THE BIRTH OF THE CHILD
The Cause of Labor—The Course of Labor—The Stage of Dilatation—The Stage of Expulsion—The Placental Stage—The Effect of Labor upon the Child—Meddling—Justifiable Intervention—Management of Birth without the Doctor—Methods of Reviving the Child.
The birth of a child is an act of nature, an act generally performed as satisfactorily as any other bodily function. Birth has, however, so deep a meaning for the mother, as well as for her family and her friends, and is, above all, so vital to the future of the race, that it has naturally become the subject of many impressive superstitions. Primitive peoples have invariably embodied in their religion their views of the origin of life and the phenomena of its inception. With these mysteries Greek and Roman mythology dealt extensively, as did also the myths of the Phoenicians, the Egyptians, the Chinese, and the people of ancient India. No race, indeed, has lacked its own interpretation of childbirth, and no phase of the process has failed to have attributed to it a supernatural significance. A number of these superstitions still distress women on the eve of motherhood. To correct exaggerations and to deny many utterly false impressions of childbirth there is no better way than to give a frank account of what does actually occur. I shall adhere to a purely physiological description of the event, for, although I appreciate fully the fact that its sociological and sentimental aspects are perhaps equally important, these are not, in my opinion, pertinent to a medical discussion.
In a scientific sense the act of birth may be described as a series of muscular contractions which widen the birth-canal and expel the contents of the pregnant womb. Since the process requires an expenditure of energy, it has come to be called labor. Intrinsically, labor does not differ from many other physiological acts. The heart drives blood into the arteries; the bladder empties itself; the intestine moves its contents and finally expels the undigested residue. All these acts strongly resemble that of birth; but they also differ from it, for the head of the fetus is a hard body which resists being molded to the shape of the passageway through which it enters the world. To this resistance the pain which accompanies delivery is largely due. And yet even in this respect the act of birth is not unique; certain circumstances lead to painful contractions of the muscle fibers in the intestine and less frequently of those in other organs.
It is natural to ask what purpose is served by the pain associated with labor; and a moment's reflection will make it clear that one reason for the discomfort is the warning which it gives of the approach of birth. If the mother were not thus cautioned, she might be delivered under very awkward circumstances, and even under such conditions that occasionally the infant would perish the instant it was born. All mammals suffer in giving birth to their young, though with quadrupeds the period of suffering is shorter, for the upright posture of man has changed the shape of the pelvis, rendering birth somewhat more difficult. Anyone who observes the lower animals preparing for delivery will be convinced that they also are responding to pain, the most compelling call of nature.
That the suffering is at all essential to the mother's love for her child I cannot believe. Under certain circumstances, as for example when the Cesarean operation is performed before the onset of labor, the delivery is painless; yet I have never known a mother less devoted to her child on that account. Biology throws no light upon the relation of the "curse of Eve" to present-day confinements.
THE CAUSE OF LABOR.—It is evident that, in a general way, the muscular contractions of the womb cause the birth of the child; but before we thoroughly understand the act, science must discover what stimulates the muscle to contract. Although careful research has thus far failed to disclose the source and character of the stimulus, it has taught many properties of the contractions themselves. Their force has been measured and found to increase as the end of labor is approached; the pressure they exert varies between nine and twenty- seven pounds. We also know that the patient can neither hasten nor delay the contractions voluntarily. Strong emotions are believed to accelerate them at times, and we find a very extraordinary illustration of this effect recorded in I Samuel, IV, 19, where we read: "Phineas' wife was with child, near to be delivered; and when she heard the tidings that the ark of God was taken, and that her father-in-law and her husband were dead, she bowed herself and travailed; for her pains came upon her." On the other hand, and much more familiarly, excitement checks the contractions after they have begun. Every obstetrician has heard patients say that with his arrival the pains died down. Yet such an influence is never permanent; the contractions soon reappear, and labor advances as though no interruption had occurred.
For the artificial induction of labor, the physician has at his disposal means that resemble the method sometimes employed by nature. Suitable appliances introduced into the womb provoke contractions, and labor proceeds step by step as if the stimulus were a normal one. Nature does not, however, ordinarily employ mechanical irritation to start the uterine contractions. The initial factor is more remote and, as I have said, is not yet well understood.
Since, as everyone admits, delivery occurs with conspicuous regularity about the end of the fortieth week of pregnancy, and pregnancy corresponds, therefore, to ten menstrual cycles, some have been led to believe that labor and menstruation have a common basis. The truth of this supposition, however, must be doubtful until we know the cause of menstruation. Yet it is a matter of common observation that the uterus becomes unusually irritable about the time when the tenth menstrual period would be due. Strong purgatives administered with other drugs on or after the calculated date frequently bring about delivery, whereas previous attempts of this kind prove unsuccessful. To account for this peculiar irritability of the uterus about the fortieth-week of pregnancy, microscopical changes in its tissues have been suggested but sought in vain. Nor will the distention of the organ explain it.
A great many theories have been offered to explain the causation of labor, but they have now only an historical interest. To-day we are just beginning to learn the correct methods of studying the problem. The experience of ages has firmly established the fact that the fetus is expelled when ready to enter the world, or as we say, when it has become mature. But how does the fetus assert its maturity? There is the kernel of the matter; that is the real problem, a problem for the solution of which, happily, we possess better facilities than have heretofore existed. One solution that has been suggested assumes that the fetus loses ultimately its power to assimilate the nourishment provided through the mother's blood. In consequence, it is argued, the material which previously enabled the fetus to grow now collects— in the maternal circulation, stimulating the womb to contract.
A part of this explanation, namely, that the material which stimulates the muscle fibers, whatever it may be, is a chemical substance and that it circulates in the mother's blood, is almost certainly true. There are, however, very weighty reasons for believing that this substance has not the character of food. A more plausible supposition is that the fetus produces this material in the course of its natural living processes, and the substance would accordingly be a waste-product.
