The Prospective Mother, a Handbook for Women During Pregnancy

by J. Morris Slemons

THE LYING-IN PERIOD

The Changes in the Uterus—The Lochia—The Return of Menstruation—
Other Restorative Changes: The Loss in Weight; The Abdominal Wall;
The Pelvic Floor—The Care of the Patient: The Elimination of Waste
Material; Cleanliness; The Diet; The Environment; The Time for
Getting up—The Final Examination.

A generation ago physicians were accustomed to see their obstetrical patients only at the time of labor. No preliminary examination was thought necessary, and after the delivery visits were not made unless the family became alarmed and requested them. When thus asked to come back the physician sometimes found that an infection had developed; occasionally the breasts were giving trouble, or some other difficulty in the care of the mother or of the infant was baffling the nurse. It is now recognized that the medical attendant should not wait for the appearance of untoward symptoms. Although the strict observance of the various precautions which I have already emphasized should lead and usually do lead to an uneventful convalescence, it is none the less true that the danger of infection and of other immediate complication has not passed until several weeks after delivery. For this reason and also because skillful guidance of the mother at this time will prevent unwelcome sequels in the later years of life, physicians now extend their watchfulness beyond the hour of birth. The number of visits ordinarily required is not large. In each case, to be sure, the circumstances will determine the number; but, as a rule, ten visits, if properly distributed, will be sufficient. During the month succeeding delivery these visits should be made in about this order: a daily visit for the first five days, subsequently one upon the seventh, the tenth, the fourteenth, the twenty-first, and the twenty-eighth day.

At the conclusion of labor there begins a series of changes which are the reverse of those incident to pregnancy, and which restore the body to its original condition. Six weeks are generally required for these alterations. They should leave the mother in perfect health, but traces of pregnancy are not entirely effaced; even in the absence of outward evidence, if a woman has ever given birth to a child a thorough internal examination will disclose the fact.

The initial steps in these restorative processes are taken most promptly and effectively when patients remain in bed. The traditional custom of doing so has given to the first few weeks following delivery the popular name, "the Lying-in Period." To these weeks physicians usually apply the technical term puerperium, the child's period, a designation which brings to mind the secretion of milk which, though not a retrogressive change, is, nevertheless, one of the most distinctive results of childbirth.

Radical as the bodily changes in progress at this time are, the lying-in period is not a period of illness. But there is, perhaps, no other time in a woman's life when she may cross the boundary between sickness and health so easily; for here nature tolerates no trifling. Not infrequently puerperal patients who are feeling well attempt too much, and suffer a more or less serious set-back; it is an all- important duty of the obstetrician, therefore, to restrain them from harmful activity. In my experience patients yield to restraint most readily, and secure the best results, if I explain to them the anatomical facts which should guide the management of the lying-in period.

THE CHANGES IN THE UTERUS.—Since of all the organs the uterus undergoes during pregnancy the most extensive development, it also holds the place of prominence during the lying-in period. Immediately after delivery the womb weighs two pounds and measures some eight inches in height, five in breadth, and four in thickness. In the course of a few days it begins to dwindle in size, gradually sinking in the abdomen until it lies entirely within the pelvic cavity. Toward the end of five or six weeks it resumes the position occupied before conception, regains approximately its original dimensions, and weighs two ounces. We speak of the process which leads to these results as the involution of the uterus. Since a great deal depends upon the rapidity with which involution progresses, we must understand just what it is and how it may be influenced.

The muscle of the womb, to which this property of involution belongs, is an aggregation of thousands of individual fibers. In response to excellent nutrition during pregnancy, these fibers have grown thick and strong, in order that they may furnish the power needed at the time of labor. When this purpose has been fulfilled each fiber becomes smaller and gradually passes into a resting stage the better to preserve its vigor. It is the shrivelling of the individual fibers, therefore, which accounts for the total reduction in the size of the womb.

