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The cover image was created by the transcriber and is placed in the public domain.

OBSTETRICS
FOR NURSES

BY

CHARLES B. REED, M.D.,

Obstetrician to Wesley Memorial Hospital, Chicago.

ONE HUNDRED THIRTY ILLUSTRATIONS

ST. LOUIS

C. V. MOSBY COMPANY

1917

Copyright, 1917, by C. V. Mosby Company

Press of

C. V. Mosby Company

St. Louis

TO HIS LOYAL FRIEND

EUGENE S. GILMORE

THIS BOOK IS AFFECTIONATELY DEDICATED BY THE AUTHOR

PREFACE

It might seem that an apology was necessary for presenting a new textbook on obstetrics for nurses when so many are to be had for the asking. But when a teacher is rarely or never satisfied with his own work it is too much to expect that he will ever fully endorse the product of another. It may be therefore largely a personal matter that none of the existent books seem to exhibit the fullness of information, the conciseness of expression, and the emphasis due to certain subjects that the present writer would hope to find.

The necessities apparently demand such an arrangement of our obstetrical doctrine that the book may serve for class instruction and at the same time be complete enough for post-graduate reference.

To secure this much discrimination is necessary. The confusion attendant upon overabundance must be avoided as well as the discouragement that is not infrequently produced by a large book or a periphrastic style.

Hitherto there has been a tendency to teach the nurse too little rather than too much but conditions have changed. Vocational instruction is not only more methodical and far reaching but it is developmental. The present day nurse expects not merely to assist the physician and earn a stipulated reward, but she is constantly alert to attain her own maturity as a professional woman.

To be a capable and intelligent assistant it is not sufficient to have a clear comprehension of her particular duties, but she must have a defined and critical conception of what the doctor is aiming to accomplish.

This is especially true in obstetrics where the nurse has the additional responsibility of giving support and counsel to her patient in the various emergencies that arise. Moreover, to attain her intellectual maturity the nurse must strive unremittingly to understand the complicated processes that take place under her observation.

She must cooperate with her doctor whose associate she is and secure the confidence of her patient who relies upon her for guidance in the perils she is facing. For childbirth is a peril. It is no longer the normal process it once was. Civilization has changed the shape of the pelvic bones, altered the muscles of parturition and weakened the nerve centers that control the event.

The birth of a child is equal in severity and seriousness to many of the major operations. It is not an affair to be entered upon lightly nor managed without the utmost foresight and care.

The dangers that are recognized and prepared for in this book by what may seem to some to be an extravagant technic, are very real dangers, extremely subtle, and against them at times every precaution and every defense proves unavailing.

Nevertheless, skill, thoughtfulness, and above all, cleanliness, will avert the worst, as well as unhappily the most common of these disasters. If our nurses could be convinced of this, the difficulties and apprehensions of childbirth would be greatly diminished.

The nurse should see to it that her patient is surrounded by all the precautions and safeguards against infection that she would demand for a member of her own family. This means of course that her work will be far more exacting and onerous but also it will save many nights of anxiety and not infrequently a life.

This book represents the obstetric ideas and technic which the writer has endeavored for years to impress upon his students and nurses with such emendations and changes as experience and scientific progress have suggested. It is a selective essence distilled from the recurrent harvests that workers in this field have brought forth during centuries of consecrated effort. To all these forerunners the writer acknowledges a deep personal indebtedness.

In the preparation of the book thanks are due particularly to Charlotte Gregory, Head Nurse of the Wesley Maternity, whose rare ability as teacher, technician and executive and whose untiring vigilance has been a leading factor in securing and maintaining the high state of efficiency in this department. She has kindly contributed Chapters XXIII and XXIV, together with valuable suggestions and criticisms in other portions of the text.

The author also takes pleasure in acknowledging his obligations to Florence Olmstead, Head Nurse of the Dispensary of the Northwestern University Medical School, whose long experience in feeding babies gives to her words an unquestioned authority. Chapter XXII is almost entirely her work.

To the various publishers who have courteously allowed the reproduction of valuable illustrations from the books of other writers thanks are also extended, and to his own publishers especially for their cordial and sympathetic cooperation the author wishes to express his warmest gratitude.

C. B. R.

Chicago, 1917.

CONTENTS

ILLUSTRATIONS

OBSTETRICS FOR NURSES

CHAPTER I
ANATOMY

The study of obstetrics is an investigation of the passage, the passenger, and the driving powers of labor, as well as of the various complications and anomalies that may attend the process of reproduction.

The passage is composed of a bony canal, called the pelvis, and the soft tissues which line and almost close its outlet.

The pelvis is made up of four bones; the sacrum, the coccyx, and two other large structures of irregular shape, called the hip, or innominate bones. Joined by cartilage and held in place by ligaments, they form a cavity or basin which, in the male is deep, narrow, small and funnel-shaped, while in the female, slighter bones, expanded openings and wider arches make a broad, shallow channel, through which the child is born.

The bony pelvis is divided for description into two parts, the upper or false pelvis, and the lower or true pelvis. The upper pelvis is formed by the wings of the innominate bones and has but two functions of importance to child-bearing. It acts as a guide to direct the child into the true passage, and when measured by the pelvimeter, it gives information as to the shape and size of the inlet to the true pelvis. The true pelvis is of most concern to the obstetrician, because anomalies in its size or shape may impede the progress of labor or render it impossible. The pelvis is divided conveniently into three parts: the brim, the outlet, and the cavity.

The brim, inlet, or upper pelvic strait, is the boundary line between the false and true pelvis. It is traced from the upper border of the symphysis along the iliopectineal line on both sides to the promontory of the sacrum. The shape and size of this opening varies much in different races and individuals, both normally and through disease; and when pathologically altered, both shape and size may exercise a marked influence on the course of labor. In American women, the outline of the brim is roughly heart-shaped, like an ovoid with an indentation where the promontory of the sacrum impinges upon the opening.

Fig. 1.—The normal female pelvis. (Eden.) The lines ab and cd divide the pelvis into the right and left anterior and the right and left posterior quadrants. ab indicates the anteroposterior diameter of the brim, cd shows the transverse diameter while gh and ef represent, respectively, the right and left oblique diameters.

The brim or inlet has four important diameters to be remembered; important because the hard, round head of the child must pass through them by accommodating its diameters as favorably as possible to those of this opening. These diameters are named respectively the anteroposterior or conjugate diameter, the transverse, and the right and left oblique diameters. The two oblique diameters attain their greatest importance when the pelvis is irregularly distorted, but the others are essential in every case where labor impends. It is to secure an estimate of these latter diameters that the bony prominences are measured. This upper opening lies not horizontally, but in oblique relation to the body in standing position, and the weight of the abdominal viscera rests largely upon the bones and in consequence does not crowd into the inlet unless forced in by corsets or faulty habits.

Fig. 2.—The planes of (a) the brim, (b) the cavity and (c) the outlet. (Eden.)

Passing through the brim, a cavity is found below it, midway between the inlet and outlet, which is nearly round in shape. This is the “excavation,” or the true pelvis. Then comes the outlet, bounded in front by the pubic arch and soft parts, and behind by the coccyx pushed back as far as it can go. It is ovoid in shape, but the long axis of this ovoid lies at right angles with the axis of the ovoid inlet.