THE COURSE OF LABOR.—The current view that labor begins in the early evening and generally ends during the night is incorrect. This impression has grown out of the fact that the whole process frequently consumes twelve hours and must in such an event include some part of the night. Statistical evidence indicates that almost as many births occur at one hour of the twenty-four as another; to be precise, only five per cent. more children are born between 6 P.M. and 6 A.M. than between 6 A.M. and 6 P.M.
As already pointed out, labor commonly begins with transient discomfort in the lower part of the back. At first the uterine contractions are far apart; they last but a moment and cause only twinges of pain. Gradually, the preliminary contractions give place to others of more definite character, which appear at intervals of five to ten minutes. Estimates of the total length of labor will vary according as one counts from the first warning or from the advent of typical contractions which we hear called "pains of the right kind." These generally continue for about four hours, and this period represents the average length of time the physician remains constantly with his patient. Estimates which include the initial symptoms are longer, varying from ten to eighteen hours. Prolonged labors are rare; and extremely short labors are also infrequent, though now and again it will be only an hour or two from the very first pain until the child is born.
To predict absolutely the length of labor for any particular patient is impossible. The averages calculated from large groups of cases have no more than a broad scientific interest; when applied to any individual they are apt to be very misleading. Thus, from statistics we should expect the first labor to be longer than subsequent ones, but we are often surprised by an unusually rapid delivery.
To facilitate description, labor is divided into stages which are conveniently designated the first, the second, and the third. During the first stage the way is prepared for the expulsion of the child; at the end of the second stage the child is born; the third stage is occupied with the separation and the expulsion of the after-birth. The progress of labor may be ascertained from time to time by means of suitable examinations. Whereas formerly vaginal examination was the only method which served this purpose, we are now acquainted with several. For example much of the information necessary for the proper management of delivery may be gained from examination of the patient's abdomen; and this may be supplemented by observations too technical to consider here.
Occasionally I have heard doctors accused of negligence because they failed to make numerous vaginal examinations. Censure of this kind generally is unjust, for discretion in limiting the number of vaginal examinations provides against infection a guarantee which cannot be overestimated. In many cases, of course, they are still invaluable toward determining what treatment should be pursued, yet they are never employed to the extent once customary. Moreover, physicians have learned to take extraordinary precautions whenever vaginal examinations must be made.
Anyone who practices obstetrics in these days appreciates how careful he must be, especially of the cleanliness of his hands. Energetic scrubbing with soap and water and the free use of antiseptics, as physicians now employ both these measures, appear ridiculous to some women who have witnessed deliveries under a less stringent regime. They may be bold enough to express their disapproval. They may remind us that many women have been successfully delivered without such care. And in this they are correct; we know that nine of every ten mothers passed through childbirth uneventfully before modern precautions were dreamed of. Such precautions as are now taken, however, are necessary to secure the safety of the tenth patient. And it is because they are anxious that all their patients shall enjoy the greatest possible security that physicians dare not omit any precaution.
Disinfection of the physician's hands does not entirely exclude the danger of infection through vaginal examinations. Although he may have been most conscientious, there is some risk of carrying contaminating material into the birth-canal from the region about the opening of the vagina. Unless that region has been satisfactorily disinfected, sterilizing the dressings and cleansing the hands may become a waste of time. Sensible patients, therefore, will never object to the preparations which the nurse is instructed to make.
THE STAGE OF DILATATION.—For reasons which are sufficiently clear, the womb must remain closed while fetal development is in progress; but under normal conditions, when this development is complete, the mouth of the womb dilates and the infant is expelled. The infant never takes an active part in its birth, although physicians once thought it did and attributed tedious labors to stubbornness on its part. The error has been corrected in medical teaching, but many persons unacquainted with the facts cling to the idea that the infant forces its own way out of the womb.
At the end of pregnancy the mouth of the womb is small, too small, often, to admit an instrument as broad as a lead pencil. It is obvious, therefore, that very radical changes must be wrought before the infant can pass. The door, as it were, must be widely opened. This phenomenon, which we call dilatation of the womb, is brought about by involuntary contractions of the muscle fibers in its wall, every point of which they draw upward. Now, the top of the womb is directly opposite its mouth, consequently the contractions inevitably pull its lips wider and wider apart. Ordinarily another factor is concerned in this mechanism. To understand the whole process we must recall that a fluid surrounds the fetus, and that this fluid is contained within elastic membranes. The uterine contractions compress the fluid, drive the membranes, like a wedge, into the mouth of the womb and spread its lips apart. Thus, to the pulling effect just mentioned, a pushing force is added. After full dilatation has been accomplished and the membranes can serve no further purpose, they rupture; as the midwife puts it, "the bag of waters breaks." The quantity of fluid which escapes will vary. Occasionally, a huge gush will drench the patient's clothing; but more often what is lost at first amounts to only a few teaspoonfuls, though small quantities of fluid often dribble away with subsequent contractions.
Although not the rule, it is by no means unusual for the membrane to rupture at the onset of labor, or at least before the mouth of the womb is fully dilated. Exceptionally, rupture occurs a few days before labor begins; and still longer intervals, though extremely rare, have been recorded. Whenever the membranes rupture prematurely, the pushing force of the uterine contractions becomes less effective, though the pulling force is never impaired. Under these circumstances, which occasion what is called a "dry labor," delivery is apt to proceed slowly, yet that does not follow necessarily, for the part of the fetus which happens to lie over the mouth of the womb may act as efficiently as the unruptured membrane would.
During the first stage, the longest of the three, the patient is comfortable between the contractions and generally interests herself in some diverting occupation. The presence of the physician can be of no assistance then, and patients rarely demand it. Usually, they are satisfied to know he is ready to come when called. It is wrong to deceive patients with various recommendations from which they will vainly expect help during this stage; their welfare is best served when they are left alone. Generally the advice of well-meaning friends will be as harmless as it is futile, yet I must emphasize that during the first stage straining to expel the fetus is ill advised. Such effort will surely be ineffective then and may exhaust the patient; in that event it becomes harmful, for she will be fatigued when she most needs strength.