Although the source of the stimulus which causes the muscle-fibers to atrophy is not so clear as we should like it, we are acquainted with certain influences to which involution is susceptible. Of these none merits so much attention as the influence of the breasts. The intimate relation between the breasts and the uterus manifests itself in such a variety of ways and with such force that no one doubts its existence. Thus, if a nursing mother becomes pregnant her infant is usually deprived of sufficient nourishment or suffers some digestive disturbance; if not, and the mother, ignorant of her condition, continues with the breast feeding, she may jeopardize the newly begun pregnancy. Very likely she will be warned of the fact by the signs of threatened miscarriage. More frequently, but in quite the same way, we find that nursing causes uterine contractions in the early part of the lying-in period, when they are called after-pains. Women who experience them tell us they are more severe while the infant nurses; and they also say that the discomfort disappears after several days, a fact which indicates that involution has made notable headway. The physician is not dependent on such evidence, however; for a simple examination reveals at any time how far involution has progressed. By this means we have learned that nursing facilitates the involution process. On the other hand, it is found to be true, as we should naturally expect, that women who decline to suckle the infant recover from childbirth somewhat less rapidly than those who follow nature's plan. In this fact, therefore, is found a selfish motive, yet a very good one, which should impel mothers to perform this exceedingly important duty.

Aside from the change in the mass of the uterus, notable results of involution relate to its mouth and to its ligaments, for these structures are also chiefly muscle. The mouth of the womb, lately stretched to permit the exit of the child, gapes widely for a time; but ultimately its lips are drawn together, the tissues which compose them stiffen, and the canal which they enclose is narrowed to almost microscopical dimensions. When involution is complete, the uterus has so far regained its virginal character that no trace of childbirth remains other than a few small fissures in the margin of its mouth.

It is the office of the ligaments to hold the uterus in proper position. In consequence of pregnancy they have been stretched, and, as we might anticipate, after the contents of the womb are expelled the ligaments hang loosely from its sides, very much as sails hang when a breeze dies down. Immediately after delivery, therefore, the ligaments give the womb little or no support; eventually they shorten and tighten, readily accommodating themselves to the existing conditions. Until the accommodation is perfected, it is especially desirable to permit no pressure which might push the womb backward. It is for this reason that many obstetricians object to the time- honored custom of applying a tight bandage about the abdomen at the conclusion of labor; for, though bandaging is not always harmful, it has a distinct tendency to misplace the womb. A friend who has served as an assistant in one clinic where patients were bandaged regularly and in another where they were not, tells me that displacements of the womb were much more common among women treated by the former method.

While the process of involution is altering the shape and size of the womb, other forces are at work within the organ to provide its cavity with a new mucous membrane. In character and in extent the inner surface of the womb, left raw and bleeding at the conclusion of labor, is comparable to the wound which would result if some accident removed the skin from the palms of both hands. No one would question the wisdom of guarding such an injury to the hands; but cleanliness is even more necessary to the prompt and healthful restoration of the uterine mucous membrane. However, the wound within the uterus is so far from the surface of the body that it need not be directly covered with a surgical dressing; sterile pads are kept over the vulva to exclude contaminating material until the healing is completed. Since bleeding ceases after that point is reached, we have no difficulty in knowing when the mucous membrane has been restored.

THE LOCHIA.—The vaginal discharge which regularly follows the termination of pregnancy gets its name from the Greek word lochia. At first the discharge is pure blood, because it issues exclusively from the vessels left open by the removal of the after-birth. The greater part of the blood flows out of the birth canal, but frequently some of it collects in the cavity of the uterus or of the vagina; there it coagulates, and the clots may not be expelled until several days later. In that event, as whatever effect the bleeding may have had has long since passed, the appearance of the clots is usually no occasion for alarm.

The amount of lochia varies, and will likely fall below the average in small or anemic women and rise above it in those who are large or robust. Then again, the discharge is less profuse if considerable blood has been lost immediately after the labor. For the first ten days the total quantity seldom exceeds eight or ten ounces; after that time it is so small that it cannot be accurately estimated. Formerly much larger amounts were considered normal, and, therefore, it is probable that modern aseptic treatment of child-birth has lessened the subsequent loss of blood. Toward the end of a week the lochia changes from a bright red to a brownish color, because the discharge now includes certain products of disintegration. Somewhat later the lochia consists almost entirely of mucus, being only streaked with blood; but there will be an increase in the bleeding when the patient gets up; and injudicious activity may cause flooding. A slight bloody discharge may be expected to continue until five or six weeks after the child was born.

