret that his ancestors and he himself employed so long and so profitably.

About a century ago what are probably the original models of the instrument were discovered in a country home of Essex which once belonged to the Chamberlens; there they had been hidden in a trunk in the garret.

The box in which they were concealed contained four pairs of forceps, representing different stages in their development, besides other instruments and a number of letters which established their ownership.

After an unsuccessful attempt to sell the family secret in Paris, Hugh Chamberlen found a purchaser in Amsterdam.

The privilege of using it in Holland was then granted physicians for a monetary consideration, and that practice continued until two philanthropists purchased the secret to make it public.

It was ultimately learned, however, that the sale was a swindle, for the device which the purchasers obtained consisted of only half the genuine instrument.

The real secret was revealed by a son of Hugh Chamberlen, who bore the same name as his father; but probably the first accurate printed description of the forceps was made by Samuel Chapman, in his treatise on obstetrics which appeared in 1733. Subsequently they came into general use, and, with many modifications, remain the most important instrument in the obstetrician's equipment.

There can be no exaggeration in the claim that the instrument has done more to save human life than any other surgical appliance.

The obstetrical forceps have been of such great service in diminishing the number of still-born infants that they were once called the child's instrument.

The need of its employment in behalf of the child may be determined by careful observation of the fetal heart-sounds, which are heard over the mother's abdomen, and by means of which one may learn the condition of the child.

Signs of danger are extremely uncommon so long as dilatation of the womb is not complete, for any strain which labor may impose upon the child will usually occur during its passage through the pelvis.

Most often, therefore, the head has reached the outermost part of the birth canal before extraction becomes advisable.

The forceps are used also on behalf of the mother, if the continuation of labor seems likely to throw undue stress upon her.

On this account the physician frequently resorts to them if his patient is suffering from pneumonia, typhoid fever, or any acute illness at the time of labor.

Other maternal indications for their use include various chronic derangements, well exemplified by certain diseases of the heart.

Furthermore, even when there are no preexisting complications forceps are employed on account of exhaustion or other conditions which may develop during the course of labor.

It must be clearly understood, however, that the physician alone can determine when intervention is justified, as well as what operative procedure is most appropriate; for even though good reasons for terminating labor exist, forceps cannot be properly used unless nature has already fulfilled very definite requirements.

By no chance can the patient, much less her friends, decide this matter.

And besides, none but a trained observer can detect the symptoms which clearly indicate Nature's incompetence to effect delivery.

Disregard of these truths by the family with consequent urging that something be done must be held partly responsible for the reckless use of the instrument.

It will be a step in the right direction, therefore, when the laity comes to understand that the value of the instrument generally pertains to the welfare of the child, and that, in any event, its use will be harmful if employed before the womb has been completely dilated.

Although forceps can be employed only in cases of head presentation, intervention may be warranted when some part of the fetus other than the head will be born first.

Two or three times in every hundred patients we meet with breech presentations, that is, cases in which the buttocks precede; after their expulsion, the body, the arms, and the head follow.

Breech presentations occur more frequently among women delivered prematurely, as might be expected since an examination eight to ten weeks before the calculated date reveals a larger percentage of breech presentations than a similar examination about the normal end of pregnancy.

In explanation of these results we accept the view that the size of the fetus at the earlier date does not require nicety of adaptation to the cavity of the womb, whereas at term, unless the child is small, the best accommodation is secured when the head lies downward.

Most breech cases are delivered spontaneously; if not, the outlook for the mother is no less favorable on that account.

Assistance, when undertaken, is usually prompted in the interest of the child, which will be seized by the legs and extracted if there are indications to terminate labor.

Purely as a precautionary measure, a second physician will often be called about the time the stage of expulsion begins.

Foresight of this kind must give the patient confidence rather than alarm her.

Indeed, should operative intervention of any kind become necessary in the practice of obstetrics, the inclination of the doctor to call an assistant must be regarded as an evidence of superior judgment.

MANAGEMENT OF BIRTH WITHOUT A DOCTOR.

--A prospective mother should not be left alone during the four weeks prior to the expected date of delivery, for it is important that during this period aid may be quickly summoned in the event of an emergency.

However, if the confinement be the first, ample warning of delivery will always be given.

Even in a later confinement several hours will probably elapse between the preliminary signs and the birth itself.

It is extremely rare to have labor progress so rapidly that the child is born before the doctor arrives.

Under such circumstances, if the nurse be present she will be master of the situation; whenever she has been unable to reach the patient, someone near by should be called to render what assistance may be needed.

A labor which advances so rapidly that skilled assistance cannot be procured is proof in itself that everything is going in an ideal manner, and that interference is not necessary.

Although the doctor may not arrive until after the child is born, he frequently renders valuable service in expelling the placenta or in sewing up lacerations.

No one should presume then that there is never need for a physician after the second stage is over.