Since, during the first stage, the progress of delivery is not influenced by what the patient may choose to do, she may follow her own inclinations. The average patient will be restless and will keep on her feet most of the time; alternately she will walk or stand still as one or the other happens to make her more comfortable. As a contraction begins she often seeks support, leaning upon a chair or bending over the foot of the bed, and presses with her hands against the lower part of her back. Patients may sit down or lie down whenever they wish; if so inclined they may even go to sleep.
Most patients take no food during the whole course of labor, but, if nourishment is desired, there is no reason for abstaining from it. They may always drink water as freely as they like, and may also have milk, weak tea or coffee, or broth; but alcoholic beverages should never be taken without the specific consent of the physician. This same caution applies to strong coffee and tea. If desired, crackers or toast and rice or other cereals may be eaten in reasonable quantity. For fear of vomiting a patient will occasionally be told not to partake of any food. This advice is given, not because the symptom is alarming, but to save her needless annoyance. Indeed, vomiting frequently indicates that dilatation is well advanced, and, therefore, may generally be regarded as an encouraging sign. Ordinarily a persistent inclination to have the bowels move has the same significance. On the other hand, a constant desire to empty the bladder is more prominent at the onset of labor than later.
To know the moment which marks the transition from the first to the second stage of labor can be of no benefit to the patient; but for the medical attendant the greatest interest centers about this point. Casual observation sometimes enables the physician to recognize it, for characteristically at the close of the first stage the whole picture changes. In a typical case the membranes will rupture at this instant, expulsive efforts will begin, and, as we have just learned, there may be symptoms referable to pressure. Moreover, a blood-tinged discharge, spoken of as the "show," usually makes its appearance about the same time. Since slight bleeding frequently occurs at the beginning of labor, or a little later, this manifestation, like all others, may not be implicitly trusted to indicate the end of the first stage. Such uncertainty, however, is a matter of no great consequence, for in the absence of all these symptoms the physician may, if necessary, accurately determine the degree of dilatation by an internal examination.
THE STAGE OF EXPULSION.—The term delivery has been broadly applied to include the whole of labor. More strictly, its use should be limited to the second stage, for this period alone is concerned with the actual birth of the child. Although dilatation has been completed, the uterine contractions continue, devoting their force to emptying the womb. In this they now receive assistance from the voluntary contractions of the abdominal muscles.
The second stage is very much shorter than the first; for this reason and others, too, it proves much less trying. As the child is moved downward through the birth-canal, the mother usually appreciates for herself that she is making headway; whereas in the first stage she may know of progress only through what she is told. Moreover, it is possible in this stage for the physician, by means of inhalations of chloroform, to relieve her of the pain attending the expulsion of the child.
Since the anesthetic properties of chloroform were discovered by an obstetrician who was searching for a drug with which to lessen the pain of childbirth, the facts connected with the discovery have a peculiar interest for mothers. Sir James Y. Simpson had always been anxious for some means to prevent the suffering endured during surgical operations "without interfering with the free and healthy play of the natural functions." He, therefore, welcomed the introduction of ether anesthesia from America; and in January, 1847, at the Edinburgh Medical School, administered ether to an obstetrical patient. This was the first instance in which an anesthetic was employed at the time of childbirth. Since ether, to his mind, had certain shortcomings, Simpson set about finding another anesthetic, and devoted all his spare time to testing the effect of numerous drugs upon himself. How he came to try chloroform has been vividly told by one of his neighbors. [Footnote: "Late one evening, it was the 4th of November, 1847, Dr. Simpson, with his two friends and assistants, Drs. Keith and Duncan, sat down to their somewhat hazardous work in Dr. Simpson's dining room. Having inhaled several substances, but without much effect, it occurred to Dr. Simpson to try a ponderous material which he had formerly set aside on a lumber- table, and which, on account of its great weight, he had hitherto regarded as of no likelihood whatever; that happened to be a small bottle of chloroform. It was searched for and recovered from beneath a heap of waste paper. And with each tumbler newly changed, the inhalers resumed their vocation. Immediately an unwonted hilarity seized the party—they became bright-eyed, very happy, and very loquacious—expatiating upon the delicious aroma of the new fluid. But suddenly there was talk of sounds being heard like those of a cotton mill, louder and louder; a moment more, and then all was quiet—and then a crash! On awakening, Dr. Simpson's first perception was mental—'This is far stronger and better than ether,' said he to himself. Hearing a noise, he turned round and saw Dr. Duncan beneath a chair, quite unconscious, and snoring in a most determined manner. More noise still and much motion. And then his eyes overtook Dr. Keith's feet and legs making valorous attempts to overturn the supper table. By and by Dr. Simpson having regained his seat, Dr. Duncan having finished his uncomfortable and unrefreshing slumber, Dr. Keith having come to an arrangement with the table and its contents, the sederunt was resumed. Each expressed himself delighted with this new agent, and its inhalation was repeated many times that night. Miss Petrie, a niece of Mrs. Simpson, gallantly took her place and turn at the table, and fell asleep, crying: 'I'm an angel! Oh, I'm an angel!'"—Quoted from "The Life of Sir James Young Simpson," by H. Laing Gordon; Masters of Medicine Series.]
The introduction of chloroform met with violent opposition, not upon medical grounds alone, but also for moral and religious reasons. "To check the sensation of pain in connection with the visitations of God," zealous theologians announced, "was to contravene the decrees of an all-wise Creator." Simpson reminded them "that the Creator, during the process of extracting the rib from Adam, must necessarily have adopted a somewhat similar artifice—for did not God throw Adam in a deep sleep?" Nevertheless, a number of years passed before the prejudice against artificial sleep was overcome. Chloroform only became popular after Queen Victoria consented to its use at the birth of her seventh child, Prince Leopold, in 1853.
