Getting ready to be a mother

by Carolyn Conant Van Blarcom

HELPING TO PREVENT COMPLICATIONS

I have described to you the details of personal hygiene which your doctor is likely to want you to adopt during your months of expectancy, and some of the simple things that you may do to relieve minor discomforts when they arise, for having these things in black and white may make the whole matter a little easier for you.

But there is still more that you can do to help the doctor help you. You can tell him about any discomfort or any new condition that appears, and follow his advice instead of talking it over with your family or friends. This will make it possible for him to prevent serious complications by treating them in the very beginning.

You have probably learned, in one way or another, that the complications associated with childbirth that are most serious are infections (childbed fever), convulsions, abortions or miscarriages and severe bleeding, but perhaps you have not heard that you, yourself, can help greatly in the prevention of all of these conditions, in your own case, and chiefly by little more than exercising good common sense.

Your part in preventing childbed fever, if your baby is to be born at home, lies in having in readiness a clean room, sterile sheets, towels, gauze pads, etc., as will be described in the next chapter.

Concerning the other complications we shall say a word here.

Convulsions. You can do a great deal toward preventing the condition that causes convulsions by following the advice about your personal care that we have just gone over and by making it possible for the doctor to treat early symptoms promptly. In fact, after looking over the records of many thousands of mothers who have had prenatal care, it seems almost safe to say that the expectant mother who follows such a course will not have convulsions.

One of the commonest of the early symptoms is headache, sometimes persistent and very severe. Others which you can detect are blurred vision, spots before the eyes, dizziness, vomiting which is more persistent or severe than could be called “morning sickness,” puffiness under the eyes or elsewhere about the face or hands, swelling of the feet and ankles and severe pain in the stomach. It might be that if you had even one of these symptoms your doctor would think it worth while to put you to bed and give you nothing but milk, or only water, for a day or two, not because you were sick, but to keep you from being so, on the same principle that you darn a thin place in a stocking to keep a hole from coming.

In any event, tell your doctor about the symptoms and let him decide what is to be done, for therein lies your safety.

Miscarriages. The question of abortions, miscarriages and premature births is one of enormous importance, and one about which there is a good deal of misunderstanding. As to the meaning of the terms, many women are puzzled to know the difference between them. Doctors are not likely to use the word miscarriage, but will describe as an abortion a termination of pregnancy which occurs before the end of the seventh month and as premature labors those occurring from that time until the expected date of confinement. In the minds of lay people, however, the term abortion is often associated with criminal practice, miscarriage being a term loosely applied to all births occurring before the seventh month, while the premature baby is the one born after the seventh month of pregnancy but before the expected date of confinement.

Of all of these accidents, abortions are the most frequent, though in the nature of things it is impossible to say how often they occur. They sometimes happen so early in pregnancy that the expectant mother is unaware of the accident; or if she does know of it she may make the mistake of taking no notice of it or regard it of so little consequence that she does not consult a doctor. But such information as is available suggests that at least one out of every five pregnancies ends in abortion, the tragedy of this being that it is very largely a preventable disaster.

Since the ovum is insecurely attached to the uterine lining until the sixteenth or eighteenth week, an abortion is more likely to occur during this time than later, while of this period, the second and third months seem to be the most perilous. Abortions are less likely to happen during first pregnancies than succeeding ones and their frequency seems to increase with the number of pregnancies. They occur more often among women over thirty-five years than in younger ones, and in all cases are most likely to take place at the time when menstruation would fall due were the woman not pregnant.

The prevention of abortions is of such obvious importance and there is so much that you can do to this end, that we shall take up the question somewhat at length. Preventive treatment really begins very early. In the discussion about menstruation we referred to the importance of finding out the cause of painful periods, in the interest of good obstetrics, since inflammation of the uterine lining or a misplaced uterus might be responsible for the pain and if neglected might cause an abortion later on. The correction of such troubles, no matter when they are discovered, is an early step toward preventing abortions.

But after pregnancy has actually begun, there are certain preventive measures which have proved to be very effective. A woman who is pregnant for the first time, and who, therefore, does not know whether she is likely to have an abortion or not, should avoid such risks as fatigue, sweeping, lifting or moving heavy objects, running a sewing machine by foot, running, jumping, dancing, traveling or any action which might jar or jolt her during the first sixteen or eighteen weeks.

An expectant mother who has had an abortion will have to take even greater precautions, as she is in more danger than is a woman who has not had this experience. It is of prime importance, to begin with, that she have the cause of her previous abortion discovered, and if possible corrected. And since the accident is most likely to be repeated at about the same time, or a little earlier, in each succeeding pregnancy it is a wise precaution for the expectant mother to remain quietly in bed for at least a week before and after the time when an abortion may be feared.

Complete rest and relaxation are such effective preventive measures that patients with a tendency to have abortions who have been willing to stay in bed during most of their pregnancy have sometimes been rewarded by going through the entire period and in the end giving birth to a normal, fully developed baby. As out-of-door exercise is clearly impossible in such cases, it is important that the patient keep her room very well ventilated all of the time, and possibly, under the doctor’s direction, have massage or bed exercises.

The marital relation is usually considered inadvisable in all cases after the eighth month of pregnancy, and among women who have had abortions or miscarriages it is best omitted throughout the entire period. This is particularly true of women over thirty-five who are pregnant for the first time.

To sum it up in a word, your part in preventing an abortion or miscarriage after pregnancy has begun, consists largely of avoiding fatigue; resting when tired; avoiding physical shocks such as blows upon the abdomen, jolts or falls particularly during the first sixteen or eighteen weeks and at the time when menstruation would ordinarily occur if you were not pregnant, and avoiding overwork during the later weeks of pregnancy.

The common symptoms of abortions or miscarriages are bleeding, often accompanied by recurring pain, beginning in the small of the back and finally felt as cramps in the lower part of the abdomen. Since menstruation is suspended during pregnancy you should always regard bleeding or a bloody discharge as a symptom of a possible miscarriage, whether you have pain or not. Upon its appearance you should send for the doctor, go to bed at once and keep absolutely quiet.

Should you be so unfortunate as to have a miscarriage, in spite of all your precautions, bear in mind that you will need to stay in bed quite as long afterwards and have the same care as though you had given birth to a fully developed baby. It is because so many women fail to appreciate this that abortions and premature births are often followed by ill health and invalidism. Under proper care, an abortion or premature labor is not, of itself, any more serious for a woman than a normal delivery.

Bleeding from the vagina, or a sudden increase in the size of the abdomen with perspiration and a sudden feeling of faintness, may be the beginning of severe bleeding, or hemorrhage, from any one of a number of causes, and in such a case the expectant mother should notify her doctor, go to bed at once and keep quiet until he arrives.

Summing up the whole question of preventing complications, we find that the following symptoms may be forerunners of serious trouble and therefore should be watched for and reported to the doctor as soon as they are noticed:

1. Persistent or severe vomiting. 2. Persistent or severe headache. 3. Dizziness. 4. Blurred vision or the appearance of black spots before the eyes. 5. Puffiness under the eyes, or elsewhere about the face. 6. Swelling of the feet, ankles or hands. 7. Sharp pains, particularly in the stomach. 8. Prolonged failure to feel the baby’s movements after they have once been felt. 9. Bleeding, or a bloody discharge. 10. Pain in the small of the back followed by cramp-like pains in the abdomen, before the expected date of confinement. 11. Unwarranted mental depression, anxiety or apprehension.

These are generally accepted as the danger signs of pregnancy, any one of which, alone or in combination with one or more of the others, is of importance. In addition to these it really is important that you talk to your doctor or your nurse freely if you are feeling worried or depressed about anything at all. Sometimes one feels blue without knowing why, and if you should feel so during your pregnancy you should not keep it to yourself but talk it over with your doctor or your nurse.

When all is said and done, what we want for each expectant mother is little more than that she shall live a normal, regular, wholesome life; that she shall be able, and what is of equal importance, be willing to weave into her everyday life the principles of personal care which every one should adopt; that she shall watch and be watched for symptoms of complications throughout the entire period of pregnancy, in order that they may be detected early, speedily treated and serious troubles thereby prevented.

The adoption of such simple precautions will pave the highroad to health and happiness for yourself and your baby.

CHAPTER VI
MAKING READY FOR THE BABY

In making ready for the actual arrival of the baby there are several factors to consider, chief among them being the doctor; the nurse; the place where the baby is to be born; the room he is to occupy and an equipment which will facilitate the care of yourself and the baby, at the time of his birth and afterwards.

Of course you have long since placed yourself under a doctor’s care, so that is settled. If you are in the care of a privately engaged physician, he will, in all probability tell you his wishes in regard to your engaging a nurse. She should be satisfactory to both you and the doctor from the standpoint of training and professional fitness as well as her personality. The selection of the nurse, therefore, should be made in coöperation with your doctor. It is wise to engage her during the early part of your pregnancy both to insure your securing the one that you and the doctor want especially, and to have that much of the preparation off your mind. It is usually a good plan to engage the nurse to hold herself in readiness to respond to your call at any time after two weeks before the expected date of your confinement. Quite reasonably, if she is obliged to give up or refuse an engagement in order to hold herself available for you, from a given date, she will do so at your expense. Try to arrange to have the nurse stay with you for six weeks after the baby is born, even though this involves considerable financial sacrifice on your part. Of course if you can afford to keep her still longer, so much the better.