If the suggestions made in the preceding chapter are heeded, immediately after labor begins the room will be set in order and the bed will be properly protected; the patient will take a tub-bath and will put on a freshly laundered nightgown.

The sterilized dressings are then placed where they can be easily reached, but are not opened until needed.

Antiseptic tablets have been procured, and, following the directions on the bottle, it will be simple to make up a solution of bichlorid of mercury of a strength of 1-1,000. After the contractions become strong and return at intervals of five minutes, or if the waters have broken, the patient should go to bed;

the knees should be drawn up and spread apart, but bearing down with the pains should not begin until the inclination is irresistible, since this forbearance will make the delivery slower and thus afford protection against lacerations which physicians ordinarily seek to prevent by the use of chloroform.

In the absence of a doctor it is never permissible to administer this or any other anesthetic.

As long as a physician familiar with its action gives the chloroform untoward results need not be feared in obstetrical cases; but the risk would be too great to allow anyone to give it who was unacquainted with the early signs of an over-dose.

Again, fear of accident should prevent patients from using the closet when labor is progressing rapidly, for an inclination to empty the bladder or the rectum often signifies that birth is about to take place.

Even though this is true, if there is need, patients may try to use the bed-pan.

About the time when the patient goes to bed the attendant prepares to render such assistance as may be required.

First she should scrub her hands thoroughly with soap and water and subsequently soak them in the bichlorid solution for five minutes, or longer if there be no need for haste.

A large delivery-pad is then placed under the patient, the leggins put on, and, from this moment, the outlet of the birth-canal should be exposed to view.

After the scalp of the child comes into sight, the attendant is not to leave the bed-side, though she must keep "hands off" until the head has been completely expelled.

A pause occurs between the birth of the head and of the rest of the body.

It is usually safe to await further expulsive contractions, but should the child's face turn a dusky blue, which indicates that it needs to breathe, the patient is to be advised to strain vigorously and to make firm pressure over the womb with both her hands.

At the same time the attendant must pull the child downward, having seized its chin with one hand and the back of its head with the other.

The straining of the mother combined with traction by the attendant will be certain to effect delivery quickly.

As soon as the child is born, it should take a breath and begin to cry.

If it does not cry of its own accord, it can usually be made to do so by holding it up by the feet and slapping it on the back several times.

Subsequently the child is placed between the patient's legs in such a way as to prevent stretching of the cord.

Usually the nurse will leave it in this position and turn her attention to the mother.

After the birth of the child it is easy to feel through the mother's abdominal wall, which has now become lax and flabby, the organs which lie beneath it.

The top of the womb, once just below the edge of the ribs, may now be found about the level of the uppermost part of the hip bones, a position which it keeps until detachment of the after- birth begins.

As the after-birth peels off, the firmly contracted womb gradually rises in the abdominal cavity, and by the time when the separation has been completed reaches the region of the navel.

While these changes, which naturally require from ten to thirty minutes and occasionally longer, are taking place, the attendant must wait patiently; attempts to hurry the separation of the placenta are never wise, for they may lead to excessive bleeding.

No effort should be made to bring away the after-birth by pulling upon the cord.

It is equally unwise for inexperienced persons to press upon the womb in the hope of pushing out the placenta.

To encourage the mother to strain just as she did in assisting the birth of the child would always be a safer plan.

And if that is ineffective, further delay is necessary; in several instances a natural separation of the placenta has repaid me for waiting as long as two hours.

Prolonged delay may be annoying, yet, provided that the doctor arrives within a reasonable time, it can scarcely lead to anything more serious than annoyance.

Rather than authorize frantic efforts to remove the afterbirth, I should much prefer to have a patient of my own call another doctor.

If the after-birth comes away of its own accord, as will generally happen when due patience has been exercised, it may be severed from the child and put aside for the inspection of the doctor, for he should learn by examining it whether everything has come away properly.

The cord must be securely tied in two places with the sterilized bobbin mentioned in the list of articles for confinement.

One ligature is applied about two inches from the child's abdomen, the other an inch nearer the placenta; the cord is then cut between them with a pair of sterile scissors.

Anyone fearful of injuring the infant may prevent accident by spreading a diaper under the part of the cord to be severed.

This precaution also protects the bed from soiling, for there will be a single spurt of blood the instant the cord is cut.

So long as the child is in good condition there is no urgent need of this operation.

If the child is breathing satisfactorily it may generally be deferred until the doctor arrives.

When this course is chosen the attendant will wrap the infant in a warm blanket, place it along with the after-birth in a safe spot, and subsequently devote herself to making the mother comfortable.

The vulva and neighboring parts are bathed with a 1-1000 bichlorid solution.

Soiled dressings are removed, the gown changed, and, if necessary, clean sheets put on the bed.

A sterile sanitary pad is placed over the vulva and a fresh one substituted as often as necessary, but none of the pads should be destroyed.

All the dressings must be saved so that the doctor may see how much blood has been lost.