There is still some difference of opinion regarding the routine employment of chloroform in obstetrical practice, though the weight of authority favors its use during the contractions at the end of the second stage, providing always that no preexisting organic derangement renders the drug dangerous. Under no circumstances, however, should chloroform be given in the first stage, and seldom at the beginning of the second. Prolonged administration will exert an injurious influence upon both mother and child; under these conditions it ultimately weakens the uterine contractions and delays the delivery. Such an effect must be avoided, since it would endanger the life of the child by asphyxiation as well as exhaust the mother. On the other hand, a few drops of chloroform inhaled with each pain toward the end of the second stage will dull sensibility, although consciousness remains unaffected. When the drug is thus administered, the uterine contractions are scarcely, if at all, altered, and the assistance which the patient is willing to give herself generally becomes more powerful. Should the anesthetic have the opposite effect, it must be withheld; but that is seldom necessary. As the head advances the anesthesia is deepened, and the mother sleeps soundly while the child is being born.
As long as dilatation is in progress, the patient may sit up or walk about; but with the advent of the second stage she should go to bed, for there she will be able to make the best use of the expulsive pains. The appropriate posture for delivery is still the subject of dispute, though modern views in no instance advocate the unnatural absurdities formerly supported by custom or superstition. Students of ethnology relate that among savage tribes almost every conceivable position was advocated for women in labor. Subsequently it became customary to have delivery take place in specially constructed chairs which are still used in semi-enlightened countries. With civilized nations at present women are always delivered in bed; yet national peculiarities still prevail. Some physicians favor what is known as the English position, in which the patient lies on her left side with her face inclined toward the chest, the trunk bent toward the knees, and the legs drawn up toward the abdomen. The majority of obstetricians, however, prefer that the patient should lie flat on her back. With the average case, and from the standpoint of facility in delivery, which of these postures happens to be chosen is a matter of indifference. But it is so much less awkward for the physician when the patient is on her back that this position has been widely adopted in America.
During the expulsion of the child the mother intuitively desires to help herself; generally she cannot resist straining, and rarely needs encouragement. Assisting the uterine contractions with voluntary muscular effort, the act commonly described as "bearing down," may be performed most effectively when the patient is lying on her back. The knees are drawn up and spread apart; the feet are braced against some firm object; the hands grasp straps fastened at the foot of the bed; and the head is slightly raised so as to bring the chin near the chest. When the contraction begins the patient takes a deep breath and holds it while she strains vigorously, as if to make her bowels move. All voluntary effort should cease as the contraction wears away, for straining between the contractions can accomplish nothing. Her own inclination to "bear down" will clearly indicate to the patient when she ought to act.
In the second stage patients regularly experience a feeling of pressure against the rectum, and this sensation, since it depends upon a low position of the child's head, is a welcome sign. Cramps in the legs also indicate progress, for they result from similar pressure against nerves adjacent to the lower part of the birth- canal. The cramps disappear immediately after the child is born, and are consequently never dangerous. Straightening out the legs or rubbing them usually gives relief. Most women, however, complain during the expulsive period only of pain in the back, and find nothing so grateful as firm pressure over this region.
Energetic efforts quickly bring the head to the outlet of the birth- canal, where it may be seen, at first only during the contractions, but later during the pauses as well. The crown of the child's head is generally directed upward and becomes fixed against the pubic bones of the mother, which lie just in front of the bladder. Around this firm pivot the child's head rotates upward, and, as a result of the movement, forehead, eyes, nose, mouth, and chin successively emerge from the birth-canal. Following the birth of the head, natural forces turn the body upon one side, the better to accommodate the shoulders to the passageway. After these are born, the rest of the body slips easily into the world, and the second stage ends.
THE PLACENTAL STAGE.—Although the third stage is chiefly concerned with the separation and the delivery of the after-birth, on which account it is known as the placental period, the description of other no less remarkable events belongs here. Even after the infant is born the umbilical cord extends from its navel to the placenta, just as it has done throughout pregnancy. Among larger mammals separation of the new-born from the mother is brought about in one of two ways; sometimes the activity of the young breaks the navel-string, though more frequently the mother bites it in two. Both these methods, we are told, have been employed by savages; but at the beginning of civilization it became customary to sever the cord with a cutting tool, and the tie thrown round it represents the first attempt of man to ligate blood-vessels. Ordinarily there is no need for haste in this operation. On the contrary, some delay is often of advantage, since an appreciable quantity of blood that otherwise would remain in the placenta is thus given opportunity to enter the infant's body. According to present ideas, as long as the heart-beat can be felt in the cord it should not be tied.
The sleep induced toward the close of the previous stage lasts for a few minutes, so that most patients are unconscious through the greater part of the brief placental stage. Before the influence of the anesthetic has worn off, the physician has an excellent opportunity to sew up any laceration which may have occurred in the course of delivery. Slight injuries are not uncommon, especially if the confinement be the first, for the most skillful treatment often fails to prevent them. Since superficial tears are never serious if promptly closed, it is not their occurrence, but the failure to recognize them, or to sew them up when they are recognized, that deserves condemnation.
After the birth of the child the womb becomes smaller, its walls grow thicker, and the cavity within is narrowed. This series of changes partly detaches the placenta, but the separation depends chiefly upon the uterine contractions. These contractions also force the after- birth into the vagina, whence it may ultimately be dislodged by the patient if she bears down again. Usually, however, it is preferable to save her further efforts of this kind, and, as a routine, the physician places one hand upon the abdominal wall, grasps the womb, and, during the contraction, makes firm pressure downward. The maneuver expels the after-birth, which consists of the placenta, the membranes, and the umbilical cord. Then the empty womb will form a hard, spherical mass about the size of the child's head, lying just above or to one side of the bladder.