All of this is in case you are in the care of a privately engaged physician and are to have a special nurse. If you are being cared for during pregnancy by doctors and nurses connected with a dispensary, health center or prenatal clinic, they will advise with you about your nursing care at the time of confinement and afterwards.

The next question to consider is whether the baby is to be born at your home or in a hospital. The doctor who is advising you will have his wishes on this subject, too, and as they are entirely in your interest, you will, of course, do as he advises. You will be likely to find that for the birth of the first baby he will want you to go to a hospital, if there is a good one available; also if you have had any symptoms of complications during this pregnancy or difficulty with previous labors.

If you are going to a hospital you or your doctor will make the necessary arrangements about your room, well in advance of the date upon which you expect to go, in order to feel sure that a room will be ready for you.

It sometimes happens, that for a variety of reasons it is nearly or quite impossible for the expectant mother to go to a hospital, or that her doctor is entirely willing that she shall be confined at home. If it is decided that you are to remain at home, it will be possible, with a little planning and effort on your part, to imitate very nearly in your own home the advantages which are offered by a hospital.

You will remember that in the last chapter I mentioned childbed fever as being one of the serious complications, associated with childbirth, that could be prevented by careful work. In the old days, when the importance of cleanliness was not appreciated, this fever was very common in maternity hospitals, but nowadays it seldom occurs in well conducted institutions because the doctors and nurses know how to do clean work and also because they have clean things to work with. So if you are to be attended at home by a good doctor and a good nurse you may make the conditions of your confinement practically ideal by providing a clean room and such an outfit of sterile sheets, towels, dressings and certain other articles as would be available for their use in a hospital.

Suppose we settle the question of the rooms first.

It is a very important one but need not be the bugbear that some people think it is. In all probability you will have no choice as to a room for yourself and will have to use the one you ordinarily occupy. Should you have a choice, however, it will be well to select one that is cool and shady, if the baby is coming during the summer, but one that is bright and sunny for occupancy during most of the year. It should be conveniently near a bathroom, if possible; have an adjoining room for the nurse and one near by for the baby.

The ideal to work toward is: A room with a washable floor with small, light rugs; freshly laundered curtains at the windows but no heavy draperies; a single brass or iron bedstead, about thirty inches high, with a firm mattress, and so placed as to be accessible from both sides and with the foot in a good light, either by day or night; a bedside table and two others (folding card tables are a great convenience); a bureau; a washstand, unless there is a bathroom on the same floor; one or two comfortable chairs, two or three straight chairs and a couch or chaise longue, all of which should be of wood or wicker or covered with freshly laundered chintzes.

Between such a room as this and the one that must be used there may be a wide difference, but it will be worth while to approach this standard as nearly as possible. It is not necessary to make the room bare; in fact, it should be as cheerful and pretty as is compatible with cleanliness. There is no objection to pictures on the walls, but the room should be free from useless, small articles which are likely to be dust catchers, give the nurse unnecessary work and occupy space needed for other things.

The room should be given a thorough house-cleaning about two weeks before the baby is expected. If there is a carpet on the floor that cannot be taken up conveniently, it might be well to have in readiness a large canvas or rubber or an abundance of newspapers to protect the floor near the bed. If the bed is low, the attentions of the doctor and nurse will be made much easier if you have ready four solid blocks of wood, of the same size, upon which to elevate the bed, after the casters have been removed. The blocks should be of such a size as to bring the height of the bed up to thirty inches. And it is important, too, to have a large board, or table leaves, at hand, to slip under the mattress to make it firm, particularly if the bed is soft or sinks in the middle.

The chief requisites for the baby’s room are that it may be well ventilated and easily cleaned. The floor should be of hard wood, or covered with linoleum, in order that it may be wiped up with a damp cloth every day, and the walls should be freshly papered, or, better still, painted. As bright light and glare are bad for the baby the walls would better be of a soft shade, such as grayish green or blue, than white, and there should be dark shades at the windows, in order that the room may be darkened at will.

The furnishings may consist of a brass or enameled crib, with a hair mattress; a chest of drawers; a low straight chair and low rocker, both without arms, and a low table for the baby’s toilet articles. An ordinary kitchen table, enameled and with the legs sawed off, serves admirably. All of the furniture should have smooth, washable surfaces, such as hard wood or enamel, and the walls should be free from pictures, for the baby’s room will have to be kept scrupulously clean and free from dust.

So much for the rooms.

When it comes to the question of providing the outfit to be used in your personal care, the matter of nightgowns and the like will be determined by your tastes and your means, rather than by specific needs. But six or eight nightgowns, a warm bed jacket if the weather is cool, a dressing-gown and a pair of slippers, will probably be enough to keep you fresh and comfortable, so far as these things are concerned, whether you are in a hospital or at home.

But the preparation of necessary dressings and other articles for a home confinement is a different matter and you should learn the wishes of your doctor concerning them.

If his instructions are not specific, you may find that the following lists will be helpful guides in assembling an equipment which will prove adequate to meet the ordinary requirements of a home confinement. Most of the articles listed, or satisfactory substitutes, are to be found in the average household, but they should be gotten together in one place so as to be ready at a moment’s notice.

For the Confinement and Your Own Care:

Plenty of sheets, pillow cases and towels.

4 sanitary belts.

1 piece rubber sheeting or oil cloth, 1 × 1½ yards.

1 piece rubber sheeting or oilcloth, 2 × 1½ yards.

Two or three dozen safety-pins.

Hot water bag with flannel cover.

1 two-quart fountain syringe.

1 douche pan.

1 bed-pan.

2 covered slop jars or covered pails.

3 basins, about 16, 14 and 12 inches in diameter.

2 stiff nail brushes, nail scissors and file or orange stick.

3 agate or enamel pitchers, holding at least 1 quart each.

Medicine glass.

Medicine dropper.

2 bent glass drinking tubes.

100 bichlorid tablets.

4 ounces chloroform.

4 ounces boric acid powder.

4 ounces green soap.

1 pint grain alcohol.

Small jar of vaselin to be sterilized.

Lard, olive oil, vaselin or albolene to oil the baby.

Roll of adhesive plaster, 1 inch wide.

One package of absorbent cotton.

One clinical thermometer.

In addition to these, a certain supply of sterile dressings will be needed. Complete outfits of such dressings, sterilized and ready for use, may be obtained from any one of a number of firms, of which your doctor will know; or they may be prepared by the nurse, or you yourself may prepare and sterilize the following:

One dozen towels.

Three sheets. Five or six dozen sanitary pads, about 10 inches long and 4 inches wide, made of gauze and cotton batting with a top layer of absorbent cotton.

Two to four bed pads, about 30 inches square and 4 inches thick, made of gauze and cotton waste or cotton batting with a top layer of absorbent cotton; or of newspapers covered with muslin.

One pair of leggings made of canton- or outing-flannel, either loose fitting hose reaching to the thighs or a yard square folded diagonally and stitched on one side. See Fig. [16]. Five or six dozen gauze sponges, made by folding pieces of gauze 18 inches square into small pads with all raw edges inside.

Two or three dozen gauze squares, 4 inches square.

Four or five dozen cotton pledgets, or wads of absorbent cotton about the size of an egg with the edges drawn together between thumb and finger and twisted into a spiral.

Six pieces of bobbin or narrow tape, 9 inches long, to tie the baby’s cord.

Fig. 16.—Two types of easily made leggings, suitable for use at the baby’s birth.

To make these supplies you will need about four pounds of absorbent cotton, 6 or 8 packages of cotton batting, and possibly 40 yards of gauze in addition to cotton flannel for the hose.

In preparing the dressings for sterilization, you may divide them into packages as follows: The sheets in one package; 6 towels in a package; 6 sanitary pads in a package; 2 delivery pads in a package; the gauze squares in two packages; the leggings in one package; the bobbin in one package. The sponges and pledgets should be put up in bags or small pillow cases, 2 or 3 dozen in a bag. Wrap each package in heavy muslin, either new or old, using pieces large enough to well protect the contents from contamination by dust or handling, tie them securely with string and sterilize as follows: Fill a wash boiler about a quarter full of water and fashion a hammock by securely tying a towel or strip of muslin to the handles at each end and allowing it to hang so that the bottom of the hammock is about halfway down in the boiler. As the weight of the dressings makes the hammock sag low in the middle it is a wise precaution to place a rack or support of some kind in the bottom of the boiler, to hold the dressings well above the bubbling water, at the point where they hang lowest. Pile the dressings into the hammock, cover the boiler tightly and keep the water boiling vigorously for an hour; dry the packages in the sun, or by placing them in the oven for a few moments, taking care that they are not loosened or opened, and at the end of twenty-four hours repeat the steaming and drying process, wrap the packages in a clean sheet and put them in a drawer or covered box where they may remain undisturbed until needed. The nail brushes, douche pan and fountain syringe may be wrapped in muslin and sterilized in the same way, or the nurse may boil them when the time comes to use them.