A faint but characteristic odor to the lochia proves very disagreeable to some patients, and on that account it was formerly customary to give them a daily douche throughout the lying-in period. This was before the characteristics of the puerperal uterus and the nature of infection were thoroughly understood. Most physicians are now convinced that the early use of douches is rarely beneficial; and since there is danger of washing infectious material from the lower part of the vagina into the uterus, they may, if given prior to the second week after delivery, actually do harm. Consequently douches are not now used in a routine way. Whenever irrigations are indicated the doctor will prescribe them. Late in the puerperium vaginal douches are unobjectionable, and patients may take them unassisted, for then the fluid will not penetrate the womb so long as it has a free escape from the outlet of the vagina. Moreover, it is immaterial if some of the fluid should pass into the womb, for its lining will have been largely restored by this time, and at points where restoration is incomplete defenses have been thrown up against infection.

THE RETURN OF MENSTRUATION.—On account of the dilatation at the time of labor women who have previously suffered with menstruation may look forward to relief after child-birth. Menstruation generally becomes as painless as the flow of the lochia; and so far as a patient can tell the two phenomena are identical. Actually, however, they bear no relation to each other. The fact that the cavity of the uterus has been deprived of its lining is responsible for the lochia, whereas the menstrual discharge occurs in spite of the lining, through which it breaks at regular intervals in response to a stimulus that is absent for a longer or shorter period after the birth of a child.

In the latter part of the puerperium there may be doubt as to whether a discharge is menstrual or lochial; though, if necessary, an examination of the interior of the womb would always settle the question, for structural changes in the uterine mucous membrane form the most characteristic feature of menstruation. If, therefore, small bits of this tissue are removed and studied under the microscope, a definite conclusion can be reached. Physicians may resort to such an examination when the significance of a discharge is not clear without it; but other evidence usually enables them to decide the matter.

The secretion of milk often exerts an influence upon the reestablishment of menstruation. Under ideal circumstances the mother does not menstruate while she nurses her infant; whereas, if the breasts are not in use, the menstrual function returns six to eight weeks after delivery. Other pertinent clinical facts also lend weight to the opinion that the activity of the breasts, more technically called lactation, should not only prevent menstruation but also hinder the ripening of egg-cells in the ovary. Thus, the nursing infant has a potent influence upon the reproductive function of its mother, enabling it to preserve its food supply; for in the event of conception the milk usually decreases in amount or becomes of an inferior quality. To secure this protective influence should prove a strong incentive for the mother to nurse her child; in barely half the cases, however, is it effective throughout a year. One-third of nursing mothers, statistics indicate, begin to menstruate about two months after delivery, and month by month the proportion gradually increases.

Since menstruation appears so frequently during lactation, it cannot be considered abnormal. It does not follow that the function will become permanently reestablished after a patient has menstruated once; in many instances several months elapse before there is another period, and in a few cases there will be only one period during the year the child suckles. Nevertheless, when the function has once made its appearance extraordinary precaution should be exercised to avert a return, and about the time its reappearance would be expected the woman should go to bed for several days. Although this measure may prove futile, we know of no other so likely to prove successful.

Menstruation is more apt to return prematurely after the birth of the first child than of later ones. This may be due in part to a kind of accommodation of the maternal organism to the reproductive process as one pregnancy follows another; but I am convinced that it is also due in part to the greater physical and mental composure of experienced mothers. Until a woman has learned the unwelcome consequences she is apt to take over household duties before she is equal to the task, or she may engage in too strenuous amusements; and most mothers err in a too energetic care of the baby.

OTHER RESTORATIVE CHANGES.—Many of the restorative changes in the mother's body are either so intricate or so devoid of practical significance that we may pass them by; though all of them have great interest for the specialist, and some have occasioned bitter controversy. The alterations in the heart, for instance, have been the subject of a prolonged dispute between French and German scientists. The former still assert that this organ regularly enlarges during pregnancy and subsequently returns to its normal size. The Germans deny both these contentions. Certainly the alterations are insignificant from a practical standpoint; otherwise competent observers would not disagree.

The really important changes in the body, other than those pertaining to the uterus, are familiar to women who have passed through pregnancy; but other prospective mothers may not understand that they will regain the bodily condition which existed before conception.