Slight bleeding also occurs during the third stage, and further loss of blood follows the removal of the after-birth. The total loss varies between a half pint and a pint, though larger amounts may be noted occasionally without appreciable effect upon the mother. Naturally, large, robust women can spare much more blood than those who are anemic. And yet pregnancy invariably prepares the mother for a loss of blood that would alarm anyone unfamiliar with obstetrical practice. Often the woman just delivered is not harmed by a hemorrhage that would endanger the life of a healthy man. This may seem paradoxical, but it is not; for the surplus blood, which formerly performed important duties in connection with the nutrition of the fetus, must now be removed to readjust the mother's circulation.
In a very small number of cases an unduly large loss of blood follows the expulsion of the placenta. Fortunately, by treatment which consists usually in spurring Nature to more vigorous action we are well equipped to deal with this emergency. A wonderful mechanism has been provided by Nature to control excessive bleeding after delivery. If the forces upon which this mechanism depends are sluggish, the physician stimulates them. As in the preceding stages, the muscle fibers of the uterus supply the power in question, and because of this role an observant obstetrician once called them, "living ligatures." Certain of these fibers encircle the mouths of the blood- vessels which have been left open through the detachment of the placenta. When they contract the vessels are squeezed, impeding the escape of blood. The necessity of this action explains the contractions which continue even after the placenta has been expelled, when they are vigorous enough to cause discomfort they are spoken of as "after-pains." After-pains seldom follow the birth of the first child, but they regularly follow later confinements. In any case, such contractions do not persist very long, for tiny clots form within the blood vessels and effectually close them. As soon as the lining of the womb has been restored the clots are absorbed, leaving the organ in much the same condition as before conception took place.
THE EFFECT OF LABOR UPON THE CHILD.—Unless the experience of countless generations had taught us otherwise, we should fear the child would be injured by its passage through the birth-canal. Immediately after the birth evidence of the journey is seldom wanting, but it quickly disappears.
The unusual size of the infant's brain requires the head to be large, and bestows upon it a contour which differs from that of the mother's pelvic cavity. Since the bones of the pelvis are rigid, while those of the fetal skull are malleable, the head is molded as it descends into the pelvic cavity, so that its passage may be made the easier. As the result of this process of accommodation the skull becomes relatively longer from crown to chin than in adults. Within a few weeks, however, the modification vanishes. If an infant is born with the buttocks first, the head does not linger in the birth-canal, a fact which in such cases explains the pleasing shape of the skull, which emerges with the contour determined by fetal growth.
Whenever a soft swelling appears over that portion of the scalp which was foremost during the birth, the curiosity of the family is aroused; but the swelling is harmless and subsides quickly. It originates for the same reason that a finger swells if too tight a ring is worn, which, as everyone knows, is because of interference with the circulation. Just as the swelling of the finger disappears when the constriction is removed, so the swelling of the scalp subsides shortly after the child is born. Usually no trace of it can be found the next day; but even when more persistent it will always vanish after a short time.
For the child the most notable result of labor relates to the revolutionary changes in its mode of existence. Up to the time of birth the fetus received nourishment by way of the placenta, but after separation from the mother another source of food must be found. The health of the tissues, perpetually in need of oxygen, requires that the lungs act very promptly. Contact with the air, which is cooler than the previous environment of the child, irritates the nerve-endings in the skin; in response to the sensation thus produced breathing is established automatically. Whenever the temperature stimulus proves insufficient, physicians employ a stronger one, spanking the child until it cries lustily. Crying not only expands the lungs, but also has a favorable influence upon needful alterations in the fetal circulation.
The lungs, since they must from this time on provide oxygen for the infant, need to receive more blood than formerly. The vessels leading toward them must be widely opened, and structures which previously diverted the blood-stream to the navel must be closed. The intricate shifting of forces which produces the change cannot be understood without a knowledge of anatomy; it will suffice for us to know that the blood is drawn into the vessels of the lungs with each inspiration. Other changes also occur. On account of some of these, namely, certain alterations in the blood current through the heart, physicians once taught that newly born infants should always be laid upon the right side. Except in very unusual cases, that precaution is now regarded as unnecessary.
Of all the elements essential to nutrition, oxygen is the only one required immediately after birth; as the child enters the world well stocked with all the others. Babies are not born hungry, as many people seem to think. Neither is their crying a proof of it, for, as we have observed, they have other very good reasons for crying; nor is their readiness to suck anything that comes in contact with the mouth, for they will behave in the same way while they are receiving an abundance of nourishment through the umbilical cord. Many hours pass before a newly born infant can possibly need food. Indeed, it could survive a week or longer without taking anything, by mouth, except water. The ability to suckle at birth merely indicates that the infant is prepared to utilize the mechanism which nature will now employ to sustain it.
After the umbilical cord has been severed the blood vessels within it can serve no further purpose. Consequently the remnant of this structure attached to the child's abdomen begins to shrivel. Formerly the care of the stump was considered a trivial matter; when cleanliness was neglected decomposition caused more rapid separation than takes place under the treatment which it now receives. No annoyance should be felt because the cord hangs on a long time; indeed, such an experience means it has been given exceptionally good care. Separation rarely occurs before the end of a week. It may be deferred for two weeks, or even longer, if the stump has been kept perfectly clean. After the shriveled cord drops off, the skin around the navel contracts, leaving a small raw area which discharges a yellow fluid for two or three days before the healing is complete.
MEDDLING.—In selecting a physician the patient will almost certainly have been guided by her confidence in his ability. It may seem strange, therefore, to insist that he be allowed to conduct the delivery as he thinks best. Nevertheless, suggestions from outsiders are so common, especially if the labor be at all prolonged, that it seems appropriate to warn patients to pay no attention to such advice. In the heat of excitement well-meaning relatives are sometimes inclined to interfere, and women who are not members of the family occasionally wish to discuss their experiences, irrelevant as they may be.