We find, therefore, a succession of three geometric figures or planes through which the head must pass by means of a spiral motion called rotation. These figures are inclined to one another so markedly in front that a line drawn through the center of each will curve forward at both ends, one end passing out near the umbilicus, the other through the vulva. This is known as the axis of the pelvis or the curve of Carus.

Fig. 3.—Visceral relations. (Redrawn from Gray.)

THE SOFT PARTS

Inside the pelvis are the organs of generation with their accessory structures and supporting tissues.

Of first importance are the ovaries, tubes and uterus, together with the vagina. These special structures are the true genital organs. They are bounded in front by the bladder, behind by the rectum, above by the abdominal viscera, and surrounded everywhere by muscular, mucous and fatty tissues, which support them and aid their function.

The Vagina.—The vagina is a hollow organ, about four inches long, attached to the cervix above and the vulva below. It is an elastic sheath bounded in front by the bladder and behind by the rectum. Under normal conditions, this tube easily admits one or two fingers, but during labor it dilates enormously to allow the head to pass. The vagina is lined with a thick mucous membrane, ridged and roughened by folds, which are called rugæ. Thus a continuous channel connects the ovary with the outside and through it pass, at appropriate times, the ovule, the menstrual blood, the uterine secretions, the child, the placenta, and the lochia.

The Uterus.—The uterus (womb) is a pear-shaped organ, flattened from before backward, and composed of unstriped or involuntary muscle cells and connective tissue. Normally the virgin uterus measures from two and one-half to three inches in length, and weighs about two ounces. It is suspended in the middle of the pelvis by strong ligaments, so that the fundus inclines gently forward against the bladder. When the bladder fills, the uterus is pushed backward. Most of the organ is internal, but a small part of the lower pole is grasped by the vagina, in which the lower end with its invaluable aperture, the os, dips and swings. The part above the vagina is called the body or fundus, and is covered with the serous membrane (peritoneum) that lines the abdominal cavity. Below the fundus is the cervix or neck, which lies partly above and partly within the vagina. The cavity of the uterus is usually closed by the apposition of the walls. The inner surface is covered with a peculiar kind of membrane called the endometrium, which is highly vascular. The uterine cavity opens into the vagina through the os, which is small and round in the nulliparous woman, and slit-shaped or gaping in the woman who has borne a child.

Fig. 4.—Uterus and appendages. On either side of the uterus will be seen the ovary, the fimbriated extremity of the tube, the tube, and the round ligament. The vagina lies open below. (Lenoir and Tarnier.)

Fallopian Tubes.—On either side of the upper end of the uterus are the orifices of the Fallopian tubes, through which the egg, escaping from the ovary, finds access to the uterine cavity. These tubes extend outward from the uterus about four inches, and terminate in a bell-shaped opening with long, ragged fingers which hang loosely down toward the ovary. The tubes are lined by epithelial cells having hair-like projections, (ciliæ) which wave automatically toward the uterus. Thus impelled by a gentle current, the egg moves definitely along the tube toward the uterus and against this current the spermatozoa force their way to meet and fertilize the egg.

The Ovaries.—On either side of the pelvis, close to the fringed end of the Fallopian tube and attached to it, lies a small, hard, almond-shaped organ, called the ovary. This is the intrinsic sexual gland of the female. It contains the small cells which are to ripen and become eggs. Each ovary is said to contain about thirty-six thousand eggs, or ovules.

The Bladder.—The bladder lies between the pubic bone and the uterus. It is a reservoir for urine, filled by means of two little tubes called ureters, that run down from the kidneys. It drains through the urethra which opens just below the pubic bone in front of, and just above, the vaginal opening. The bladder should be emptied frequently during labor.

The Anus.—The large bowel (colon) terminates in an opening near the middle of the genital crease. This opening is called the anus. It is closed by a contracting muscle, the sphincter, which acts like a puckering string. Just inside of the opening is a group of large veins which may become enlarged, inflamed, and bleed during pregnancy. They are then called hæmorrhoids.

The Rectum.—Upward from the anus and to the left of the uterus extends the rectum. This is the end of the intestinal canal and is supplied with an abundance of nerves. When the head presses upon it, it gives the sensation of a bowel movement, and warns the observer of the low position of the head. The anus pouts as the head comes down and the anterior walls become visible. In severe cases of labor, the sphincter is sometimes torn. The bowels should be emptied by an enema as early as possible in the first stage of labor.

The Peritoneum.—The peritoneum is a thin, glistening, serous membrane, which lines the abdominal cavity and drops down from above over the uprising tops of the bladder and uterus. Folding together at the sides and extending to the walls of the pelvis, it encloses the tubes and round ligaments in deep, flat masses, called the broad ligaments. This is the structure that becomes so perilously inflamed (peritonitis) when infected by germs that find entrance through the genital passage.

Fig. 5.—Normal position of pelvic organs, seen from above and in front. They are enveloped in peritoneum. (Bougery and Jacob, in American Text Book.)

THE EXTERNAL GENITALS

The external genitals form the vulva. Under this name are included the mons veneris, the labia majora, the labia minora, the clitoris, the vestibule, the hymen and the glands of Bartholin.

The entire groove from the mons veneris to a point well up on the sacrum forms a deep fold or crevice, which is known as the genital crease. That part of the genital crease lying between the anus and vulva is technically known as the perineum (q.v.)

Fig. 6.—The external genitals. (Redrawn from Gray.)

The Mons Veneris.—The mons veneris is a gently rounded pad of fat lying just above the junction of the pubic bones (the symphysis). The overlying integument is filled with sebaceous glands and covered with hair at puberty.

The Labia Majora.—The labia majora are the large lips of the vulva. They are loose, double folds of skin extending downward from the mons veneris to the anterior boundary of the perineum and covered externally with hair. Normally they lie in apposition and conceal the vaginal opening. They correspond to the male scrotum.

The Labia Minora.—The labia minora, or nymphæ, are two small folds of skin and mucous membrane, that extend from the clitoris obliquely downward and outward for an inch and a half on each side of the entrance to the vagina. On the upper side, where they meet and invest the clitoris, the fold is called the prepuce, but on the under side they constitute the frænum.

The labia minora are sometimes enormously enlarged in the black races and are then called the Hottentot apron.

The Clitoris.—The clitoris is an erectile structure analogous to the erectile tissue of the penis. The free extremity is a small, rounded, extremely sensitive tubercle, called the glans of the clitoris. About the clitoris there forms a whitish substance called smegma. This is a good culture medium for germs and must be carefully sponged away when the vulva is prepared for delivery.

The Vestibule.—The vestibule is bounded by the clitoris above, the labia minora on the sides, and the vaginal orifice below. It contains the opening of the urethra, which is called the meatus urinarius.

The Hymen.—The hymen is a thin fold of membrane which closes the vaginal opening to a greater or lesser extent in virgins. It varies much in shape and consistency. It is sometimes absent, or it may persist after copulation, hence its presence or absence can not be considered a test of virginity. When torn, the edges shrink up and form little irregularities called carunculæ myrtiformes.

Fig. 7 A.—Varieties of hymen. (American Text Book.)