Loss in Weight.—While the weight lost during the lying-in period is not so vital as some other alterations, many have a keen interest in it. In addition to the loss of ten to fifteen pounds at the time of birth, a further loss occurs in the course of a few weeks. Diminution in the size of the uterus is responsible for the loss of nearly two pounds, and the lochial discharge for at least another; but the chief factor concerned is the removal of water from the tissues, many of which have become dropsical toward the end of pregnancy. Altogether patients do not lose less than ten pounds during the lying-in period, and often lose a great deal more. The average loss for the first week alone is said to equal one-twelfth of the patient's weight at the conclusion of labor; the total loss for the whole of the puerperium corresponds to one-tenth of her weight at the beginning of it. Variations from the rule are attributed to individual peculiarities of nutrition. In general, stout women lose more than slender ones, but with all types the loss is greater if the mother nurses her infant. On the other hand, a generous diet tends to counteract any loss in weight whatever.

The Abdominal Wall.—Much more important than the question of weight is the recovery of the abdominal wall from the strain imposed by the enlargement of the womb. In normal cases, to be sure, there is very slight disproportion between the size of the pregnant uterus at term and the capacity of the abdomen, yet the abdominal wall invariably suffers a little stretching and unless it retains its elasticity, the viscera are deprived of essential support, and cause more or less discomfort.

The restorative changes in the abdominal wall involve the skin, the fatty tissues, and the muscles. As soon as the distention has been relieved the skin falls into folds, less noticeable if the pregnancy was the first; and the muscles become so flabby that one has no difficulty in pushing the wall backward until it touches the tissues which cover the spinal column. Within a few weeks, if all goes well, the muscles regain their "tone." Coincidently, the excessive fat over the abdomen is absorbed. The skin becomes smooth, and its pigmentation fades completely; but the pregnancy streaks rarely vanish entirely, although they always become very much less noticeable.

Whether or not the abdominal wall will recover from the distention of pregnancy depends entirely upon the muscles. As the lying-in period advances each fiber should gradually shorten until the whole muscular structure becomes as firm and tight as it ever was. But this takes time, and no artifice can hasten the repair. Perfect recovery is most likely with the body in a recumbent position, which relieves the muscles from any strain. These facts are better appreciated than formerly, hence most physicians encourage their obstetrical patients to remain in bed somewhat longer than their mothers did. Generally nothing else will be required, and only under extraordinary circumstances will nature need assistance. Thus, if there has been unusual distention, as, for example, that due to twins, the muscular impairment may be extreme; or if pregnancies follow one another in quick succession the strain becomes so nearly continuous that there is not sufficient time for adequate repair. Whenever nature does need encouragement calisthenics of some kind are advisable. These systematic exercises, which the patient practices in bed and flat on her back, are usually begun about a week after delivery, though there may be some reason for beginning them earlier or later than this.

The physician will always select the proper calisthenics, but the following "movements" generally prove satisfactory. To exercise the muscles at the front of the abdomen one leg after the other is raised and lowered; as this is being done the knee will be bent (flexed) at first, but later the leg may be held straight (extended). Other muscles come into play when the feet are alternately brought together and separated as widely as possible. A third movement which exercises the muscles at the side of the abdomen consists in raising the shoulders from the bed and twisting the trunk so that the weight of the chest rests now on the right, now on the left elbow. When these movements can be performed fifteen or twenty minutes without fatigue more vigorous exercises may be adopted. For example, the buttocks, together with the lower part of the back, are raised off the bed, while the shoulders, elbows, and the heels remain stationary. A day or so before getting up the patient should practice alternately raising herself from the recumbent to the sitting posture and returning to the above position without assistance from the arms.

The value of bandaging the abdomen immediately after delivery as a means of strengthening the abdominal muscles is questionable; though physicians agree to the advantages of a supporter after patients are out of bed. We constantly see perfect restoration of these muscles without the early use of a binder; in fact, women who have employed it throughout the lying-in period do not secure an efficient abdominal wall more frequently than others who began its use two weeks after they were delivered. Even those physicians who advocate an early application of the binder concede that it works harm in certain cases and do not recommend it indiscriminately.