The patient's intimate friends, quite naturally, have the keenest personal interest in the event, an interest that of itself disqualifies them from reasoning calmly at the time. Their influence may be positively harmful if they persuade the physician to undertake procedures which his judgment convinces him are inadvisable. Should he turn a deaf ear, they will think him lacking in sympathy; but should he adopt their suggestions he would assume the full responsibility, and would perhaps be censured later by the very persons whom he sought to please. There can be no question of the proper course for him to pursue. Any influence which such entreaties may have will always be in the direction of too early interference, which is fraught with danger to mother and child alike. The master- word is patience, and it applies alike to the mother herself, to the doctor, and to her friends.
Almost always the whole duty of the doctor consists in watching the progress of labor, so that he may be ready to render assistance should it be needed. Until the second stage begins there is no real necessity for him to remain in the room. Indeed, it is better for him not to do so after he has made sure that satisfactory conditions prevail, for his judgment will be less biased if the patient is not continuously under his observation.
JUSTIFIABLE INTERVENTION.—It is quite true that in the progress of the birth difficulties now and then arise; yet they are far less common than rumor would lead us to believe. The unusual always attracts attention, often receiving greater emphasis than it merits. The particulars of confinement provide no exception to this rule; a delivery which requires artificial aid will be talked about, while hundreds that terminate naturally pass without comment. In this way the public gets an exaggerated notion of the frequency of difficult labors. Moreover, the nature of the trouble is usually distorted, for reports of medical events are apt to be incorrect, and errors multiply with each rehearsal. Obstetrical patients who wish, so far as possible, to escape the depressing influence of such inaccurate reports will be most likely to succeed if they follow the advice to select a physician at the beginning of pregnancy. When this is done the physician will have opportunity to explain or discredit alarming rumors, a task which it is usually necessary for him to perform, for there are always some persons who feel that a prospective mother should listen to everything that they have heard of childbirth.
The most frequent cause for intervention during labor is insufficiency of the muscular contractions to overcome the resistance of the birth-canal. Unusual resistance of this kind explains the longer labors of women who have passed middle life before becoming pregnant. They may need to exercise more patience than younger women, though they have no greater reason to apprehend serious difficulties. Whenever rigidity of the muscles adjacent to the birth-canal arrests delivery the physician may employ the obstetrical forceps, which have been in use since the seventeenth century.
Although it is widely known that physicians sometimes terminate labor in this way, the public estimate of the merits and of the limitations of the instrument is so inexact that the truth about it should be understood. Obstetrical forceps were devised by one of the Chamberlens, a family of French Huguenots who fled to England in 1569. The invention was long kept a secret; therefore its date cannot be fixed, nor even the inventor clearly identified, though everyone agrees that he was a member of this family. Clearly the instrument had been in use for some generations prior to Hugh Chamberlen, who translated from French into English the foremost obstetrical textbook of his time. The book, published in 1672, does not contain a description of the forceps, but in his preface Hugh Chamberlen refers to delay in delivery, saying, "My father, my brothers, and myself (though none else in Europe as I know) have by God's blessing and our own industry attained to and long practiced a way to deliver women without prejudice to them or their infants in this case." It is not questioned that the forceps was the secret that his ancestors and he himself employed so long and so profitably. About a century ago what are probably the original models of the instrument were discovered in a country home of Essex which once belonged to the Chamberlens; there they had been hidden in a trunk in the garret. The box in which they were concealed contained four pairs of forceps, representing different stages in their development, besides other instruments and a number of letters which established their ownership.
After an unsuccessful attempt to sell the family secret in Paris, Hugh Chamberlen found a purchaser in Amsterdam. The privilege of using it in Holland was then granted physicians for a monetary consideration, and that practice continued until two philanthropists purchased the secret to make it public. It was ultimately learned, however, that the sale was a swindle, for the device which the purchasers obtained consisted of only half the genuine instrument. The real secret was revealed by a son of Hugh Chamberlen, who bore the same name as his father; but probably the first accurate printed description of the forceps was made by Samuel Chapman, in his treatise on obstetrics which appeared in 1733. Subsequently they came into general use, and, with many modifications, remain the most important instrument in the obstetrician's equipment. There can be no exaggeration in the claim that the instrument has done more to save human life than any other surgical appliance.
The obstetrical forceps have been of such great service in diminishing the number of still-born infants that they were once called the child's instrument. The need of its employment in behalf of the child may be determined by careful observation of the fetal heart-sounds, which are heard over the mother's abdomen, and by means of which one may learn the condition of the child. Signs of danger are extremely uncommon so long as dilatation of the womb is not complete, for any strain which labor may impose upon the child will usually occur during its passage through the pelvis. Most often, therefore, the head has reached the outermost part of the birth canal before extraction becomes advisable.
The forceps are used also on behalf of the mother, if the continuation of labor seems likely to throw undue stress upon her. On this account the physician frequently resorts to them if his patient is suffering from pneumonia, typhoid fever, or any acute illness at the time of labor. Other maternal indications for their use include various chronic derangements, well exemplified by certain diseases of the heart. Furthermore, even when there are no preexisting complications forceps are employed on account of exhaustion or other conditions which may develop during the course of labor. It must be clearly understood, however, that the physician alone can determine when intervention is justified, as well as what operative procedure is most appropriate; for even though good reasons for terminating labor exist, forceps cannot be properly used unless nature has already fulfilled very definite requirements. By no chance can the patient, much less her friends, decide this matter. And besides, none but a trained observer can detect the symptoms which clearly indicate Nature's incompetence to effect delivery. Disregard of these truths by the family with consequent urging that something be done must be held partly responsible for the reckless use of the instrument. It will be a step in the right direction, therefore, when the laity comes to understand that the value of the instrument generally pertains to the welfare of the child, and that, in any event, its use will be harmful if employed before the womb has been completely dilated.