Bed pads made of newspapers offer excellent protection and are, of course, less expensive than those made of cotton. They consist of six or eight thicknesses of newspaper opened out to the full size of the page and covered with a piece of freshly laundered muslin which is folded over the edges and basted in place or held with safety-pins, as shown in Fig. [17]. These pads may be made virtually sterile by ironing them on the muslin side with a very hot iron, folding the ironed surface inside without touching it, ironing the outside after it is folded and wrapping the pads in a clean sheet or muslin, also recently ironed, and putting them away with the other dressings, in a place protected from dust.

Fig. 17.—Reverse side of pad made of newspapers and old muslin to protect bed during a home confinement. If muslin is held in place with safety-pins it may be removed easily, washed and used for another pad. (By courtesy of the Maternity Centre Association.)

Baby Clothes. In planning the baby clothes, there are a few general principles to bear in mind that are of considerable importance to the baby’s welfare. His health actually may be injured by having his clothes too warm or not warm enough, and also if they are tight enough to bind or constrict any part of his body or so ample as to form bunches and wrinkles which will make him uncomfortable and restless.

To be entirely satisfactory his clothes should be simple in design and so made as to slip on easily, fit loosely and at the same time smoothly; the materials should be soft, light and porous. Complete outfits of baby clothes may be bought outright, but few expectant mothers are willing to forego the sheer ecstasy of fashioning the little garments themselves, while they dream dreams of the baby who is to wear them. The following list of garments will meet the baby’s needs, and those which you may make are really very simple:

Two to four dozen diapers, about 18 inches square.

Three flannel bands 6 inches wide and 27 inches long, unhemmed.

Three knitted bands with shoulder straps.

Three shirts, infants’, size 2, of cotton and wool, silk and wool but not all wool.

Four wool and cotton flannel petticoats.

Four wool and cotton flannel nightgowns.

Six thin white cotton slips, or dresses.

Flannel wrapper or a yard square of flannel for extra wrap in cool room.

Cloak and cap or other wrap for out door use in cool weather.

Let us take these up in turn.

The diapers may be of any soft, absorbent, loosely woven material, such as cheesecloth, stockinette, bird’s-eye, cotton flannel or thin Turkish toweling, single or double thickness, according to the weight of the material used, and about 18 inches square when hemmed.

The first bands are of cotton and wool flannel, torn-straight across the width of the material in 6–inch strips and left unhemmed. After the cord separates, this band is usually replaced by a knitted band with shoulder straps.

The shirts should have high necks and long sleeves, come well down over the hips and open all the way down the front. They should be of cotton and wool or silk and wool but not all wool as this is too warm. During very warm weather the shirts should be of thin cotton or silk. It is better to start with size 2 as the smaller size will soon be outgrown.

Fig. 18.—Pattern for baby’s petticoat (shown in C. Fig. [20]) requiring ¾ yard of material one yard wide. The cotton dress (A) and flannel nightgown (B) in Fig. [20], may be made from this pattern with the addition of straight sleeves.

The petticoat is a very important item in the baby’s wardrobe, for, helping as it does to keep his body evenly warm, it is worn constantly except during very warm weather. It should be a straight little slip, about 27 inches long, hanging from the shoulders, made entirely of flannel, without the broad cotton waistband that has tortured so many babies in days gone by.

The chief purpose of the dresses or slips is to keep the petticoats clean and add to the daintiness of the baby’s attire and they are made, therefore, of very thin, soft cotton or linen material. They are made from the same pattern as the petticoats, except that they have sleeves and these may be set in or cut out in one piece with the rest of the garment like kimono sleeves, as in Fig. [19].

Fig. 19—Pattern for kimono-style dress or nightgown, shown in E, Fig. [20], and requiring 1½ yards of material 27 inches wide.

The nightgowns are made like the slips, but of the same part wool flannel as that used for the petticoats.

The petticoats, slips and nightgowns should all open down the back and may be fastened with either tapes or buttons and buttonholes. These fastenings present about equal advantages but there is perhaps a slight preference for buttons as babies sometimes tangle their fingers in tapes or get them in their mouths.

Fig. 20.—An outfit of satisfactory baby clothes:
A. Thin cotton dress, open down the back.
B. Flannel nightgown with set-in-sleeves.
C. “Gertrude” petticoat, open down the back.
D. Shirt, opened all the way down the front.
E. Flannel nightgown with kimono sleeves.
F. Knitted band with shoulder straps.
G. Flannel square with tapes run through casings to form hood of one corner.
H. Bag, with hood, suitable for premature baby or for outdoor sleeping.

A satisfactory little wrap to use at first may be made from a yard square of soft, warm material with a hood formed of one corner by running tapes through casings.

Patterns for these baby clothes may be obtained from two or three of the large pattern concerns, or you may cut them out, yourself, by using Figs. [18] and 19 as guides, while Fig. [20] shows how the various little garments look when finished.

The question of socks for the new baby is one upon which doctors hold different opinions, some believing that the warmth provided by the petticoat is sufficient; others, that there is an advantage in the extra protection afforded by socks, so you would better learn the wishes of your own doctor in this connection.

Additional Articles Which Are Needed or Useful in the Care of the Baby:

Bath tub, tin, enamel, agate or rubber.

Drying frames for shirts and stockings.

Rubber bath apron.

Flannel, or Turkish toweling bath apron.

Low chair without arms.

Low table.

Screen to protect baby during bath.

Rack upon which to hang clothes to warm during bath.

Scales, with beam and basket or scoop, not the spring variety.

Hot water bag and cover.

Crib, basket or box, to be used as bed.

Folded felt pad, blanket or hair pillow for mattress.

Rubber or oilcloth to cover mattress.

6 crib sheets.

1 thermometer.

2 crib blankets.

Soft towels and wash cloths.

An old blanket to be used for bath blanket.

3 or 4 dozen safety-pins, assorted sizes.

Castile soap.

Boric acid powder.

Olive oil or albolene.

Absorbent cotton pledgets, preferably sterile.

Enamel pail and cover.

Fig. 21.—Baby’s toilet tray equipped with jelly glasses, bottles, celluloid hair receiver for cotton, and a soap dish, as follows:
1. Safety-pins sticking in cake of soap.
2. Jar for sterile nipples.
3. Jar of sterile water.
4. Jar of boracic acid solution.
5. Nursing bottle.
6. Sterile water to drink.
7. Nursing bottle for water.
8. Small tooth pick swabs.
9. Liquid petrolatum.
10. Gauze mouth swabs.
11. Absorbent cotton.
12. Soap.
(By courtesy of the Maternity Centre Association.)

The giving of the baby’s daily bath, after he comes, will be greatly simplified if you will assemble beforehand and keep in readiness on a tray or small table, all of the things which are to be used each time. Dainty little outfits for this purpose may be bought, or you may arrange an entirely satisfactory one from jars and bottles to be found in the house, as suggested in Fig. [21].

The above lists of dressings and articles to be used in the care of both mother and baby can be considerably modified, according to one’s tastes and means, and still be satisfactory. They merely represent a fair average of what has been found adequate to meet the usual needs of the mother and baby at home.

It will be a good plan for you to have in readiness, by about the end of the seventh calendar month, all of the dressings and other articles to be used during the confinement. This is in case you should have a premature labor, for which the same dressings are needed as in a normal delivery. The baby’s clothes, however, will be in time if they are ready by the end of the eighth month. A baby born before this time would probably be so frail that he would be wrapped in cotton at first, instead of being dressed in the clothes ordinarily prepared for a fully developed baby.

If you will make such preparations for the baby’s arrival as I have suggested, you will be doing a great deal toward securing his safety and well-being, as well as your own.

CHAPTER VII
THE BABY’S ARRIVAL

During the past nine months you have had the happiness of guarding the little life within you and of making soft, warm garments to have in readiness for the baby when he comes. You have prepared your room and his; folded up the packages of gauze and cotton and prepared all sorts of other things to be pressed into service upon the baby’s arrival, and through it all you have dreamed and planned and built the loveliest of castles in Spain.

And now, at last, the baby is coming!

It almost takes your breath away to realize it after all those months of waiting and dreaming, and though it scarcely seems possible, the waiting is almost over.

This same waiting grows very hard toward the end for you are tense with expectation and suspense. The hours and days seem endlessly long, as they pass without giving the looked-for signs that the baby has started. You find it very hard not to grow discouraged and impatient, he seems so long in coming. Your physical discomfort is aggravated by the greater pressure made by the baby during this period, and you cannot get away from it day or night. The desire to urinate is almost constant; your back aches; your feet feel heavy and swollen and the baby disturbs your nights by his increasingly vigorous kicking.

But this does not last long, so try to minimize the fatiguing effects of it all by resting and sleeping as much as possible during the day. The time does slip by and the baby really does come and you don’t want to be tired before the big event.

The miracle of the baby’s origin at the moment of conception; of his growth and the development of the intricate parts of his little body, is equaled only by the miracle of his birth—his separating from your protecting body and coming into the world as a new human being when the time comes that he is able to exist separately and independently.

Since very early in pregnancy, you will remember, your uterus has been growing alternately hard and soft as the muscles have contracted and relaxed. But these contractions have been as painless, and so far as we know, as fruitless as the contractions of a boy’s biceps as he clenches his fist and produces a hard lump on his arm.