Bartholin Glands.—Bartholin glands are located on each side of the commencement of the vagina. Each gland discharges by a small duct just external to the hymen. They are often the seat of a chronic gonorrhœal inflammation and must be watched carefully, lest infection extend to the mother after labor, or to the eyes of the child in passing.

Fig. 7 B.—Varieties of hymen. (American Text Book.)

The Perineum.—The perineum is a body of muscle, fascia, connective tissue, and skin, situated between the vagina and the rectum. The vagina bends forward and the rectum backward, so a triangular area is left between them which is filled by the perineal body. It is about two inches long from before backward, and becomes progressively thinner the deeper it extends.

Fig. 8 A.—The excreting ducts of the mammary gland. (Lenoir and Tarnier.)

Fig. 8 B.—Lobules and duct of the mammary gland. (Lenoir and Tarnier.)

The perineal body is flattened out and compressed by the passage of the head and in many cases torn. (Thirty per cent of primiparas and ten to fifteen per cent of multiparas.) It should be repaired immediately.

The Mammary Glands.—The mammary glands are secondary but highly important parts of the genital system. They are formed by a dipping down of skin glands and they perform the special function of secreting milk.

The breast is made up of fifteen or twenty lobes, each of which, like a bunch of grapes, clusters about and discharges into a single tube which, in turn, leads to the nipple. The area between the lobes is filled with fat and connective tissue.

Fig. 9.—Nipple, areola, and the glands of Montgomery. (Eden.)

The nipple is pink or darkly pigmented. It is composed of erectile tissue and under stimulation, it rises from the surface of the gland so that it is easily taken into the mouth.

Fig. 10.—Supernumerary milk glands in the axillæ. They may be found also below the breasts. (Witkowski.)

Fig. 11.—The three ages of the breast—virginity, maturity, and senescence. (Witkowski.)

Surrounding the nipple is a darkly pigmented area from one inch to four inches in diameter that is called the areola. It contains hard, shot-like nodules, the glands, or tubercles, of Montgomery. These often secrete milk and sometimes become infected. It occasionally happens that more than two breasts may be found on the human female, and not infrequently pieces of mammary tissue may be discovered in the axilla or on the chest or back.

The mammary gland is undeveloped at birth, but, nevertheless it may fill with milk (witches’ milk). At puberty, after marriage, and during pregnancy, the gland reaches maturity. It is only after delivery, however, that the functional climax is attained.

CHAPTER II
PHYSIOLOGY

Ovulation.—Ovulation is the process whereby the eggs are discharged from the Graafian follicle which matures and protects them in the ovary. The egg is a true cell with one, and sometimes more than one, nucleus.

The ripening of the eggs, as well as their discharge, is attended with much general disturbance and great physical changes. This phenomenon begins from the twelfth to the fifteenth year, depending on race, climate, occupation and temperament, and marks the transition of the individual from childhood into maturity.

This period is called puberty. At this time the breasts enlarge, the hips round out, the vagina, uterus and external genitals increase in size. Hair appears upon the vulva, the emotions become more evident, and modesty develops through a consciousness of sexual difference and attraction.

Simultaneously a new function appears—

Menstruation.—Menstruation may be defined as a process wherein a bloody fluid is discharged from the uterus at regularly recurring periods between puberty and the menopause, except during pregnancy and lactation. It is a hæmorrhage which in some way is closely associated with ovulation, but it is not known positively which is the precedent of the other, or whether one causes the other.

Menstruation is not essential to pregnancy, for pregnancy may occur when the flow is normally absent, as before puberty, after the menopause, or during lactation. Nevertheless, regularity of menstruation is the rule in fertile women and clinicians agree that while conception may occur at any part of the menstrual cycle, it is most likely to happen just before or just after the menstrual flow.

The best authorities at present support the theory that ovulation usually occurs soon after the close of the menstrual period. This is confirmed by the similarity of the physical changes that take place in the endometrium during menstruation and after conception.

Fig. 12.—Development of the ovary (after Wiedersheim). A, an ingrowth of the germinal epithelium, forming a cell-cord, which breaks up into primitive Graafian follicles; B, a primitive Graafian follicle, with its contained primitive ovum; C, D, E, later stages in the development of the Graafian follicle. (Crossen.)

As the period of the flow approaches, the lining membrane of the uterus becomes hyperæmic and swollen with blood, serum, and glandular secretions. The blood vessels are engorged, the glands become longer and more tortuous, little hæmorrhages appear, and the superficial epithelium is thrown off. A large amount of mucus is produced by the increased activity of the glands, and all is discharged into the vagina as a bloody, incoagulable flow with an odor of marigolds. The process continues usually from three to seven days, when the discharge ceases and the endometrium slowly resumes its uncongested state.

Fig. 13.—Graafian follicles. One contains two ovules which, if fertilized, will produce twins. If all three ovules are fertilized, triplets will result. (Bumm.)

Meanwhile, the psychic and bodily conditions have not remained unaffected. The nervous system is disturbed, the disposition is irritable and capricious and the head may ache. The woman takes cold easily. She is indisposed to exertion from a sense of languor and malaise. Pain may develop in the back, or cramps in the pelvis, so severe as to keep the woman in bed. Frequently the approach of the period is signalized by skin changes, such as a marked odor or an eruption of acne pustules.

The flow usually returns every twenty-eight days, but it may vary within normal limits from twenty-one to thirty days. The flow continues at such intervals regularly from puberty to the menopause (change of life), which occurs between the ages of forty-five and fifty.

Conception, or Fertilization.—This is the process wherein the male element (spermatozoon) meets and unites with the female egg. From what is known from investigations of lower animals, this meeting usually takes place in the Fallopian tube.

Fig. 14.—Human spermatozoa. h, head; c, intermediate portion; t, tail. (Williams.)

The egg expelled from the ovary is carried into the open end of the tube by peritoneal currents and passed on toward the uterus by the waving action of the hair-like outgrowths of the cells (ciliæ) that line the tube, aided, possibly, by the tubal muscle.

The spermatozoon makes its way upward from the vagina by means of its tail. This activity, like the tail of a fish, or snake, or as a boat is sculled, drives the cell forward through the thin layer of fluid that covers the mucous membranes.

The arrow-shaped spermatozoon travels at a rate that completes the passage to the ovary in twenty-four hours, but spermatozoa may lie in wait for the egg a considerable time, as is shown by the fact that they have been found alive in Fallopian tubes removed three and a half weeks after copulation. As soon as the male and female elements approach each other, they exercise a powerful magnetic attraction, which draws them together, and as soon as they touch, the two cells unite and the spermatozoon almost immediately disappears.

Only one spermatozoon is required for the fertilization of an egg, and hence enormous numbers must perish without achieving their destiny.

The fertilized egg has become the ovum, and originally 1/125 of an inch in diameter, it now begins to grow, and filled with a new energy, it passes down the tube and enters the uterus. Here it comes into contact with the soft mucosa and digs a hole for itself—a nest, very much as a warm bullet might sink into ice or snow—and is soon completely surrounded by a proliferating tissue called the decidua. The woman is now pregnant. The menstrual flow does not appear, and local and systematic changes are inaugurated.