Although forceps can be employed only in cases of head presentation, intervention may be warranted when some part of the fetus other than the head will be born first. Two or three times in every hundred patients we meet with breech presentations, that is, cases in which the buttocks precede; after their expulsion, the body, the arms, and the head follow. Breech presentations occur more frequently among women delivered prematurely, as might be expected since an examination eight to ten weeks before the calculated date reveals a larger percentage of breech presentations than a similar examination about the normal end of pregnancy. In explanation of these results we accept the view that the size of the fetus at the earlier date does not require nicety of adaptation to the cavity of the womb, whereas at term, unless the child is small, the best accommodation is secured when the head lies downward.
Most breech cases are delivered spontaneously; if not, the outlook for the mother is no less favorable on that account. Assistance, when undertaken, is usually prompted in the interest of the child, which will be seized by the legs and extracted if there are indications to terminate labor. Purely as a precautionary measure, a second physician will often be called about the time the stage of expulsion begins. Foresight of this kind must give the patient confidence rather than alarm her. Indeed, should operative intervention of any kind become necessary in the practice of obstetrics, the inclination of the doctor to call an assistant must be regarded as an evidence of superior judgment.
MANAGEMENT OF BIRTH WITHOUT A DOCTOR.—A prospective mother should not be left alone during the four weeks prior to the expected date of delivery, for it is important that during this period aid may be quickly summoned in the event of an emergency. However, if the confinement be the first, ample warning of delivery will always be given. Even in a later confinement several hours will probably elapse between the preliminary signs and the birth itself. It is extremely rare to have labor progress so rapidly that the child is born before the doctor arrives. Under such circumstances, if the nurse be present she will be master of the situation; whenever she has been unable to reach the patient, someone near by should be called to render what assistance may be needed. A labor which advances so rapidly that skilled assistance cannot be procured is proof in itself that everything is going in an ideal manner, and that interference is not necessary. Although the doctor may not arrive until after the child is born, he frequently renders valuable service in expelling the placenta or in sewing up lacerations. No one should presume then that there is never need for a physician after the second stage is over.
If the suggestions made in the preceding chapter are heeded, immediately after labor begins the room will be set in order and the bed will be properly protected; the patient will take a tub-bath and will put on a freshly laundered nightgown. The sterilized dressings are then placed where they can be easily reached, but are not opened until needed. Antiseptic tablets have been procured, and, following the directions on the bottle, it will be simple to make up a solution of bichlorid of mercury of a strength of 1-1,000.
After the contractions become strong and return at intervals of five minutes, or if the waters have broken, the patient should go to bed; the knees should be drawn up and spread apart, but bearing down with the pains should not begin until the inclination is irresistible, since this forbearance will make the delivery slower and thus afford protection against lacerations which physicians ordinarily seek to prevent by the use of chloroform. In the absence of a doctor it is never permissible to administer this or any other anesthetic. As long as a physician familiar with its action gives the chloroform untoward results need not be feared in obstetrical cases; but the risk would be too great to allow anyone to give it who was unacquainted with the early signs of an over-dose. Again, fear of accident should prevent patients from using the closet when labor is progressing rapidly, for an inclination to empty the bladder or the rectum often signifies that birth is about to take place. Even though this is true, if there is need, patients may try to use the bed-pan.
About the time when the patient goes to bed the attendant prepares to render such assistance as may be required. First she should scrub her hands thoroughly with soap and water and subsequently soak them in the bichlorid solution for five minutes, or longer if there be no need for haste. A large delivery-pad is then placed under the patient, the leggins put on, and, from this moment, the outlet of the birth-canal should be exposed to view. After the scalp of the child comes into sight, the attendant is not to leave the bed-side, though she must keep "hands off" until the head has been completely expelled.
A pause occurs between the birth of the head and of the rest of the body. It is usually safe to await further expulsive contractions, but should the child's face turn a dusky blue, which indicates that it needs to breathe, the patient is to be advised to strain vigorously and to make firm pressure over the womb with both her hands. At the same time the attendant must pull the child downward, having seized its chin with one hand and the back of its head with the other. The straining of the mother combined with traction by the attendant will be certain to effect delivery quickly. As soon as the child is born, it should take a breath and begin to cry. If it does not cry of its own accord, it can usually be made to do so by holding it up by the feet and slapping it on the back several times. Subsequently the child is placed between the patient's legs in such a way as to prevent stretching of the cord. Usually the nurse will leave it in this position and turn her attention to the mother.
After the birth of the child it is easy to feel through the mother's abdominal wall, which has now become lax and flabby, the organs which lie beneath it. The top of the womb, once just below the edge of the ribs, may now be found about the level of the uppermost part of the hip bones, a position which it keeps until detachment of the after- birth begins. As the after-birth peels off, the firmly contracted womb gradually rises in the abdominal cavity, and by the time when the separation has been completed reaches the region of the navel.
While these changes, which naturally require from ten to thirty minutes and occasionally longer, are taking place, the attendant must wait patiently; attempts to hurry the separation of the placenta are never wise, for they may lead to excessive bleeding. No effort should be made to bring away the after-birth by pulling upon the cord. It is equally unwise for inexperienced persons to press upon the womb in the hope of pushing out the placenta. To encourage the mother to strain just as she did in assisting the birth of the child would always be a safer plan. And if that is ineffective, further delay is necessary; in several instances a natural separation of the placenta has repaid me for waiting as long as two hours. Prolonged delay may be annoying, yet, provided that the doctor arrives within a reasonable time, it can scarcely lead to anything more serious than annoyance. Rather than authorize frantic efforts to remove the afterbirth, I should much prefer to have a patient of my own call another doctor.