Those who postpone for a fortnight the use of the binder will escape the tendency it has to cause displacements. By this time the involution will have advanced so far that the womb lies within the pelvic cavity, where it is surrounded by the hip bones, which protect it from external forces that otherwise would influence its position. When permitted to get up patients ought to use a binder, because it counteracts the feeling of "falling to pieces" of which some complain when the abdominal walls are not comfortably supported. But there is no evidence to show that a binder plays any part in restoring the figure. When, in spite of ample rest, the abdominal muscles fail to recover completely, we have no better way of strengthening them than by use of calisthenics or massage.

The Pelvic Floor.—Second only in importance to having the womb restored to its original position is the necessity of restoration of the pelvic floor. This structure, also called the perineum, we should know, lies between the thighs, shuts in the bottom of the abdomen, and prevents prolapse of the viscera. In women it forms the lower portion of the birth-canal, enclosing the aperture through which the child enters the world. Although intelligent management of labor is of the greatest value for the protection of the pelvic floor, under certain circumstances it may be impossible to preserve it intact; injury to it is the rule when the first child is born, and not unusual in later births. There can be no doubt regarding the advisability of uniting the edges of a tear; indeed, to do so immediately is the very first essential toward restoring the pelvic floor to its wonted integrity. But even though tears are sewn up successfully, there is invariably some relaxation of the perineum until the restorative process, which here again chiefly concerns the muscles, has been given opportunity to become effective.

As with all the restorative changes in the lying-in period, to rest calmly in bed favors the perfect recovery of the pelvic floor more than anything else. Keeping the thighs together during the first few days undoubtedly assists tears in healing, but that precaution is not always necessary, and when it is the physician will call attention to the fact. The really important matter, as I have said, is that the upright position should not be resumed until the pelvic floor has become firm.

THE CARE OF THE PATIENT.—Now we have learned enough of the manifold changes in the lying-in period to appreciate the fact that patients require medical direction even though they are feeling perfectly well. The view held by former generations that women can get along without a doctor and with any sort of nursing is partly responsible for the existence of gynecology, the branch of medicine which deals with the diseases of women. Recently delivered women should be treated as surgical patients, not because they are ill, but to keep them from becoming so.

If the patient desires the highest degree of protection an experienced nurse is indispensable, for she will make systematic observations which would consume too much of the doctor's time for his personal attention, yet without which he would not be sufficiently conversant with his patient's condition to guide her properly. The temperature, the rate of the pulse, and of the respiration should be recorded at regular intervals during the day and night. An elevation of temperature at the conclusion of labor need give no uneasiness, for experience has shown that it generally subsides within a few hours. Moreover, slight elevations in the course of the following week are so frequent that obstetricians have agreed to regard as a normal temperature for this period 100.4 degrees instead of the usual normal of 98.4 degrees. The pulse-rate most frequently does not depart from what is characteristic for the individual, though about one-fifth of puerperal women have a slowing of the pulse, a phenomenon of favorable significance. Any difficulty in breathing that may have existed in the latter part of pregnancy disappears when the abdominal distention is relieved, and the respiratory rate becomes normal. So long as the body is getting rid of the tissue-substance essential to pregnancy, but now without any purpose, more than the usual amount of waste material is present in the expired air.

The Elimination of Waste Material.—As we might expect from the loss in body weight, the excretory organs are particularly active during the lying-in period. In quantity the loss of water exceeds all the other waste-products together; and pronounced activity of the kidneys or of the sweat glands may become a source of annoyance. Since it is undesirable to interfere with these functions, whatever inconvenience either may cause will be borne with less complaint if the patient understands that a large loss of water at this time indicates a healthful condition of the body.

Shortly after delivery there may be difficulty in emptying the bladder; and, under such circumstances, the doctor or nurse used to catheterize the patient immediately; this habit once begun, it was often necessary to repeat the operation day after day, or, for that matter, several times a day. But as physicians came to know more of the relations of bacteria to inflammation of the bladder, they grew more cautious, and preferred to wait a long time before resorting to the catheter. The reward of this patience was to find that, with remarkably few exceptions, puerperal women ultimately void of their own accord. Accordingly catheterization after child-birth is now postponed, and is never performed until a number of devices to get the patient to void spontaneously have been tried without success. Often urination follows putting a hot-water bottle over the bladder; or pouring warm water over the vulva; or placing the patient upon a bed-pan from which steam is rising. When these and other devices well known to every nurse are not effective, catheterization becomes necessary. With the elaborate precautions taken to avoid infection of the bladder, catheterization is now performed with very slight risk.

