The Prospective Mother, a Handbook for Women During Pregnancy

by J. Morris Slemons

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.