If the after-birth comes away of its own accord, as will generally happen when due patience has been exercised, it may be severed from the child and put aside for the inspection of the doctor, for he should learn by examining it whether everything has come away properly. The cord must be securely tied in two places with the sterilized bobbin mentioned in the list of articles for confinement. One ligature is applied about two inches from the child's abdomen, the other an inch nearer the placenta; the cord is then cut between them with a pair of sterile scissors. Anyone fearful of injuring the infant may prevent accident by spreading a diaper under the part of the cord to be severed. This precaution also protects the bed from soiling, for there will be a single spurt of blood the instant the cord is cut. So long as the child is in good condition there is no urgent need of this operation. If the child is breathing satisfactorily it may generally be deferred until the doctor arrives. When this course is chosen the attendant will wrap the infant in a warm blanket, place it along with the after-birth in a safe spot, and subsequently devote herself to making the mother comfortable.
The vulva and neighboring parts are bathed with a 1-1000 bichlorid solution. Soiled dressings are removed, the gown changed, and, if necessary, clean sheets put on the bed. A sterile sanitary pad is placed over the vulva and a fresh one substituted as often as necessary, but none of the pads should be destroyed. All the dressings must be saved so that the doctor may see how much blood has been lost. As we have learned, bleeding regularly occurs while the placenta is separating and thereafter; excessive bleeding will rarely follow a normal delivery if the attendant has heeded the precaution to leave everything to nature. If ever the loss of blood should become alarming before the doctor arrives, it is advisable to raise the foot of the bed, to keep the patient quietly on her back, to grasp the womb through the abdominal wall, and to massage it constantly until the nearest physician can be gotten.
Of these directions the most important is that which relates to the management of the womb, for in cases in which labor has been normal in other respects the relaxation of its muscle is most often responsible for flooding. What to do in this event must therefore be made plain. First the patient should try to empty her bladder, and, if she cannot, pressure made above the organ will usually expel the urine. The attendant will then take her seat on the edge of the bed, facing the patient's feet, and will locate the womb. When there is flooding one may expect to recognize the womb as a large, rather soft mass lying in the mid-line of the abdomen with its upper margin somewhat above the navel. With one hand, or with both if necessary, the mass is grasped in such a way that the fingers cover the top of it and pass backward toward the spinal column; the thumb remains in contact with the front of the organ. The womb is stroked and squeezed much as one kneads dough, and for this reason the procedure is technically called kneading. Such manipulations cause the muscle fibers to contract firmly, and in consequence the blood vessels are tightly closed and bleeding ceases. Similarly, cold applications to the abdominal wall tend to provoke uterine contractions; placing over the womb an ice-cap or towels wrung out of cold water and doubled several times often have a beneficial influence when there is a tendency toward relaxation. Some physicians also recommend that the child be placed at the breast, since suckling is known to cause uterine contractions. There are other measures which are occasionally employed, but they should be used only by physicians, for in the hands of an inexperienced person they may do more harm than good.
Very often a slight chill follows labor. It has a nervous origin and need never give uneasiness; a drink of warm milk, hot-water bags to the feet, and extra blankets will be sure to make the mother comfortable. On the other hand, excitement of any kind aggravates this condition. In general, recently delivered patients must be kept quiet no matter how well they feel. A few hours of sleep, or, at least, of repose, are justified by the fatigue incident to labor, and nothing should be permitted to interfere with it.
METHODS OF REVIVING THE CHILD.—Complications which interfere with the child's vitality rarely occur when labor proceeds so rapidly that there is not time to get a doctor. Nevertheless a description of child-birth would be incomplete without reference to the measures intended to revive asphyxiated infants.
Such measures aim, first of all, to make the infant breathe for itself, and if breathing does not begin promptly we resort to artificial respiration. Mucus in the mouth or in the lower air- passages hinders the entrance of air into the lungs; consequently it is the duty of the attendant to remove this mucus by means of gauze or some light fabric wrapped about a finger and passed backward over the tongue. In most cases nothing else will be necessary. But if breathing is not immediately established, the child should be grasped by the feet with one hand and held downward while its back is vigorously slapped with the other. Usually, it gasps at once; when it does not, the attendant may stroke its face and chest with her hand, which has been previously held in cold water for a moment; or she may dash a handful of cold water upon its body. With very rare exceptions these procedures make the child cry.
One must always be alert to see the very first attempt at breathing, for unduly prolonged manipulations may defeat their own object; the natural inclination always is to do too much rather than not enough. In some instances, however, the measures thus far indicated will not prove successful, and, if not, the cord must be tied and cut through, for subsequent treatment cannot be conveniently carried out while the child remains attached to the placenta. As soon as the cord is severed the child is placed in a tub of warm water, about the normal temperature of the body, and is moved about in the bath for a few moments, the attendant watching closely all the while, for the breathing is often very superficial. Should signs of beginning respiration not appear, the attendant should grasp the child by the shoulders, dip it up to the neck in a basin of cold water and quickly return it to the warm tub. This operation may be repeated five or six times; generally the instant the child touches the cold water it draws up its feet, opens its eyes, and cries. One must take care that the plunge lasts but a moment; if the child becomes chilled efforts to revive it will likely be unsuccessful. Indeed, the necessity for keeping it warm must be constantly borne in mind.
With the very exceptional cases in which hot and cold tubs are ineffective, the following method becomes valuable. Wrap the child in a blanket and lay it face downward upon a table or chair, allowing the head to hang over the edge. Roll the body on one side or a little beyond; then slowly roll it back upon its face and onward to the other side. This maneuver is repeated fourteen times to the minute, but not more frequently. When properly performed it secures a flow of air to and from the lungs with the same rapidity as in the normal respiration of an infant. Efforts to revive the child must not be quickly given up, as a successful outcome occasionally requires half an hour of work or even longer. One method after another should be tried in the order which I have indicated. A physician always perseveres so long as the heart-sounds can be heard; but, since an inexperienced person might be unable to decide upon this point, the most reliable course for the layman is to persist in the resuscitation until the physician arrives.