But when the baby is ready to take up his life among the rest of us human beings, the contractions of your uterine muscles are altered in such a manner that you gradually become conscious of them and they become so purposeful that they are able slowly but steadily to force the baby down through that narrow part of the pelvis called the inlet, through the cervix, and finally out into the world.

Since, at the proper time you will be able to help these altered muscular contractions to accomplish their high purpose, you will want to watch their progress, with your mind’s eye, as far as possible.

Recall, for a moment, the fact that the baby is contained in a sac of fluid in the cavity of the uterus, above the cervix; that the cervix, below, is a canal drawn in tightly at the upper end, or internal os, and also at the lower end, or external os.

Quite evidently after the baby’s head has been squeezed through the pelvic inlet by pressure of the uterine contractions, the cervix must open widely in order that he may pass through it, too. And so Nature gradually stretches this narrow canal by using the lowermost part of the bag of waters as a water-wedge and forcing it down into the internal os, a little farther with each pain. The opening grows wider and wider as the bag of waters is pressed farther and farther down into the cervical canal, which also widens slowly, and finally the external os, too, is stretched wide open by the water-wedge. Fig. [22] shows how the cervix looks with the bag of waters pressed against the upper opening and how the entire canal is gradually dilated by this wedge, as it is pressed downward.

As you doubtless know, the process of your baby’s emergence into the world and separation from your body is termed labor. The onset of labor is usually marked by the expectant mother becoming conscious of the uterine contractions through dragging pains which are felt first in the small of the back and then in the lower part of the abdomen and thighs. In the beginning the pains are feeble and infrequent, but they gradually grow more severe and more frequent. Sometimes the first sign of labor is a gush of fluid, caused by the rupture of the membranes, or the appearance of blood, but these are not typical. Intestinal colic is sometimes mistaken for labor pains by women who are pregnant for the first time, but when the cramps come regularly and the uterus is felt, through the abdominal wall, to grow hard as the pain increases, and soft as it subsides, there can be no doubt that they are labor pains.

This is the time, usually, when you will go to the hospital, if your baby is to be born there, or when you will notify your doctor that you think you are in labor. If you are to remain at home the doctor may want you to send for the nurse at once, in which case he depends upon her to communicate with him. Or he may prefer that you notify him and let him send the nurse. Either arrangement is simple and easy to carry out, but you must be sure that you understand just what the doctor wants you to do when you think labor has started. It is not a bad plan to write down his instructions about this, with the telephone number and street address of the one to be summoned, so that you will know exactly how to proceed when the time comes.

Fig. 22.—Diagrams showing how the cervix is dilated as the bag of waters is forced downward by the uterine contractions.

The entire duration of labor may vary from a few moments to several days, but the average length of the first labor is about eighteen hours and of subsequent births about twelve hours. The process is usually described as being divided into the first, second and third stages of labor, approximately as follows:

	First stage	Second stage	Third stage	Total
First labor	16 hours	1¾ hours	15 minutes	18 hours
Later labors	11 hours	45 minutes	15 minutes	12 hours

The first stage begins with the onset of labor and lasts until the cervical canal is completely dilated; the second stage begins when the cervix is dilated and lasts until the baby is born; the third stage begins with the birth of the baby and lasts until the afterbirth is expelled.

First Stage. The pains are mild at first and occur at intervals of from fifteen to thirty minutes, but they gradually increase in frequency and intensity until by the end of fourteen to sixteen hours, they are very severe, and recur every three or four minutes, each pain lasting about one minute. The pains begin in the back, then pass slowly forward to the abdomen and down into the thighs.

The average woman is entirely comfortable between pains and until they become very frequent she will usually prefer to be up and about, but if she is on her feet when a contraction begins she will usually seek relief by leaning forward on something secure, as the foot of the bed or a table, or by sitting down until the pain subsides. As time passes, there is an increasing, sometimes persistent desire to empty the bowels and bladder because of pressure upon these two organs by the baby’s head as it is forced slowly downward. There may be vomiting, also when the cervix becomes nearly, or quite dilated.

In the course of the stretching process, the cervix sustains many tiny tears from which blood oozes and tinges the vaginal discharge. This bloodstained discharge is often called the “show” and usually appears toward the end of the first stage.

When the cervix is fully dilated, the membranes, or bag of waters, usually rupture, and there is a sudden gush of fluid, but the rupture of the membranes does not necessarily mark the end of the first stage. Sometimes, though not often, they break before labor begins, thus producing what is known as a “dry” labor. They may rupture before the cervix is fully dilated or they may not rupture at all until the doctor punctures them to facilitate the baby’s birth.

If the nurse is delayed in reaching you, there is a good deal that you can do and have done, during this first stage of labor, in the way of preparing for the baby’s arrival, this preparation relating in general to yourself and to the room including placement of the sterile dressings.

As to yourself, try first to picture what takes place during the fifteen or sixteen hours of the first stage. The baby’s head has usually passed through the pelvic inlet and not much happens, now, beyond the widening of the cervical canal, as the bag of waters is forced down by the squeezing of the uterus each time that it contracts. (See Fig. [23].) As the contractions grow stronger and more frequent you may have a desire to help matters by “bearing down,” or straining, but this is very unwise for nothing that you can do will hasten the dilation of the cervix. The bearing down will tire you and then you will not be able to make as much helpful effort during the second stage as you would in a fresh and rested condition. For this reason, if your pains begin at night, don’t get up, but stay in bed and try to get as much sleep as possible. If they begin during the day, keep up and about during most of the time, but lie down often enough and long enough to prevent your getting tired. But above all don’t bear down during the first stage.

Fig. 23.—Drawing showing the baby’s descent at the time of birth. The head is passing through the inlet and pressure by the bag of waters has started to dilate the cervix. (Drawn by Max Brödel. Used by permission of A. J. Nystrom and Co., Chicago.)

Take a warm soapsuds enema; a thorough, warm, sponge or shower bath, scrubbing the inner surface of the thighs and lower abdomen thoroughly, but do not bathe between the labia. Put on a freshly laundered nightgown, stockings, dressing-gown and slippers and braid your hair, preferably in two braids.

Drink all of the water you want and about every three or four hours take some form of liquid nourishment such as milk, cocoa, strained soup or broth, with toast or crackers. Such nourishment will help to keep you from getting tired and will do no harm, but it may not be altogether wise to take anything more solid without your doctor’s permission. It is not uncommon for one to feel nauseated toward the end of the first stage and this tendency may be aggravated by taking solid food.

One thing to remember is the very great importance of your poise and favorable mental attitude. So much of proved value has been done, and still is being done, to safeguard you and your baby, that you have every reason to feel calm and secure, and it is of very practical importance that you cultivate this attitude. The woman who allows herself to become excited, nervous and apprehensive has much harder time than the one who asserts her self-mastery and preserves a tranquil state of mind. This is so definitely the case that for the sake of your own comfort I cannot urge you too strongly to remember it and to exclude disturbing or exciting influences as far as possible. One of the most troublesome of these is excitable but well-meaning and officious friends or relatives. Accordingly, if your nurse is not at hand try to have some one cool-headed woman with you and insist upon excluding those who would be upsetting or likely to offer advice and suggestions. In getting yourself ready, then, it is advisable to take a bath and an enema; put on clean clothing; not to stay in bed entirely throughout the first stage, but on the other hand to try to keep mind and body fresh and rested by lying down when you begin to feel tired, taking light nourishment regularly, not bearing down during pains and denying yourself to visitors who might be excitable.

This is all simple enough and you will not find it difficult to carry it out. And, happily, the preparations relating to the room are equally simple and uncomplicated.

Either you or the friend who is with you, may make the bed—you if you feel like it, she, if you are tired. The mattress is covered with the larger of the two pieces of rubber sheeting that you have in readiness and over this is placed the lower sheet, stretched very smooth and tight and tucked well under the mattress at head, foot and sides. If the sheet is not very large, it may be made secure by being pinned with safety-pins to the under side of the mattress. The smaller rubber is then placed across the middle third of the bed and over this a muslin sheet, folded once through the middle, tucked well under the sides of the mattress. Next, the upper sheet, a light blanket and a thin counterpane, all left open at the foot, and a pillow.

The packages of sterile dressings, douche pan, fountain syringe, pitchers and basins may be placed on the tables, and the washstand equipped for the doctor’s hands with soap, sterile nail-brush, nail scissors and file. A large kettle or pail of water should be boiled, covered and put aside to cool and a large receptacle such as a wash-boiler, half or two thirds full of water put on to boil when the pains begin to come about every five minutes.

The baby’s bathtub should be near at hand for sometimes babies do not breathe quite satisfactorily at first and are helped to do so by being held in a tub of warm water. There should be, also, a box, basket or crib, in readiness to receive the baby, furnished with a clean blanket and hot water bottle with a flannel cover.

These are the preparations which may be made during the first stage—that period when the cervix is being slowly but steadily dilated by the bag of waters as it is forced downward by the uterine contractions. You feel these as pains beginning in the back, and finally in the lower abdomen and thighs, gradually growing stronger and more frequent.