As we have learned, bleeding regularly occurs while the placenta is separating and thereafter; excessive bleeding will rarely follow a normal delivery if the attendant has heeded the precaution to leave everything to nature.

If ever the loss of blood should become alarming before the doctor arrives, it is advisable to raise the foot of the bed, to keep the patient quietly on her back, to grasp the womb through the abdominal wall, and to massage it constantly until the nearest physician can be gotten.

Of these directions the most important is that which relates to the management of the womb, for in cases in which labor has been normal in other respects the relaxation of its muscle is most often responsible for flooding.

What to do in this event must therefore be made plain.

First the patient should try to empty her bladder, and, if she cannot, pressure made above the organ will usually expel the urine.

The attendant will then take her seat on the edge of the bed, facing the patient's feet, and will locate the womb.

When there is flooding one may expect to recognize the womb as a large, rather soft mass lying in the mid-line of the abdomen with its upper margin somewhat above the navel.

With one hand, or with both if necessary, the mass is grasped in such a way that the fingers cover the top of it and pass backward toward the spinal column; the thumb remains in contact with the front of the organ.

The womb is stroked and squeezed much as one kneads dough, and for this reason the procedure is technically called kneading.

Such manipulations cause the muscle fibers to contract firmly, and in consequence the blood vessels are tightly closed and bleeding ceases.

Similarly, cold applications to the abdominal wall tend to provoke uterine contractions; placing over the womb an ice-cap or towels wrung out of cold water and doubled several times often have a beneficial influence when there is a tendency toward relaxation.

Some physicians also recommend that the child be placed at the breast, since suckling is known to cause uterine contractions.

There are other measures which are occasionally employed, but they should be used only by physicians, for in the hands of an inexperienced person they may do more harm than good.

Very often a slight chill follows labor.

It has a nervous origin and need never give uneasiness; a drink of warm milk, hot-water bags to the feet, and extra blankets will be sure to make the mother comfortable.

On the other hand, excitement of any kind aggravates this condition.

In general, recently delivered patients must be kept quiet no matter how well they feel.

A few hours of sleep, or, at least, of repose, are justified by the fatigue incident to labor, and nothing should be permitted to interfere with it.

METHODS OF REVIVING THE CHILD.

--Complications which interfere with the child's vitality rarely occur when labor proceeds so rapidly that there is not time to get a doctor.

Nevertheless a description of child-birth would be incomplete without reference to the measures intended to revive asphyxiated infants.

Such measures aim, first of all, to make the infant breathe for itself, and if breathing does not begin promptly we resort to artificial respiration.

Mucus in the mouth or in the lower air- passages hinders the entrance of air into the lungs; consequently it is the duty of the attendant to remove this mucus by means of gauze or some light fabric wrapped about a finger and passed backward over the tongue.

In most cases nothing else will be necessary.

But if breathing is not immediately established, the child should be grasped by the feet with one hand and held downward while its back is vigorously slapped with the other.

Usually, it gasps at once; when it does not, the attendant may stroke its face and chest with her hand, which has been previously held in cold water for a moment; or she may dash a handful of cold water upon its body.

With very rare exceptions these procedures make the child cry.

One must always be alert to see the very first attempt at breathing, for unduly prolonged manipulations may defeat their own object; the natural inclination always is to do too much rather than not enough.

In some instances, however, the measures thus far indicated will not prove successful, and, if not, the cord must be tied and cut through, for subsequent treatment cannot be conveniently carried out while the child remains attached to the placenta.

As soon as the cord is severed the child is placed in a tub of warm water, about the normal temperature of the body, and is moved about in the bath for a few moments, the attendant watching closely all the while, for the breathing is often very superficial.

Should signs of beginning respiration not appear, the attendant should grasp the child by the shoulders, dip it up to the neck in a basin of cold water and quickly return it to the warm tub.

This operation may be repeated five or six times; generally the instant the child touches the cold water it draws up its feet, opens its eyes, and cries.

One must take care that the plunge lasts but a moment; if the child becomes chilled efforts to revive it will likely be unsuccessful.

Indeed, the necessity for keeping it warm must be constantly borne in mind.

With the very exceptional cases in which hot and cold tubs are ineffective, the following method becomes valuable.

Wrap the child in a blanket and lay it face downward upon a table or chair, allowing the head to hang over the edge.

Roll the body on one side or a little beyond; then slowly roll it back upon its face and onward to the other side.

This maneuver is repeated fourteen times to the minute, but not more frequently.

When properly performed it secures a flow of air to and from the lungs with the same rapidity as in the normal respiration of an infant.

Efforts to revive the child must not be quickly given up, as a successful outcome occasionally requires half an hour of work or even longer.

One method after another should be tried in the order which I have indicated.

A physician always perseveres so long as the heart-sounds can be heard; but, since an inexperienced person might be unable to decide upon this point, the most reliable course for the layman is to persist in the resuscitation until the physician arrives.

CHAPTER XI