Constipation, for various reasons, becomes a regular feature of the lying-in period. The confinement in bed, restricted diet, relaxation of the abdominal wall, and sensitiveness about the region of the rectum, all have a tendency to prevent spontaneous movements of the bowels. As one of these influences after another is removed the bowels begin to act naturally. Childbirth may cause chronic constipation, but this sequel would occur much less often if a little care were taken to prevent it.

The routine use of enemas deserves to be condemned. I see no objection to an occasional enema if purgative medicine has been taken without effect, but constant use of them, more than likely, will result in the enema habit. Similarly, long-continued administration of strong purgatives tends to make them a permanent necessity. While in bed if medicine is taken every other day the bowels will have opportunity on the intervening days to move spontaneously, though we do not really expect them to move naturally until six or eight weeks after the delivery, when the patient is able to take as much exercise as she likes. Toward the end of the second week, however, mild laxatives generally prove effective, and it is important to select one the dose of which may be gradually decreased. Senna prunes, which were described in Chapter V, fill the purpose very well. Six or eight of them may be needed at first, but the number may be gradually reduced, until finally none are necessary.

Cleanliness.—In view of the excessive elimination of waste products from the body, the maintenance of cleanliness during the lying-in period may require the use of a large amount of linen. Occasionally patients perspire so freely that the night clothes have to be changed several times in twenty-four hours, and the bed linen only a little less frequently. But at any cost it is imperative not to hinder but rather to promote this function and to keep the skin in a healthful condition through bathing and massage. Nurses are taught, on this account, to give a warm soap and water bed-bath in the morning and an alcohol rub at night. Patients are usually allowed to take tub-baths after the third week.

Local cleanliness, which is a matter of the very first importance, can only be attained through bathing the vulva with an antiseptic solution and the use of sterile pads. At first the pads are changed very frequently, but after the discharge becomes less profuse they are renewed at intervals of four to six hours.

The Diet.—For the first week of the lying-in period not all patients are given the same diet, and the physician always leaves specific directions regarding it. Generally the diet consists of liquids, such as milk and broths, for a couple of days; under some circumstances liquid nourishment is continued longer. As the appetite increases easily digestible but nutritious food is added, and before long the patient resumes her ordinary diet.

The modern tendency is to give solid food and to give it in substantial amounts much earlier than was once customary; restrictions, none the less, are still observed so long as the patient remains in bed. With the body at rest, its food requirements are diminished and hearty meals are unnecessary. If convalescence proceeds satisfactorily such wide latitude in the choice of food is permissible that the nurse may regulate the diet, consulting the physician whenever necessary.

The Environment.—A large, bright room that can be quickly heated and easily ventilated adds notably to the comfort of the lying-in period. The windows may be opened through the greater part of the day and at night should always be left so. To make thorough airing of the apartment more feasible and to protect the mother from annoyance when the baby cries, it is more satisfactory to have the baby occupy an adjoining room where the nurse sleeps within call. Under any circumstances some arrangement must be made so that the mother's rest at night will not be broken needlessly.

No pains should be spared to keep the patient quiet for at least ten days. Household cares and petty worries materially delay convalescence. During this period only a limited number of the immediate members of her family ought to see her, and their visits should be brief. Unfortunately, if too many relatives and friends visit her a number of questions will be repeatedly asked which are decidedly wearing on any patient.

The Time for Getting Up.—How long a woman should stay in bed after the birth of a child is a question which has given rise to prolonged discussion. The majority of obstetricians adhere to the traditional ten days; but there are advocates of a longer period and advocates of a shorter one. The generalizations of many writers upon this subject are too sweeping, for exceptions may be found to any rule. Each patient is best counselled when the advice given is based upon her own condition and particularly upon the progress made in the involution of the uterus, which does not advance with the same rapidity in all cases.

More or less in imitation of the custom among savages, Charles White, in 1776, recommended that women should not remain in bed longer than a day or two after child-birth. Very likely the inadaptability of the method to civilized women soon became apparent; at any rate his suggestion was not widely adopted, and had been completely forgotten until a few years ago, when the custom was revived in one of the German clinics. The innovation met with violent opposition in Europe, and, so far as I know, has found but scant favor in America.