Second Stage. The first stage is ended, and the second stage begins, when the cervix is wide enough for the baby to pass through. From this time on you should stay in bed and if neither the doctor nor the nurse has arrived, your cool-headed friend must stand by and not leave you alone. The bag of waters usually, though not always, breaks at this time, and there is a rush of fluid. But the character of the pains changes even though the membranes do not rupture. They come about every two minutes, now, from the beginning of one pain to the one following, each pain lasting about a minute. They are stronger and more forcible and you begin to have an uncontrollable desire to strain or bear down.

If the doctor or nurse is with you, they will tell you how to use your pains to advantage, but if they are not there you would better avoid bearing down since you want to retard the baby’s birth, if possible, until one or the other arrives. In such a case, you may delay matters by opening your mouth and breathing deeply during pains and by lying on your side.

We all know that in spite of the most careful planning, babies are sometimes born before the arrival of doctor or nurse and that the mother and her cool-headed friend, who is standing by, meet the emergency together. Fortunately, births occurring under such circumstances are not the ones that are likely to be associated with trouble for either mother or baby, so there is little or no cause for concern. Most doctors feel that the wisest course for the cool-headed friend to follow at such a time is to do nothing at all. So if the baby arrives in advance of the doctor, why, he is here, and that is about all there is to it! The moment you have been longing for, for nine long months, has come; your anxiety and waiting are all over, and with much less trouble than you expected.

Third Stage. After the baby is born, your pains will subside for a few moments and then the uterus will begin again to contract and gradually detach the placenta from its inner surface, forcing it out just as the baby was expelled.

In the meantime the baby is lying on the foot of the bed with the cord connecting him with the placenta which is still within your uterus. Under no circumstances should anyone pull on the cord to aid in the expulsion of the placenta. It will come away, naturally, in due time. When the placenta is finally expelled, the third and last stage of labor is over.

In case you and your cool-headed friend feel that something should be done, perhaps I would better assure you once more that when a baby is born so quickly and easily that he arrives before the doctor, you have cause for relief only—not anxiety. Practically the only unfavorable conditions which may arise are hemorrhage in your case and failure to breathe satisfactorily, on the part of the baby, and you and your cool-headed friend may as well understand how simply these possibilities may be met.

Although, as everyone knows, there is normally a certain amount of blood lost at the time of confinement, varying from one half to one pint, this is accepted as a matter of course. A serious hemorrhage very rarely occurs because of one of Nature’s ingenious provisions. The tiny muscle fibers that make up the uterine wall run in every direction, criss-cross, up and down and around, forming a veritable tangle. After the placenta comes away, all of these little fibers contract, or grow shorter, and the result is that the muscles squeeze down upon the blood-vessels so tightly that they are closed and blood cannot escape.

Accordingly, as long as the uterine muscles are contracted there can be no hemorrhage. The fortunate thing about this is that you can find out if they are contracted, and if they are not, you, yourself can stimulate them to do so. If you will press your fingers down deep into your abdomen, near the navel, you will feel the uterus as a hard round mass, which is often likened to a baseball. If it continues to feel hard and round there cannot be any serious amount of bleeding, but if it becomes soft, the tiny muscle fibers are relaxing their grip on the vessels and bleeding may possibly occur. Quite naturally the thing to do, then, is to stimulate the muscles to contract and this is done by kneading the uterus through the abdominal wall. You will feel it grow hard under your hand and then you will know that everything is all right.

Your friend may want to bathe you and put on a pad but it would be better to leave this for the doctor or nurse for this reason: Childbed fever is the result of introducing infective material into the vagina. Remember that. If no germs gain entrance, there will be no childbed fever. When your baby came quickly and there was a rush of water, your vagina was well washed out. If you and your friend keep fingers and everything else away from the vaginal outlet and the area immediately surrounding it, it will remain clean and you need not worry about the possibility of infection.

Perhaps I have given more space to all of this than seems warrantable, but I want you to know just what is going on so that you will not be worried. And also, in order that you will not make trouble for yourself by trying to do something when all that you really need do is to lie still, as comfortably as possible, keep your hand on the uterus and knead it enough to keep it hard.

If your friend can slip out the wet sheet and put a dry one in its place, without your having to turn over, you will be just that much more comfortable, but the doctor will attend to everything else when he comes.

Next the baby. Presumably he is lying there on the foot of the bed, all safe and sound, trying to get used to the new order of things. He is probably making his presence known by crying lustily and though the day may come when that sound will not be altogether pleasant, it is nothing short of music to you now, for you have been waiting a long time to hear it. The baby has come from a very warm place and has suddenly undergone the most abrupt change in his entire mode of living that he will ever experience, so the transition should be made as easy for him as possible. There are two things which he must do immediately, that your body has been doing for him. He must breathe through his lungs and he must keep his body warm. If he has cried loudly, your faithful cool-headed friend may just wrap a little blanket about him, letting him lie as he is until the doctor comes, taking care that his face is not covered for he needs plenty of air. If the room is chilly she might place a flannel covered bag of warm water beside him outside the blanket.

If the baby has not really cried lustily, as we know that even the youngest baby can, he should be made to cry, as that is the way he gets his breathing apparatus to running as it should. Your friend may take one of the clean little gauze squares that you prepared, and wrapping it around her little finger reach well back into the baby’s mouth and remove any mucus that may be lodged there and interfere with his breathing. She will do this more easily and thoroughly if she will pick the baby up by the feet, with one finger between his slippery little ankles so that her grip will be firm, and wipe out his mouth as he hangs head down.

Fig. 24.—Helping the new baby to breathe by holding him head downward and sharply spanking him. Note that the nurse has one finger between the baby’s ankles to prevent his slipping from her hand.

The main thing to remember is that the lining of that new little mouth is as delicate as a rose leaf and if it is wiped with other than the gentlest stroke the surface may be injured and give trouble later on. While he is hanging, head down, your friend may rub his back or stroke it with her free hand and in all probability you will then hear the baby use his lungs to your heart’s content. But if he still does not cry well he may be sharply spanked two or three times as shown in Fig. [24]. In this picture the cord has been cut and the baby is removed from the bed, but that is not necessary for it is very common to hold the baby up, wipe out his mouth, stroke his back or spank him, before the cord is cut.

You need not be at all disturbed if your baby needs these little forms of encouragement, at first, for remember that all of a sudden he is given some very complicated and taxing work to do and it is only reasonable that he should have all possible help as he undertakes it.

Remember, too, in looking forward to this event, that the probability that you or your friend will have to think of any of these things is very remote for the doctor and nurse are almost certain to be with you, and you will be able to give yourself over entirely to being very happy that at last your baby has come.

THE MIRACLE[^[1]]

By

Elizabeth Newport Hepburn

The wind blows down the street,

A shutter bangs somewhere,

While twilight falls as softly as

A woman’s flowing hair.

Within a quiet room,

Adventurers at rest,

A mother holds her new-born son,

Safe, now, upon her breast!

For out of Night and Pain,

The womb of mystery,

Is sprung this miracle of Life

That she can touch and see.

No seer’s prophetic dream,

No star in all the skies

Burns with a luster half so bright

As happy mother eyes.

No questor for the Grail,

No searcher for the Truth,

Counts more than those who bear and rear

And love and nurture Youth!

Within her curving arm,

All safe and warm he lies,

The heir of all that Man has won

Down countless centuries!

[1]. Written expressly for “Obstetrical Nursing” by Carolyn Conant Van Blarcom.

CHAPTER VIII
THE BABY’S MOTHER

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.

Fig. 25.—Straight binder for supporting heavy breasts, or holding ice caps in place on breasts that are painful. Darts are pinned in below the breasts and the binder is held up by shoulder straps, pinned on front and back.

Fig. 26.—Supporting heavy breasts by means of three folded towels; one fastened about the waist, one over each shoulder, crossing front and back.

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.

Fig. 27.—Indian binder for supporting heavy breasts, used at The Montreal Maternity Hospital. The tapering ends tie in a knot in front.

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.

Fig. 28.—Sterile gauze held in place over nipples by means of tapes and adhesive strips.

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.

Fig. 29.—A comfortable position for mother and baby, while nursing in bed.

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.

Fig. 30.—Protecting cracked or sore nipples by having the baby nurse through a shield.

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.

Fig. 31.—Nipple shield used in Fig.
[30].

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:

	Day					Night
First and second days	6	12	6			12
First three months	6	9	12	3	6	10	2 a.m.
Third to sixth month	6	9	12	3	6	10
After the sixth month	6	10	2	6		10

It is becoming more and more common to omit night feedings after 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.

Fig. 32.
Figs. 32 to 38 inclusive are bed exercises the young mother. For description see text. (From photographs taken at the Long Island College Hospital.)

Fig. 33.

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.

Fig. 34.

Fig. 35.

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.

Fig. 36.

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.

Fig. 37.

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.

Fig. 38.

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.

Fig. 39.—Knee chest position.

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.

Fig. 40.—Walking on all fours.

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.

CHAPTER IX
THE MOTHER’S CARE OF HERSELF—FOR THE BABY’S SAKE

Now that you actually have your baby in your arms, soft and warm and lovely, you find yourself looking into those wide, wondering eyes of his and wanting nothing so much as to give him your protection.

If he could talk, as he looks back at you, I fancy your baby would tell you how much your care of him, during the months before he was born, has meant, and then he would beg you to stand by, very closely, for a few months more, until he is a little more used to being a separate person living outside your body.