The egg enlarges rapidly. Little glove-finger-like projections (the villi) appear on its surface and dip down into the maternal tissues. Through these villi the egg gets nourishment until about the twelfth week, when the placenta forms. Externally the ovum resembles a chestnut burr. As the egg grows, the villi on the surface find it more and more difficult to secure nutriment, and except at one place, all gradually shrink and disappear. At this significant point, they increase greatly in size, number, and complexity to form the thick, cake-like placenta.

The egg or ovum is simply a growing cyst, filled with a fluid, normally sterile, in which the developing embryo lives and swims. This fluid is the liquor amnii and it is retained by a cystic wall made up of two layers—the chorion, which represents the original cell membrane, and the amnion, which develops out of the fœtus. At maturity, the ovum will contain from one to two pints of liquor amnii.

Fig. 15.—The chorionic villi about the third week of pregnancy. (Edgar.)

The Liquor Amnii.—The liquor amnii is of vast importance to the child. It allows free movement for the growing limbs and body, protects the child from sudden changes of temperature, prevents injury both from without and within, saves the child from birthmarks and deformities by keeping it from contact with the surrounding walls, and in labor lubricates the passages for the advancing part. In a measure, too, it probably serves as a food. In labor it forms a pouch called the bag of waters, which aids in dilating the os.

Fig. 16.—Diagram illustrating relations of structures of the human uterus at the end of the seventh week of pregnancy. (American Text Book.)

Gradually, as nutrition becomes more abundant at the site of the growing placenta, a stalk-like structure thrusts out from the fœtal abdomen and forms an attachment with the formative placenta. This is called the ventral stalk and as soon as the communication with the placenta is established, it is combined with other parallel structures and becomes vascularized, to form the umbilical cord.

Fig. 17.—Maternal surface of the placenta and membranes. The cord protrudes from the cavity which held the fœtus. (Edgar.)

The Umbilical Cord.—The umbilical cord at maturity measures from five to fifty inches in length and from one-half to one inch in thickness. The cord is composed of a gelatinous connective tissue, called Wharton’s jelly, in the midst of which lie the twisted vessels (two arteries and a vein) that supply the embryo with air and food and carry off the waste.

The Placenta.—The placenta or “after-birth” is an oval or circular somewhat flattened disc, six to ten inches in diameter, and three-quarters to one and one-half inches thick. It weighs about a pound and a half. It is the organ of respiration and nutrition for the fœtus.

Fig. 18.—Fœtal surface of human placenta. (Eden.)

Fig. 19.—The egg at term with uterus removed and child showing through the membranes. (Edgar.)

It is formed about the third month outside the membranes covering the child and is more or less loosely attached to the uterine wall. The umbilical cord is attached to its fœtal surface, inside the ovum. Like a flat sponge it takes oxygen, blood, and the nourishing fluids from the blood vessels in the uterine wall, carries them to the child by means of the umbilical vein, and carries back the carbonized blood and waste products by the umbilical arteries to the placenta, and there returns them to the maternal blood for disposal. The blood of the veins is bright red, and of the arteries, dark and turbid.

Fig. 20.—Normal attitude of fœtus (complete flexion). (Barbour.)

There is no direct communication between the maternal tissues and the placenta, hence all the changes occur by osmosis, and by the activity of the cells which form the walls of the villi.

The liver of the child is large and active. The stomach and intestines functionate mildly. The kidneys act, and urine is discharged into the liquor amnii, which the child occasionally swallows.

During development, the movements of the child become more and more pronounced. Arms, legs, and entire body participate in turn. Periods of rest are also observed. Gradually the child assumes a definite attitude in the uterus. It becomes more and more folded and flexed to accommodate its size to the limitations of space. The head bends on the chest, the arms are folded, the thighs flex against the abdomen, the legs on the thighs, and even the back ultimately becomes convex. It attains a complete flexion, the normal attitude of the child. As maturity approaches, the head becomes more and more palpable and seeks its usual location in the lower pole of the uterus, resting on the pelvic brim.

Fig. 21.—Fœtal skulls showing sutures. Note the differences between the anterior and posterior fontanelles. (Eden.)

Fig. 22 A.—Child’s head at term (from side), showing diameter. (American Text Book.)

Fig. 22 B.—The child’s head at term (from above), showing diameters and fontanelles. (American Text Book.)

The fœtal skull at maturity (at term) is still incompletely ossified. The bones are thin and pliable and separated at their edges by intervals of unossified membrane which form the sutures and fontanelles. Thus the skull is compressible to a slight degree and capable of much change in shape. It can be measurably moulded by the uterine contractions to suit the pelvis.

In front, the two coronary sutures meet the frontal and sagittal sutures to produce a kite-shaped figure, called the large or anterior fontanelle, or the bregma. Behind, the lambdoidal suture meets the sagittal suture to form the small or posterior fontanelle.

The large fontanelle is made up of four bones and four angles; the small, of three bones and three angles, and are usually easy to differentiate. Furthermore, the difference between these fontanelles is of great importance in labor, since by it the observer is enabled to determine the position of the head. In America, the shape of the head is that of an ovoid with the long diameter anteroposterior (Dolico-cephalic). Thus it happens that when the head is completely flexed, the smallest diameters are presented for delivery.

The important diameters of the head, with their measurements and names, are as follows:

Nape of neck to center of bregma, 9.5 cm.—Suboccipito-bregmatic diameter. Occipital protuberance to root of nose, 11.25 cm.—Occipito-frontal diameter. Between the eminences of parietal bones, 9.25 cm.—Biparietal diameter. Between anterior ends of coronal sutures, 8 cm.—Bitemporal diameter.

The smallest circumference is that of the suboccipito-bregmatic plane, which comes into relation with the brim of the pelvis when the flexion of the head is complete. It measures 27.5 centimeters.

The fœtus grows at a definite rate throughout gestation and so regularly that the increase is rarely simulated by any other condition.

To find the probable length of the fœtus at any given time, square the month of the pregnancy (up to five) and the result is the fœtal length in centimeters. After the fifth month, multiply the number of the month by five. Thus:

7th month ×5=35 cm., the approximate length of the fœtus at the lunar month.—(Hasse’s rule.)

The Mature Fœtus.—Although subject to considerable variation, the fœtus at term will weigh about seven and one-fourth pounds, and measure 50 cm. in length. The weight is far more uncertain than the length, and therefore not so reliable as a sign of maturity.

To obtain an estimate of the weight of the child at any given month of the pregnancy, the number of lunar months minus 2, is squared and divided by 2, and the result is the average weight of the child at that time in hundreds of grams. Thus:

8th month −2=6. 6×6=36. 36÷2=18, or in hundreds of grams, 1800, the weight of the child.—(Tuttle’s rule.)

Differences between the mature and immature fœtus:

The Fœtal Circulation.—The placenta is an organ of nutrition as well as respiration, and through the umbilical vessels the food materials are brought to the fœtus and the waste products removed.

Surrounded by the jelly of Wharton that fills out the cord, and running in and out between the two arteries, the umbilical vein passes into the fœtal abdomen and divides into two branches, one, the larger, short-circuits directly into the inferior vena cava. This branch is called the ductus venosus. The other joins the portal vein and passes through the liver, after which it also enters the vena cava.

