The Prospective Mother, a Handbook for Women During Pregnancy

by J. Morris Slemons

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.