“You have given me a wonderful start,” he seems to tell you, “and now I want to go on and develop the best possible mind and body. I shall be able to do this if you will help me, for what you can give me now is of more importance than what all the rest of the people in the world can give. You can give me through your milk exactly the materials that Nature intends me to use to develop and build this partly finished body of mine, and to protect it from disease. Just tide me over this most difficult period of my life, and I’ll be a credit to us both, not only as a baby but as a growing child and later as a robust man or woman, helping to do my share of the world’s work. I’ll have fine straight limbs to bear me on my way, a good brain to help me take a creditable place among people who count, and steady nerves I’ll have, that will always be dependable. I’ll put into reality the dreams that you and I are dreaming, and when I do, I’ll look back to these early weeks and months and realize that I could not have done it but for you.”

And so you look into the eyes of this baby of yours and pledge yourself to stand by and do for him all that lies in your power, realizing already that the keeping of that pledge is going to bring you, along with its demands, an endless and satisfying happiness; a consciousness that you are doing something indispensable to your baby’s welfare that no one else in the world can do.

You know, now, that your baby’s greatest single need for the next few months is satisfactory nursing at your breast, but you will be able to give him this only if your diet and general mode of living are favorable to the production of good milk.

Quite evidently, then, your big service to your baby, for a while, is largely a matter of caring for yourself.

It seldom happens that the mother who has had good prenatal care, followed by good care during and after labor, is unable to nurse her baby if she orders her own life in the way that is known to be necessary to promote and maintain the production of breast milk. The first essential is her real desire to nurse her baby, next, her appreciation of the continuous care of herself that is necessary to this end, and third her whole-hearted willingness to take such care, for her baby’s sake.

It is safe to say that if the doctor and the nurse and the baby’s mother all want him to nurse at the breast, and all do everything in their power to make this possible, they will almost invariably succeed. This assertion can scarcely be made too positively and we should never lose sight of the fact that if the baby is not breast-fed he is being defrauded, and in the vast majority of cases, because of insufficient effort on the part of those who are caring for him.

Practically the only conditions which doctors in general now recognize as sufficient reason for the mother’s not nursing her baby are retracted nipples, tuberculosis, convulsions, severe heart or kidney trouble, certain acute infectious diseases such as typhoid fever, and the state of pregnancy.

When none of these conditions exist, a favorable frame of mind and a state of good nutrition are the two indispensable factors in establishing breast feeding and maintaining the production of a satisfactory quantity and quality of breast milk. These factors in turn are both affected by the mother’s general mode of living.

Women with happy, cheerful dispositions usually nurse their babies satisfactorily, while those who worry and fret are likely to have an insufficient supply of milk or milk of a poor quality. In addition to this sustained influence exerted by the nursing mother’s state of mind it is well to remember that the quality of milk that has been entirely satisfactory may be seriously injured, for the time being, by a fit of temper, fright, grief, anxiety or any marked emotional disturbance. Actual poisons seem to be created as a result of these emotions and they may affect the baby so unfavorably as to make it necessary to give him artificial food, temporarily, and empty the breasts by pumping or stripping before he begins to nurse again.

I realize that it is not easy entirely to reorganize your life and assume new and exacting duties, while recovering from an experience resembling an illness in some of its effects, and still remain calm, undiscouraged and perpetually cheerful. But each tiny victory that you accomplish in your attempt to achieve this end will bring such satisfaction that you will not count the cost. And the incomparable, always deepening happiness of watching your very own baby grow lovelier and sturdier, day by day, because of the things that you, and no one else, are doing, will make you deny, even to yourself, that anything you do is hard. Particularly will this be true if you repeatedly remind yourself that the satisfactorily breast-fed baby is much more likely to live through the difficult first year than is the bottle-fed baby, and also is much less susceptible to disease and infection.

We shall consider, for a moment, the more important details of the routine care that you should give yourself, for the baby’s sake, and then we shall be ready for the pleasantest task of all—the actual care of the baby himself.

In general you should try to live just a normal, tranquil, unhurried kind of life that is unfailingly regular in its daily routine.

Diet. As was the case during pregnancy, the question of your diet is an important one. Throughout the entire nursing period your food should be such that it will nourish you and also aid in producing milk of a character that will meet the baby’s needs, the needs of a growing, developing body. The best producer of such milk is a diet consisting largely of milk, eggs, “leafy” vegetables and fresh fruit, all taken with an appetite made keen by constant fresh air. Bear this in mind and it will keep you from putting your faith in so-called milk-producing foods and nostrums.

Your meals may well be made up from the groups of foods that are suitable for the expectant mother, as given in Chapter V. At this time, as during pregnancy, you should avoid all food that may produce any form of indigestion, but for the baby’s sake now, as well as your own. While it is not generally believed by doctors of to-day, that there are many, if any, articles of diet which may in themselves injure the mother’s milk, it is generally accepted that if her digestion is upset this may be, and usually is, bad for her milk and therefore bad for the baby.

Certain drugs are excreted through the milk and may affect the baby just as they would if administered to him directly, as for example alcohol and opium, from which morphine, heroin, codein, laudanum and paregoric are derived.

Although the old belief no longer holds sway, that certain substances from such highly flavored vegetables as onions, cabbages, turnips and garlic were excreted through the milk and upset the baby, it is definitely known that certain substances in certain foods are excreted through the milk to the baby’s great advantage. It is necessary to the baby’s well-being, therefore, that the nursing mother’s diet shall include, regularly, those articles of food which contain these substances. These foods are milk, egg-yolk, glandular organs such as sweetbreads, kidneys and liver; the green salads such as lettuce, romaine, endive, and cress and the citrous fruits which are oranges, lemons, grapefruit and limes.

These are called “protective foods” because they protect the body against certain diseases which will be described in the chapter on Nutrition. It is possible for a baby who nurses at the breast of a woman whose diet is poor in protective foods, to be so incompletely nourished as to be on the border line of one of these diseases, or even to develop the disease itself.

It becomes apparent, therefore, that although you did not have to “eat for two” before the baby came, you have to do so now in certain very important respects. For this reason it may be advisable for you to increase the nourishment provided by your three regular meals by taking a glass of milk, cocoa, or some beverage made of milk, during the morning and afternoon and before retiring.

The morning and afternoon lunches would better be taken about an hour and a half after breakfast and luncheon, respectively, in order not to spoil your appetite for the meals which follow. It is of considerable importance that you take your meals with clock-like regularity and enjoy them, as enjoyment promotes digestion; but at the same time you should guard against overeating for fear of causing indigestion, as this, you know, is almost sure to upset the baby. Rich and highly seasoned foods, in fact any articles of food or drink which might upset you, should be avoided for the same reason. Drink water freely but do not take alcohol nor strong tea or coffee without your doctor’s permission.

Summing up the matter of your diet, we find that you should have light, nourishing, easily digestible food, consisting chiefly of cereals, creamed dishes, creamed soups, eggs, meat in moderation, salads and the fresh fruits and vegetables that ordinarily agree with you. Many doctors advise at least a quart of milk daily, in addition to that which is used in preparing the meals and an abundance of water to drink.

Bowels. Your bowels should move freely and regularly every day, but you should not take cathartics, or even enemata without your doctor’s order. You probably will be able to establish the habit of a daily movement by taking exercise, eating bulky fruit and vegetables, drinking an abundance of water and regularly attempting to empty your bowels at the same time every day, preferably immediately after breakfast.

Rest and Exercise. You will not be likely to thrive, nor will the baby, unless you have adequate rest and sleep and take daily at least a moderate amount of exercise in the open air. You need eight hours sleep, out of twenty-four, in a room with the windows open, and as fatigue is bad for your milk it may be a good plan for you to lie down for a while every afternoon. Your exercise will, of course, have to be adjusted to your tastes, habits, circumstances and physical endurance, for it must always be stopped before you are tired. Walking is often the best form of exercise that the nursing mother can take and though as a rule she may engage in any mild sports that she enjoys, violent exercise is inadvisable because of the exhaustion that may follow.

Recreation. Part of the value of exercise lies in the pleasure and diversion which it offers, for as we have seen, a happy, contented frame of mind is practically indispensable to the production of good milk. In addition to some regular and enjoyable exercise, therefore, you need a certain amount of recreation and change of thought and environment. If life is monotonous and colorless, the average woman is almost sure to become irritable and depressed; to lose her poise and perspective; to worry and fret, and then, no matter what she eats nor how much she sleeps, her digestion will suffer, her milk will be affected and the baby will pay. This, of course, goes back to the question of the young mother’s mental state and the condition of her nerves as determining factors in her ability to nurse the baby successfully.

Just here it is important to say a word of caution about this very question of your attitude of mind, particularly as it relates to your care of yourself.

It may be that one of the most difficult tasks you will have will be that of getting out of the habit of accepting the position that borders on being an invalid—of being a protected person who is thought about, cared for and considered at every turn. This has been your position for several months and the most natural result of it all is a tendency to cling, perhaps ever so little and even unconsciously, to this very pleasant state. It is not possible for anyone to reduce so broad and intangible a subject to a few definite words of advice. But think it over for yourself and try to strike that happiest of happy mediums that lies somewhere between the equally harmful courses of coddling yourself and of overdoing.