Thus the heart is fed with a mixed blood, part coming fresh from the placenta and part coming up from the lower half of the fœtus. This blood is poured into the right auricle, where it becomes mixed again with the blood coming down from the upper pole of the fœtus through the superior vena cava.

Fig. 23.—The fœtal circulation. (Edgar.)

Now a small part goes down into the right ventricle and is forced into the pulmonary arteries to supply the lungs. But the lungs are not functionating, hence the greater part is again short-circuited through the ductus arteriosus into the arch of the aorta, where it meets with the great volume of blood which passed over into the left auricle through the hole in the septum between the right and left auricles, called the foramen ovale, thence down into the left ventricle and out through the aorta to supply the rest of the fœtal body.

With the exception of the ductus venosus and the ductus arteriosus and the foramen ovale, the circulation is the same as in the adult.

The blood in the descending aorta again divides and part goes on to supply the lower extremities while the greater part leaves the internal iliac arteries by means of the hypogastric vessels and returns through the umbilical arteries to the placenta for oxygenation.

As soon as the child is born, the fœtal structures are altered. The child breathes, the pulmonary circulation is established and the ductus arteriosus is closed. The placental circulation is abolished, and the ductus venosus and the hypogastric arteries are converted into solid fibrous cords. Owing to the immediate change of pressure in the auricles, the foramen ovale closes and the circulation assumes the adult type.

CHAPTER III
NORMAL PREGNANCY

The entire body participates in the changes brought about by pregnancy. The hips and breasts become fuller, the back broadens, and the woman puts on fat. She becomes mature in appearance, but, of course, the phenomena connected with alterations in the breasts and genitals are most important, and late in pregnancy, most conspicuous.

The uterus exhibits the most marked alteration. From an organ that weighs two ounces, it becomes the largest in the body, and increases in size from two and one-half or three inches to fifteen inches. The typical pear-shape becomes spheroidal near the end of the third month, becomes pyriform again at the fifth month, and continues thus until term.

Up to the fourth month the walls become thicker, heavier and more muscular, but as pregnancy advances, more and more tissue is demanded, until at the end, a muscle wall of only moderate thickness protects the ovum. Meanwhile the muscular functions of contractibility and irritability are greatly increased.

At the fourth month the womb, which has occupied a position of anteversion against the bladder, rises out of the pelvis. It is now an abdominal organ and as it gets heavier and heavier, it rests a certain amount of its bulk on the brim of the pelvis. About the sixth month, the uppermost part of the uterus (fundus) is at the level of the umbilicus. At the eighth month, the fundus is found a little more than midway between the umbilicus and the ensiform cartilage. About two weeks before term, it reaches its highest point, the ensiform cartilage, and then sometimes sinks a little lower in the abdomen.

The ovum, or egg, does not completely fill the uterine cavity at first, but grows from its side like a fungus until the third month. Then the uterine cavity is entirely occupied and thereafter the egg and the uterus develop at an equal rate. As the uterus rises in the abdomen, it rotates to one side, usually the right, forward on its vertical axis.

Fig. 24.—Gravid uterus at the end of the eighth week. (Braune.)

The blood vessels and lymphatics also increase in size, number, and tortuosity. Many of the veins become sinuses as large as the little finger. This increased amount of fluid both within and without the uterus has a marked effect upon its consistency. The walls of the uterus, vagina, and cervix become softened, infiltrated and more distensible. There is also an increase in size and in number of the muscle cells.

During pregnancy the uterine muscle exhibits a definite functional activity. Intermittent contractions occur, feeble at first, but growing markedly stronger as pregnancy advances. These are the contractions of Braxton Hicks. They are irregular and painless, but can be felt by the examining hand. At term they merge into, and are lost in, the regular, painful contractions of labor.

The breasts can not be said to be fully developed until lactation has occurred, nevertheless, the glands show pronounced changes as a result of marriage and pregnancy.

The size of the gland, as well as the size and appearance of the nipple and areola, varies greatly in different women; but under the stimulation of pregnancy the whole gland enlarges, including the connective tissue stroma.

About the fourth month a pale yellow secretion can be squeezed from the nipple. This is called colostrum. The pigmentation extends over a wider area and deepens in color, while the increased vascularity is shown by the appearance of the blue veins under the thin tender skin. Light pinkish lines sometimes radiate from the nipple. These are striæ and are more evident in blondes.

The milk comes into the breasts about the third day after labor, and normally continues to flow for six, to ten or twelve months.

Why the pregnancy and labor induce such marked mammary activity is not known, but the fact is patent.

The skin reacts both mechanically and biologically to the stimulus of pregnancy.

Fig. 25.—Striæ Gravidarum. (Edgar.)

Striæ Gravidarum.—Striæ gravidarum appear on the abdomen similar to those observed on the breasts and are due to the same cause—mechanical stretching. When fresh, they are pinkish in color and variable in length and breadth, but attain the greatest size below the umbilicus. Occasionally they extend to the thighs and buttocks.

After labor, they become pale, silvery, and scar-like and are called linea albicantes. They are sometimes found in other conditions than pregnancy, such as tumors or ascites.

Increased Pigmentation.—Pigmentation is not limited to the breasts. On the abdomen, a dark line will appear between the umbilicus and the pubes. This is the linea nigra, and it becomes most conspicuous in the latter half of pregnancy. In the groins, the axillæ, and over the genitals, the deposit is common, and sometimes patches appear on the face, either discrete or in coalescence, to form a continuous discoloration, called chloasma; or when extensive, the “mask of pregnancy.” The pigmentation is absorbed, or at least greatly diminished, after labor. The sebaceous and sweat glands are more active.

The hair may fall out and the teeth decay. “With every child a tooth,” is the cry of tradition. These changes are due to imperfect nutrition, or to the presence of toxins in the circulation.

Eruptions of an erythematous, eczematous, papular or pustular type are not uncommon; and itching, either local or general, may make life miserable.

The blood undergoes certain modifications that are fairly constant. The total amount is increased, but the quality is poorer, especially by an increase in water and white cells and a diminution of red cells. The amount of calcium is slightly increased and the fibrin is diminished up to the sixth month, when it rises to normal again at term.

The heart is slightly hypertrophied on the right side and blood pressure somewhat raised. A marked increase in blood pressure is suggestive of eclampsia.

The thyroid gland enlarges frequently, both as a consequence of menstrual irritation and of pregnancy. Goiters may show an increase of development, which remains after labor.

The urine is diminished in amount, but increased in frequency of evacuation. The bladder is more irritable during the first and last months, and micturition may be painful and unsatisfactory. The kidneys must be watched carefully during gestation.

The nervous system is disordered in most women, but especially in those of neurotic tendencies.

Irritability, insomnia, neuralgia of face or teeth, or perversion of appetite in the so-called “longings” are the more common manifestations.

Cramps occur in the muscles of the legs, owing to varicose veins or pressure upon the lumbar and sacral plexus of nerves.

The lungs are crowded by the growing uterus and the respiration interfered with.

The liver is enlarged, but functionally it is less competent, and constipation is common.