Generally patients are allowed to sit up in bed toward the end of the first week, but if there are stitches, sitting up is deferred until ten days or later, when the stitches have been removed. Under the most favorable circumstances, however, sitting up in bed becomes wearisome, for the weight of the body does not fall upon the spine, as it should; and besides the extended position of the legs is fatiguing. No one should force herself to keep this posture, for at best it does no more than relieve monotony. The exercises previously suggested prepare her much more effectually for getting upon her feet.

Between the tenth and the fifteenth day patients may leave the bed and sit quietly in a chair. The condition of the uterus, the character of the lochia, and the firmness of the pelvic floor will determine the day, but usually it proves wiser to defer it until fully two weeks have lapsed. As a rule, the patient remains out of bed an hour the first day, two the second, three the third, and so on until she is up all day. She should not attempt to walk until the second or third day. At first she should take only a few steps, but gradually she may increase the number and finally walk with freedom and ease. Several reasons make it advisable for patients to remain four weeks on the floor where they have been confined; going up and down stairs is especially tiresome, and, of still greater importance, patients pass from the doctor's control as soon as they go down stairs. For fear of overtaxing the strength none of the household cares should be assumed before the fourth week, and not all of them then, for women are not capable of resuming their accustomed duties fully until the sixth week; and some are not strong enough to do so until a somewhat later date.

Since patients generally feel well during the lying-in period they are apt to object to remaining in bed two weeks. Most of them acquiesce as soon as they understand the organic changes in progress and appreciate the lasting benefits of a temporary forbearance, but a few must be made to realize that very serious penalties may be attached to undue haste. For the latter it might be better if the alarming consequences of getting up too early—discomfort, hemorrhage, and collapse—occurred more frequently than they do. As it happens, the ill-effects of such indiscretion are not usually felt immediately; when too late the lesson is learned that many of the operations upon women in the later years of life are dependent on imprudent conduct just after the first child was born.

THE FINAL EXAMINATION.—Looking to complete restoration of the woman's health, the modern management of obstetrical cases breaks decisively with tradition at three points. An utter disregard of precaution has given way to very careful preparations before and at the time of labor; definite rules for the management of the lying-in period are carried out under the supervision of the physician; and finally, prompted by the same impulse, the physician examines his obstetrical patients before discharging them. Satisfactory conditions are generally found; if they are, it is a great comfort to be assured of the fact; and if not, timely treatment of the abnormality may readily correct it; with delay, on the other hand, treatment often becomes more formidable.

The end of the fourth week of the lying-in period proves a convenient time for this examination. As yet the restorative changes in the reproductive organs have not been completed, but one may definitely say by this time whether or not they will culminate in a satisfactory manner. Besides, making the examination while the changes are in progress sometimes enables the physician to treat approaching complications before they actually develop. Thus, when the pelvic floor has not regained its strength sufficiently, the patient will be advised to forego the liberty in moving about ordinarily granted at this time. When the womb inclines to an improper position, a temporary support may be introduced to hold it where it belongs; later, upon removing the device, the womb usually retains a good position. Again, there are conditions which a douche will relieve, and still others benefited by medicinal treatment. If an abnormality is recognized which cannot at once be treated to the best advantage, arrangements will be made for such prompt treatment that the woman will not become an invalid. Instead of placing obstacles in the way, patients should rather insist upon this examination, for it is important in guarding their future health.

Now and then patients are kept under observation for a longer period, but, as a rule, they are discharged as well as examined at the end of four weeks. They may also discard the abdominal binder about this time and put on corsets, which, however, should not be tightly worn. Although thrown upon her own resources from this moment, the patient will clearly understand that she must continue to exercise sound discrimination in what she does. And here, of course, we encounter the greatest difficulty in offering practical advice, for what one may do easily will overtax another. Generally speaking, going up and down stairs more than once a day is inadvisable until another two weeks have passed. Likewise the mother who would adopt a conservative policy will not take full charge of her baby before it is six weeks old, though there can be no objection if she wishes to direct its care. The same advice applies to running the household. Over- exertion, no matter what the source, delays convalescence from child- birth to such an extent that the safe plan is always to err on the side of doing too little, rather than to run the risk of doing too much.