A good many doctors think that for the sake of giving the nursing mother an opportunity to go out, mingle with her friends, take in some music or a play, it is often a good plan to replace one breast feeding, sometime in the course of each day, with a bottle feeding. The freedom which this long interval between two nursings gives the mother for diversion and amusement, will often affect her general condition so favorably that the quality of her milk is definitely better than it otherwise would be and the baby is benefited as a result. This single supplementary feeding cannot be regarded lightly, however, for it must be prepared with the same cleanliness and accuracy as an entirely artificial diet, which will be described in the next chapter.

Weaning. One advantage in giving the baby a supplementary bottle once a day, is that it paves the way for weaning, when the time comes to make this change. Under ordinary conditions, the mother begins to wean her baby about the eighth or tenth month. Having started by replacing one breast feeding, daily, with a bottle feeding, she gradually increases the number of bottles given daily until the breast feedings are discontinued by the time the baby is eleven or twelve months old. There are exceptions to this general rule, of course, and under any conditions the weaning should always be directed by a doctor, for the baby may suffer seriously unless the change in food is skillfully made. If the mother’s milk is satisfactory and the baby is doing well, it is often considered wise not to discontinue the breast feeding entirely, during the hot summer months even though the weaning falls due at this time.

It was formerly deemed advisable to wean the baby for any one of several reasons, but at present the only indications for this step which seem to be generally accepted by the medical profession, are: pulmonary tuberculosis, acute infectious diseases in the mother and pregnancy. Menstruation was long regarded as incompatible with satisfactory nursing, but it is now known that if the mother is taking proper care of herself and is in generally good condition, the impoverishing effect of menstruation upon the milk is usually for the duration of the periods only. It may be necessary to supplement the breast feeding with suitably modified cows’ milk during menstruation, but the baby should be put to the breast regularly, just the same, for if the stimulation of the baby’s suckling is discontinued, the temporary reduction in the amount of the milk secreted will probably become permanent.

The state of pregnancy, however, is different, for though some women nurse a baby satisfactorily for some months after becoming pregnant, it is not considered advisable to subject any woman to the combined strain of pregnancy and nursing. Moreover, the mother’s milk is usually so impoverished during pregnancy that the nursing baby suffers in consequence.

Drying up the breasts used to be a great bugbear. Lotions, ointments and binders were employed and often a breast pump as well. Various drugs were given by mouth and the mother was more or less rigidly dieted. It is true that some of these measures are still employed and are followed by a disappearance of the milk. But at the same time, the breasts dry up quite as satisfactorily when none of these things are done, provided the baby does not nurse. It is not known what starts the secretion of milk in the mother’s breasts, but certain it is that absence of the baby’s suckling stops it.

If it is left to you to dry up your breasts, your safest course will be to do nothing beyond applying a supporting bandage, if your breasts are heavy enough to be uncomfortable, and keeping your nipples scrupulously clean. You may rely absolutely upon the fact that the baby’s suckling is the most important stimulation in promoting the activity of the breasts and if this stimulation is not given, or is removed, the secretion of milk will invariably subside in the course of a few days. This is true whether the reason for drying up the breasts is that the baby is stillborn or has died, or a live baby’s nursing is discontinued. It is true that the breasts may be swollen and very uncomfortable for a day or two, and in addition to a supporting bandage the doctor may order sedatives, but the discomfort subsides as the milk disappears.

Quite naturally you will not drink an extra amount of milk if you are drying up your breasts, but it probably will not be necessary to place any other restrictions upon your diet.

In thinking over the nursing period as a whole, we find that after all it is a fairly simple matter so to order one’s life as to promote and maintain a satisfactory supply of milk. The milk thus produced is the ideal baby food and there is no entirely adequate substitute. Never forget that. It gives the baby enormously increased chances of living past babyhood and protects him from many diseases.

Quite evidently breast feeding is every baby’s birthright and his mother is the only one who can deprive him of it.

CHAPTER X
THE MOTHER’S CARE OF HER BABY

“The mother is the natural guardian of her child; no other influence can compare with hers in its value in safeguarding infant life.”—Sir Arthur Newsholme.

Before undertaking the care of the new baby, suppose we stop for a moment, and consider just what he represents; what he has been through; what struggles and dangers are ahead of him; what are the weaknesses of his equipment to meet these perils and what must be the character of your service to him if you are to do quite all in your power to help him safely over this hazardous period of early infancy.

At the time of birth, the baby makes the most complete and abrupt change in his surroundings and condition that he will make during his entire lifetime.

For nine months he has existed under ideal conditions; he has been safeguarded from injury; kept at the temperature which was best for him, and above all, has been furnished with exactly the proper amount and character of nourishment necessary for his growth and development. Suddenly he emerges from this completely protecting environment into a more or less hostile world, where he must assume the task of living, with a frail little body that in many respects is only imperfectly developed. And yet the baby must not only continue the bodily functions and activities that were begun during his intra-uterine life, but must develop certain functions which were imperfect and even establish others which were performed for him.

You will recall that while within the uterus, the baby received his nourishment and oxygen and gave up waste material through the placenta. Accordingly, his organs of digestion, respiration and excretion are imperfectly developed at birth and are capable of functioning only within very narrow limits at first.

His respirations are usually established immediately after birth, when he cries vigorously, for his lungs are thereby filled with air. The other functions are established more gradually and the care of the baby must be such that the immature, unused organs will have their development promoted through activity and yet not be overtaxed.

The Baby’s Condition at Birth. The newborn baby boy weighs from seven and a quarter to seven and a half pounds and is about twenty inches long, girl babies being perhaps a little smaller. His body is well rounded and his flesh firm. The skin is a deep pink, or even red, and is covered with the cheesy substance called vernix caseosa, which is likely to be thickly deposited over the back and in folds of the skin and creases, as in the thighs and under the arms. Some babies still have, when born, the fine downy hair on parts or all of the body, that they had before birth.

The head and abdomen are relatively large, the chest narrow and the limbs short. The legs are so markedly bowed that the soles of the baby’s feet may nearly or quite face each other, but they finally assume a normal position. The bones are still soft and the entire body is, therefore, very flexible. Some of the bones which unite later in life and make the adult skeleton firm and rigid, are separate at birth.

Most newborn babies have faded blue eyes, the permanent color appearing gradually, but the amount and color of the hair varies greatly, some babies being bald, while others have abundant hair from the beginning.

The shape of the baby’s head is often badly distorted at birth, being so long from chin to crown that the mother is deeply concerned. But you may rest quite assured that even though badly misshapen, your baby’s head in the course of a few days will assume the lovely, rounded contour so characteristic of babyhood. The temporary deformity of the head is caused by a molding and overlapping of the bones of the skull as it is forced through the narrow part of the pelvis, the inlet, that we learned about in Chapter III. About the middle of the top of the head you will be able to feel a soft, diamond shaped spot and farther back another soft spot, smaller than the one in front and somewhat triangular in its outline. These soft places are openings between the bones of the skull and are called the anterior and posterior fontanelles. They always may be felt on the new baby’s head.

Growth and Development. The physical progress which is made during the first year by average, normal babies who are satisfactorily nourished and cared for is fairly uniform and the average rate of this progress is somewhat as follows:

Weight. There is a loss in weight of 6 to 10 ounces during the first week of life, after which the baby usually gains from 4 to 8 ounces each week, during the first five months. From this time the gain is only about half as rapid, or at the rate of 2 to 4 ounces weekly. At six months, therefore, the average baby weighs from 15 to 16 pounds, or double the normal birth weight of 7½ pounds, and at twelve months he weighs from 20 to 22 pounds, or three times the average birth weight. Fig. [41] gives an idea of how the baby’s weight drops during the first week and the rate of the normal weekly gain afterwards, during the first year.

Fig. 41.—Baby’s weight chart showing the usual loss during the first week and subsequent gain during the first year of life.

The weight is perhaps the most valuable single index to the baby’s condition that we have, but at the same time it must be remembered that a baby whose food contains an excess of sugar or starch may be of normal weight, or over, but be incompletely nourished and very susceptible to infection, while other babies who are small and gain slowly are sometimes very well and vigorous. Moreover, quite commonly there are periods in the lives of entirely normal babies during which there is little or no gain in weight. This may occur during the period from the seventh to the tenth month, for example, or in very warm weather. But the doctor is likely to want to watch the baby’s weight, for when studied in conjunction with other conditions it gives a certain amount of information about the baby’s general state and progress.

Height. The height of the average baby at birth is about 20 inches, though boys may measure a little more and girls a little less; at six months it is about 25 inches and 28 or 29 inches at the end of a year.

Head and Chest. The circumferences of the head and chest are about the same at birth, the chest being possibly a little the smaller of the two. Both measure about 13½ inches, gradually increasing to about 16½ inches in six months and to 18 inches by the end of the first year.

Fontanelles. The posterior fontanelle, the one at the crown of the head, usually closes in six or eight weeks but the larger, anterior fontanelle is not entirely closed until the baby is about eighteen or twenty months old.