It is probable that most of the changes enumerated above are due to the circulation through the body of some definite product of fœtal activity, which is more or less toxic in character. The more pronounced effects of this toxin will be studied under the abnormal conditions of pregnancy.

Generally, if the pregnancy is normal, the whole body responds to the stimulating influence. After the nausea and vomiting of the early months subside, the woman feels energetic and ambitious. She is eager to do something at all times and feels fatigue but slightly. Music, literature or housework engages her attention and is zealously and joyfully practiced. The world seems bright and the thought of her labor does not bring solicitude, but pleasant anticipations. The body fills out in all directions and the woman takes on the appearance of maturity.

DIAGNOSIS OF PREGNANCY

The presence of pregnancy is naturally determined by the recognition of those changes in the maternal system which the growing ovum produces.

During the second half of the period the fœtus can be made out distinctly by palpation, or by its movements, and the heart tones observed by auscultation.

During the first half this is impossible and the diagnosis must be made from subjective symptoms elicited from the patient and upon physical signs observed by the physician.

It is of extreme practical importance to be able to recognize a pregnancy at all periods. The subjective symptoms of the first half are—amenorrhœa, morning sickness, irritability of the bladder, discomfort and swelling of the breasts, enlargement of the abdomen and quickening; but the appearance of any or all of these phenomena is not to be regarded as conclusive, but merely as a presumption that pregnancy exists. Either through ignorance, intent to deceive, or from pathological conditions, any or all of these symptoms may be present, but not until the tenth week are the changes in the uterus sufficiently definite to confirm a diagnosis unless the circumstances are especially favorable.

Amenorrhœa.—Cessation of the menses is practically invariable in pregnancy. One or two periods may occur after conception, but care must be used to exclude other causes of hæmorrhage. Sudden cessation of the periods in a healthy woman of regular habits who is not near the menopause, is strongly suggestive of pregnancy. Why a developing ovum causes an immediate arrest of menstruation is not understood.

Amenorrhœa may occur in consequence of chlorosis, heart disease, hysteria, tuberculosis, fright, grief, and some forms of insanity; a change from a low to a high altitude, or an ocean voyage not infrequently causes the flow to remain absent for one or more months. In addition to its value as a presumptive symptom, the amenorrhœa affords a common and convenient method of estimating the date of confinement. The method is fallacious but practical, and will be discussed later.

Morning Sickness.—This symptom is not invariable. It is most frequent in primiparas, but not so likely to occur in subsequent pregnancies. It usually appears about the second month, shortly after the first period missed. It varies in intensity. Some women have a little nausea on arising and no further trouble during the day, others are nauseated and vomit either on rising or after the first meal, and yet others after each meal; but the general health is not ordinarily affected and the tongue remains clean. Some cases are of extreme severity (hyperemesis) and will be discussed elsewhere.

The morning sickness is probably toxic in origin. It must be remembered that chronic alcoholism is accompanied by morning sickness, but with it the tongue is furred.

Irritability of bladder is shown by a frequency of urination. It is caused by the congestion and stretching of the tissues that lie between the uterus and bladder and hold them in relation to one another. After the third month an accommodation is established and the symptom does not reappear until late in pregnancy, when the pressure of the heavy uterus tends to keep the bladder empty. If especially annoying, this irritability may be much relieved by putting the patient in the knee-chest position night and morning.

Enlargement of the breasts is common in primiparas, but this, with changes in the areola, may occur at menstrual periods in nervous women. Tingling, pricking and shooting sensations may also be noted.

Enlargement of the abdomen is only noticeable toward the latter part of the first half, when the uterus rises out of the abdomen.

Quickening means “coming to life,” and refers to the first movements of the fœtus that are felt by the mother. It is described as similar to the flutter of a bird in the closed hand. It is sometimes accompanied by nausea and faintness. Quickening usually occurs about the seventeenth week of pregnancy, and continues to the end. Gas in the intestines will sometimes simulate quickening.

The movements are important in the second half as indicating that the child is alive.

Physical Signs.—During the first weeks no conclusive changes occur that can be detected by examination, and unless conditions are especially favorable, the earliest time for the definite diagnosis of pregnancy is the eighth week. Previous to this it is presumptive only.

At the eighth week, the breasts may show enlargement and tenderness, with some secretion. In the multipara, this sign has no significance. Secretion is present sometimes in the breast of nonpregnant women with uterine disease (fibroids).

Examination of the abdomen at this time is of little value, but changes in the uterus can be detected by careful bimanual examination. It is needless to say that all internal examinations should be made with the utmost care and gentleness.

Softening of the lips of the os (Goodell’s sign) may be found, but it must not be confused with erosions of the os. The os of a nonpregnant woman feels like the tip of the nose, and that of the pregnant woman like the lips.

Fig. 26.—Bimanual examination. (Edgar.)

The increased size and globular shape must also be considered as confirmatory.

Hegar’s Sign.—The upper part of the uterus is soft and distended by the ovum, the lower part is soft and not filled out by the ovum. Between the two is an isthmus that is compressible between the fingers of one hand in the vagina, and of the other upon the abdomen. When found, this sign is of great value.

At the eighth week, pregnancy can be regarded as highly probable by the conjunction of the following symptoms and signs: Amenorrhœa, morning sickness, irritability of bladder, slight breast changes in primiparas, lips of os externum softened, uterine body enlarged, softened, and nearly globular in shape, and Hegar’s sign.

Abderhalden’s test is a serum reaction based on the well established principle that the introduction into the blood of an organic foreign substance leads to the formation of a ferment to destroy it. Abderhalden’s plan was to discover whether the blood of a pregnant woman contained a ferment capable of destroying placental protein. It is a very complicated test, and subject to many inaccuracies and numerous sources of error. At the same time, the main features of this reaction have been confirmed, and when it is worked out, it will be of immense value not alone in early uterine pregnancies, but in extrauterine pregnancy. This view very properly demands that pregnancy be regarded as a parasitic disease. It is practicable as early as the sixth week to make a diagnosis, and it only fails in possibly ten per cent of the cases. The negative test is equally definite as eliminating pregnancy.

Sixteenth Week.—Morning sickness and urinary symptoms have disappeared but amenorrhœa remains. Enlargement of the breasts is noticeable, as well as the increased pigmentation. The uterus begins to rise above the symphysis as an elastic, somewhat ill-defined, boggy mass. The cervix is softer. The characteristic dull lavender coloration of the vulvar mucous membrane is now evident. It is due to the congestion and is called Jacquemins’ sign.

Two New Signs.—Irregular, painless contractions of the uterus (Braxton Hicks’ sign), and ballottement.

The contractions of Braxton Hicks now become more easily palpable.

Ballottement consists in the detection in the uterus of a movable solid body surrounded by fluid. In a standing position, the fœtus rests in the lower part of the uterus, just above the cervix. The woman stands with one foot on a low stool, and two fingers of one hand are pushed into the vagina until they touch the cervix, the other hand is placed on the fundus. A smart upward blow by the internal hand is transmitted to the fœtus, and it can be felt to leave the cervix, strike lightly the tissues underneath the external hand, and return to the cervix. It is simulated by so few things, and so rarely, that in practice it must be regarded as a positive sign.

During the second half, the subjective symptoms are of minor importance since unmistakable evidence is furnished by the physical signs. The symptoms of this period are mostly discomforts. Increased intraabdominal pressure brings on edema of the feet, cramps in the legs, varicose veins of the legs and vulva, dyspnœa, and palpitations.

Twenty-sixth Week.—About the twenty-sixth week, or, at the end of the sixth calendar month, the hypertrophy of the breasts, the presence of secretion, and the marked pigmentation are unmistakable. The abdominal protrusion is now clearly visible, and the fundus will be found at the level of the upper border of the umbilicus.

Spontaneous fœtal movements appear and may be felt by the palpating hand.

Auscultation reveals the uterine souffle and the fœtal heart sounds. The heart sounds and the fœtal movements, when obtained by the observer, are positive signs.

Uterine souffle is a soft, blowing murmur, synchronous with the mother’s pulse. It is best heard at the lower parts of the lateral borders of the uterus. It is due to the passage of blood through the greatly dilated uterine arteries. It may be heard also in cases of fibroid tumors of the uterus.

Fig. 27.—Abdominal enlargement at third, sixth, ninth, and tenth months of pregnancy. (Williams.)

Fig. 28.—Height of the uterus at various months of pregnancy. (Bumm.)

The fœtal heart sounds are the most anxiously sought for of all the signs of pregnancy. They are conclusive. They not only determine the diagnosis, but afford valuable information during labor, and nurse and student should lose no opportunity of becoming familiar with them. The heart tones can be heard as early as the twenty-sixth week, but they become more and more distinct as pregnancy advances. They vary from 140 to 160 beats to the minute at the twenty-sixth week, and at term, from 120 to 140. When they rise above 160 or sink below 120, some danger threatens the child. The fœtal heart tones have no significance as an indication of sex.

Funic souffle is the sound made by the passage of blood through the umbilical cord when a loop accidentally lies under the tip of the stethoscope. It is synchronous with the fœtal heart tones, but of no great practical importance when the heart tones can be obtained.

Determination of the period to which pregnancy has advanced is sometimes important. This can be approximated by a calculation of the time that has elapsed since the last period, or from the date on which quickening has occurred. Measurement of the height of the fundus and comparison with such scales as Spiegelberg’s, may be carried out, but it is not often required.

A method of estimation in gross, that is approximately correct, in many cases depends on the observation of the steady growth of the womb.

Thus, the uterus rises out of the pelvis at the fourth month, and may be found well above the symphysis pubis. At the fifth month the fundus is midway between the symphysis and the umbilicus. At the sixth month it reaches the umbilical level. At the eighth month it is a little more than midway between the umbilicus and the ensiform cartilage, which it attains in another month, the ninth. Then it usually sinks a little, especially in primiparas during the last two or three weeks. This is called lightening.

CHAPTER IV
HYGIENE OF NORMAL PREGNANCY

The time of confinement can never be accurately determined, because the onset of labor is purely an accident, dependent on many factors. Furthermore, conception does not take place necessarily at the time of intercourse, and we have no means of knowing whether conception occurred just after the last period present or just before the first period missed. So there is always a possible error of three weeks.

Pregnancy in the human family normally lasts from 275 to 280 days, and the approximate date of confinement can be obtained by the following convenient rules:

1. Take the first day of the last menstruation, count back three months and add seven days.

2. Or, assuming that quickening occurs at the seventeenth week, count ahead twenty-two weeks from the day on which quickening was observed.

3. Or, count two weeks from the day of lightening.

4. Or, with a pelvimeter, get the length of the fœtus by Ahlfeld’s rule (measure from symphysis to breech of child, subtract two cm. for thickness of abdominal wall and multiply by two. The result is the length of the child in centimeters) and compare with fifty centimeters, which is the average length of a mature child. After the seventh month, the child in utero grows at the rate of about 1 cm. a week (0.9 cm.).

5. Or, by the tape, according to Spiegelberg’s standard of growth, as previously mentioned.

The hygienic rules to be observed during pregnancy are founded on three basic principles: (1) To watch attentively the different organs and see that they functionate normally; (2) To eliminate all those conditions that favor the premature expulsion of the egg; and (3) To provide, so far as possible, for the normal gestation and the physiological delivery of the child. These factors will be taken up in detail.

The Diet.—The appetite is usually somewhat increased, but it is unnecessary to indulge the stomach on the ground that the mother “must eat for two.” Longings, however, should be gratified so far as the demand is not for unwholesome things. Food should be simple and plainly cooked. Meat is permitted in moderation unless some organic change exists to contraindicate it. Rich pastries and gravies should be avoided, but cereals, fruits and vegetables should be used in abundance. It may be better to eat four times a day instead of three. Fluids should be taken freely, from one to two quarts daily. Milk is especially valuable, and alkaline, natural and charged waters, such as Vichy and seltzer, are useful. Wine, beer and other alcohols should not be taken, or if the patient is habituated to their use, the amount should be restricted on account of danger to the pregnancy and danger to the child.

In contracted pelves it is sometimes desired to furnish a special diet, with the idea of controlling the size of the child (see Prochownick’s Diet, p. [332]) but this is an emergency. Certain books on maternity, designed for popular reading, advocate diets that are supposed, by depriving the child of lime salts, to keep its bones soft and make the labor easy. If it succeeds, the child will be injuriously affected. If it does not succeed, the claim is false.

Exercise.—Exercise should be taken, but it should not be violent, nor attended by risk. Golf, swimming, tennis, dancing, horseback or bicycle riding and fast driving in automobiles should be forbidden, lest abortion follow. General exhaustion must be avoided and all conditions that even approximate traumatism. Walking and slow driving are best, and housework is excellent up to a mild degree of fatigue. Travel should be restricted. If exercise is not feasible, massage will furnish the required stimulation to the circulation. The menstrual epochs are peculiarly favorable to abortive influences.

The Bowels.—Most women have a tendency to constipation during pregnancy. Many times this can be corrected by increasing the “roughening” in the food; more vegetables and fruits, bran bread and muffins, whole wheat bread, spinach, beans, carrots, turnips, peas and especially potatoes, baked and eaten, skin and all. Prunes, figs, and dates are valuable aids. Agar may be eaten three or four times daily. Russian oil (liquid petrolatum), taken in tablespoon doses three times daily, is an adjuvant, and finally, some form of cascara or aperient pill may be taken, if necessary.

Violent cathartics should not be used at all, and enemas as little as possible; only when quick results are necessary.

Heartburn.—Heartburn is a frequent complication, especially in the later months. It is due to an inordinate secretion of acid in the stomach. Soda mint tablets, bicarbonate of soda, and magnesia, in cake or as milk of magnesia, will relieve. The magnesia is also a laxative.

The kidneys require particular care during pregnancy, and in every case the urine should be examined monthly, up to the fifth month, and every two weeks thereafter, until the last six weeks, when a weekly test should be made.

The amount passed in twenty-four hours should be measured. Three pints is an average quantity. Albumin, sugar, and casts must be looked for and reported. Albumin may or may not be a serious symptom. Casts are significant of nephritis and indicate danger. Sugar may be lactose and be derived from the milk secreted in the breast. Edema of feet, hands and eyelids must always be investigated, with the possibility in mind, of heart and kidney lesions. Blindness, dizzy spells, headaches and spots before the eyes are always alarming symptoms until their innocence is established.