Teeth. Although it occasionally happens that a baby has one or two teeth at birth, the average infant has none until the sixth or seventh month, when the two lower, central incisors appear. After a pause of a few weeks the two upper, central incisors come through, followed by the two lateral incisors in the upper jaw. At the end of the first year, therefore, the average baby has six teeth, or eight if the lower lateral incisors have appeared by the first birthday, as they sometimes do. This is the usual course of dentition, during the first year, as shown in Fig. [42], but there are wide variations among entirely well and normal babies, the first tooth sometimes not appearing before the tenth, eleventh or even twelfth month. As a rule, however, an entire lack of teeth by the time the baby is a year old is regarded as an evidence of faulty nutrition.

Fig. 42.—Diagram showing first, or “milk,” teeth and the ages at which they usually appear.

The baby who is properly fed and cared for, cuts his teeth with little or no trouble, in spite of the widely current but seriously mistaken belief that a teething baby is a sick baby. We have no way of estimating the number of babies who die, needlessly, as a result of this dangerous conviction, for if the baby is sick while teething, the trouble is all too often accepted as a normal occurrence and is not given the attention it needs until too late. Frail, delicate babies may have convulsions each time that a tooth is cut and if a baby is having digestive trouble, this is likely to grow worse while he is teething. But cutting teeth is a normal process and the healthy, properly fed baby suffers little or no inconvenience while it is in progress.

Stools and Urine. During the first two or three days the stools are of dark green, tarry material called meconium. In the course of two or three days they begin to grow lighter and shortly the normal stools appear, these being bright yellow in color, of a smooth, pasty consistency and having a characteristic odor. During the first month or six weeks the baby’s bowels may move three or four times daily, but after this they usually move but once or twice in the course of twenty-four hours. As the nourishment is increased, the stools grow somewhat darker and firmer and finally become formed.

Fig. 43.—Appearance of cord immediately after birth.

The newborn baby’s bladder usually contains urine and this may be passed immediately after birth or not until several hours later. After the first urination the bladder may be emptied five or six times a day or oftener.

The Cord. Within a few days after birth the stump of the umbilical cord that is attached to the baby’s navel, begins to shrivel and turn black and a red line appears where the cord joins the abdomen. By the eighth or tenth day, as a rule, the cord has shrunken to a dry, black string, when it drops off and leaves an ulcer or small red area which heals entirely in the course of a few days. Figs. [43], 44, 45 and 46 show these progressive changes.

Fig. 44.—Appearance of cord four days after birth.

Fig. 45.—Appearance of navel immediately after cord has dropped off.

Skin. The soft, downy hair that may be remaining on the surface of the body usually disappears by the end of the first week and there is often a scaling of the skin which lasts for two or three weeks, while a delicate pink tint replaces the deeper color of the skin in the course of ten days or two weeks. The baby does not perspire until after the first month, ordinarily, when a very slight perspiration begins, gradually increasing until by the time the baby is a few months old he is perspiring freely.

Fig. 46.—Appearance of a normal, well healed navel.

Tears. There are no tears at birth and opinions differ as to whether they appear in the course of two or three weeks or three or four months. The absence of tears is one reason for bathing the baby’s eyes so carefully during the early days and weeks, for if dust or other foreign material gets into the eyes it is not washed out by tears as it is after their flow is established.

General Behavior. During the first few weeks the average baby sleeps most of the time; that is, from 19 to 21 hours daily. He gradually sleeps less, as the special senses develop and will sometimes lie quietly for an hour or more with his eyes open, sleeping only 16 or 18 hours, daily, at six months and 14 to 16 hours at the end of a year.

The baby begins to make noises and “coo” at about two months and to utter various vowel sounds when about six months old. By the end of a year these indefinite noises and sounds become distinct words. At about the fourth month he grasps at objects and smiles, and very soon even laughs. He holds up his head at about the third or fourth month; sits up and also begins to creep at six or seven months, while sometime between the ninth and twelfth months he will stand while holding on to something secure and begin to walk with assistance.

These degrees of development at different ages are not to be taken as the only measure of normal progress, for some well babies mature more rapidly and many others more slowly than at the rate which is found to be average. In addition to these fairly specific evidences of the baby’s condition and progress, such as weight, height, strength and muscular development, there are other and less definite indications of his well-being which should be taken into account.

The baby who is well and is being properly fed in all respects, will have good color; his flesh will be firm; he will take his nourishment with a certain amount of eagerness and seem satisfied afterwards. He will sleep for two or three hours after each feeding; will sleep quietly at night and while awake, unless he is wet or uncomfortable for some other good reason, he will seem contented, good-natured and happy.

You have seen how the average, well baby grows and develops, provided he is given proper care. I want you now to have just a glimpse of the other side of the question, so that you may realize what happens to the unfortunate little citizens who are not given such care. This glimpse will make you realize more than ever, how worth while are all of the precautions that you take for your baby.

It is estimated that out of every 1000 babies born alive, in this country, 40 die during the first month of life, and that more than as many again, or about 85 all told, perish before reaching the first birthday.

So hazardous is this period of early infancy, in the United States, that our annual loss of baby life is between seven and eight times as great as was the yearly loss of our young men in the war, for upwards of 200,000 babies less than a year old die each year. That the first month is more dangerous than any which follow is shown by the fact that about 100,000 of these baby deaths occur during the first four weeks of life. The tragedy of these figures is made darker by the fact that at least half of the babies who are lost die from preventable causes. In other words, they die from lack of proper care.

That is the point of this for you. These babies die, not by an act of Providence, but from lack of care—not the difficult, complicated care needed by sick babies but just the everyday care which any mother may give—the care that keeps well babies well.

That is what you are going to do—keep your well baby well. And you are going to be surprised to find how easy it is, after all, to say nothing of the pleasure of it, for the thing very nearly sums itself up into feeding your baby as the doctor orders and keeping him clean in every particular. Bear these two factors in mind for errors in feeding and lack of cleanliness are the underlying causes of the vast majority of baby ills.

You will often feel a little like Alice in Wonderland, who found, one time, that she had to keep running very fast to stay where she was, for you will not be able to relax in a single detail of your baby’s care if you are to keep him well. With him, as with you, or anyone else, the satisfactory use of even ideal food is largely dependent upon the general condition and mode of living, and we find accordingly, that the question of keeping the baby well finally resolves itself into the following common sense requirements:

1. Proper food. 2. Fresh air. 3. Regularity in the daily routine care. 4. Cleanliness of food, clothing and surroundings. 5. Preservation of an even body temperature. 6. Adequate rest and sleep. 7. Periodic consultations with your doctor.

Carve these principles into the tablets of your brain and you cannot fail to give your baby the kind of care that is literally life-saving. I am going to describe the tiny, intimate details of this care, for I think this will help you, in the beginning at least, but if you will keep these fundamentals in mind and use good common sense you really need not read another word about baby care, for they give it all in a nutshell.

Let me warn you emphatically against making the very serious mistake of acting upon the advice of friends or relatives, no matter how many children they have had. These counselors are just as dangerous for babies as they are for expectant mothers, so beware of them!

“Is it not preposterous,” says Herbert Spencer, “that the fate of a new generation should be left to the chance of unreasoning custom, impulse, fancy, joined with the suggestions of ignorant nurses and the prejudiced counsel of grandmothers? To tens of thousands that are killed, add hundreds of thousands that survive with feeble constitutions, and millions that grow up with constitutions not so strong as they should be, and you have some idea of the curse inflicted on their offspring by parents ignorant of the laws of life.”

It is a very wise precaution to have your doctor see the baby every week or ten days during the first three months and once a month during the remainder of the year. Not because he is fragile or ill. Not at all. You consult your doctor in order to be sure that you are keeping your baby well.

Did you ever hear of the Chinese custom of paying the doctor as long as one is well, but not paying for attention during illness? It isn’t so very heathenish—that idea of paying for the skillful care that will prevent illness.

In addition to taking the general precaution of seeing your doctor periodically, about the baby, be sure to consult him about anything that you do not understand or about any new condition that arises. You will find any number of persons who are ready and eager to advise you, but your doctor is the only one whose advice it is safe for you to follow.

The Daily Schedule. The importance of regularity in the daily routine of the baby’s care cannot be stressed too often nor too insistently. No matter how well he is nursed in other respects, nor how skillfully the doctor directs his care, the baby cannot be expected to progress satisfactorily if his life is not absolutely regular.

Begin by arranging a daily program for the feedings, fresh air, bath, sleep and exercise and then allow nothing to interfere with your carrying it out.

The hours for the nursings, which vary with different doctors, will constitute the greater part of this daily schedule. For a baby on four hour feedings, for example, some such program as the following may be arranged, while for a baby on a three hour schedule a slightly different program may be arranged.

	6	a.m.	Feeding.
	8	a.m.	Orange juice (when ordered).
	9	a.m.	Bath.
	10	a.m.	Feeding.
10:30 to	2	p.m.	Out of doors.
	2	p.m.	Feeding.
2:30 to	4	p.m.	Out of doors.
	4	p.m.	Orange juice (when ordered).
4 to	5:30	p.m.	Indoor airing and exercises (when ordered).
	5:30	p.m.	Preparation for the night.
	6 p.m.		Feeding.
	10 p.m.		Feeding.
	2 a.m.		Feeding (when ordered).