Through constant watchfulness of the urine, many cases of eclampsia may be averted.

Bathing is more important in pregnancy than at other times. The more the skin secretes, the less the burden on the kidneys. The skin must be kept warm, clean, and active. Then again, during pregnancy the skin is often unusually sensitive and only the mildest soaps and blandest applications can be used. The water must be neither hot nor cold, but just a comfortable temperature. Cold bathing, whether shower, plunge, or sitz, must be denied. Sea bathing is also unwise. The warm tub bath of plain water or with bran answers all conditions until the expected labor is near, then the warm shower or sponge bath should be substituted, lest germs from the bath water enter the vagina.

If the kidneys need aid, a hot pack may be used; but in all cases, frequent rubbing of the skin with a coarse towel should follow the bath.

The dress must be warm, loose, simple and suspended from the shoulders. To prevent chilling, wool or silk, or a mixture of both, should be worn next to the skin,—light in summer and heavy in winter.

The patient must be sensibly clad in broad, loose, low-heeled shoes. There should be no constriction about chest or abdomen. Circular garters must not be worn. If a corset is insisted upon, it must support the abdomen from below and lift it up. No corset is admissible that pushes down on the abdomen. This is especially true if the woman has borne one or more children and has a pendulous abdomen. The breasts may get heavy and require the rest and ease supplied by a properly fitting bust supporter.

Fainting is an annoying symptom in some women. It may come when quickening is first perceived, or from the excitement of crowds, or from hysteria. It usually passes quickly. The pallor is not deep, the pulse is not affected, and consciousness is not lost. It does not affect the ovum. Heart trouble should be excluded, and the daily habits of dress, diet, and bowels investigated. Smelling salts will usually suffice for the attack.

The abdominal walls may be strengthened by appropriate exercise before and after gestation, so that the muscles will preserve their tone. After delivery nursing the child will help greatly in the preservation of the waist line and figure, by aiding involution.

About the seventh month in primiparas, the abdomen gets very tense and in places the skin is stretched until it gives way and forms striæ. This tightness can be relieved to a considerable degree by inunctions of cocoanut oil or albolene.

Pain in the abdomen at this time may be due to mechanical distention, to strain on the muscles, to stretching of operative adhesions, to gas, constipation, or appendicitis. The physician should be informed of it. In every case, constipation, swelling of feet, hands or eyelids, blurring of vision, ringing in the ears, vomiting, persistent backache, or the passage of blood, no matter how slight, should be reported to the doctor.

The Breasts.—There should be no pressure on the glands and they should be warmly covered. The nipples must be kept clean and soft by soap and water, and about a month before the labor is expected, the nipple should be anointed with albolene or cocoanut oil and rubbed and pulled for a few minutes every night. This removes the crusts and dried secretions that collect on the nipple and prepare it for the macerating action of the baby’s mouth. No alcohol or strongly astringent washes should be used. Injuries must be avoided. If the nipples become tender they may be protected from external irritation by the lead nipple shield or by a wooden shield with a hollow center, such as Williams recommends.

Leucorrhœa.—This is one of the commonest discomforts of pregnancy, and the sense of uncleanliness, if the discharge is excessive, as well as the resulting irritation, may demand attention. It must be kept in mind, however, that the normal vaginal discharge of a healthy pregnant woman is strongly germicidal and should not be douched away without definite indications.

Vaginal douches of warm boric acid solution will do for cleanliness, but the douche bag must not be higher than the waist. Stronger and more antiseptic solutions are potassium permanganate 1:5000, or chinosol 1:1000. A suppository may be used, consisting of extract belladonna, gr. ss; tannic acid, gr. v, and boroglyceride dr. ss.

Sexual intercourse is distasteful to most pregnant women, but sometimes the inclination is intensified.

Coitus often causes much pelvic discomfort and may be an influential factor in producing abortion. It should be forbidden during the early months, at all menstrual epochs, and for at least two weeks before labor. The uterus may be infected by germs beneath the foreskin and hæmorrhage may follow the act if the placenta is low. In healthy persons, at the instance of the female, intercourse in moderation is permissible.

The mental condition should be placid without either excitement or fatigue. Anxiety should be dissipated by cheerful company and surroundings. Judicious amusement is desirable and a congenial occupation, but neighbors who tell frightful tales of disaster in labor, or nurses who relate the details of their critical cases, are equally to be avoided.

Many women of neurotic temperament dread the labor desperately. They are sure that death impends and they dwell with tragic interest on the stories of complicated cases related by thoughtless or malicious neighbors. The nurse can do much to allay these apprehensions by cheerfulness, optimism, and gentleness. Her buoyant temperament will drive away the patient’s fears just as effectively as the assurances of the physician.

Great allowances must be made for attacks of irritability, for the changes going on in the woman’s pelvis keep her in a capricious and whimsical condition. A good book to read at this time is, the “Prospective Mother,” by Slemons.

The subject of maternal impressions is the cause of much anxiety during pregnancy. It is safe to assure the mother that it is nearly impossible to mark her child by emotional stress. There is no demonstrable nervous communication between mother and child, and most of the deformities that occur and are attributable to shock, etc., can be explained by our knowledge of intrauterine changes. Furthermore, the same deformities occur in lower animals, to which it is difficult to ascribe such high nervous organization.

Many of the birthmarks, supposedly due to shock, occur too late in the pregnancy to affect the child, even if it were possible, for the child is completely formed before the fourteenth week.

The Determination of Sex.—It is not possible to know in advance of delivery whether the child will be a male or a female. It is equally impossible to determine or even to influence the sex of the coming child. Many theories have been advanced, and much talent has been wasted in trying to solve this problem.

Reasoning by analogy from the facts obtained from lower animals, the sex of the child is unalterably decided the moment conception occurs. The responsibility for the decisions seems to lie with the male cell. All we really know is that the sexes appear in the ratio of 100 girls to 106 boys.

CHAPTER V
ABNORMAL PREGNANCY

After the diagnosis of pregnancy has been satisfactorily established, no further internal examinations are necessary in the absence of special indications, until about the thirtieth week.

At this time a series of complete physical examinations may be required to determine the presentation and position of the child, the presence and rate of fœtal heart tones, the diameters of the head, the length and approximate maturity of the child, as well as the condition of the bony and soft passages of the mother.

It is thus that an appreciation of the obstetrical problem is secured and a course laid out for its successful solution.

Pregnancy is not a disease, but a normal function; but the woman is exposed, nevertheless, to many grave risks that are peculiar to her condition and to many complications accidental or otherwise which are more serious on account of her pregnancy.

The Toxæmias.—The growing ovum brings about changes in the maternal metabolism that are manifested by characteristic symptoms which in other better known conditions are recognized as due to toxæmia. Therefore, while there is no positive proof as yet that these symptoms, arising during pregnancy, are toxæmic in origin, the evidence goes to show that they are; and, therefore, should be classified as toxic.

Postmortem findings in eclampsia and pernicious vomiting such as extensive thromboses, cell necrosis, and interstitial hæmorrhages are very suggestive.