IN one essential particular, the case of the modern woman differs widely from that of our grandmothers. Childbed fever, blood poisoning, and other similar germ diseases, have been from time immemorial the bete noire of the lying in chamber, and the odium of the medical profession. Since the discovery by Sir Joseph Lister, of England, that these diseases were caused by the introduction of germ bacilli into the living tissue, and that to prevent them it is only necessary to kill these germs on all things which in any way come in contact with the mother's private parts, these diseases have become very much less frequent in occurrence, and much less fatal. We know now that the skin and vagina even normally contain living germs which act as scavengers of dirt, and exert a beneficial influence on health, so long as they remain in their natural abodes; let them, however, be introduced into the system through raw surfaces, tears and excoriations consequent on labor, and the group of symptoms generated by this poison is truly frightful to think of.
To avert such catastrophes, it must be the aim of the physician and nurse, and even the patient, to use scrupulous care in keeping away from the patient anything which has not first been rendered absolutely clean or germ free.
It thus becomes evident that, first of all, as soon as labor sets in, the thighs and privates should be thoroughly washed with soap and some antiseptic, as, for instance, a five per cent solution of carbolic, acid, or better, sulpho naphthol solution, which may be made by adding one half teaspoonful of sulpho naphthol, or “oil of milk," to a quart of water; better still is a solution of corrosive sublimate of the strength of one part in two or three thousand parts of water. This poisonous drug is best bought in tablet form, so that by adding one tablet to two quarts of water, we have the required solution. During labor, and even after, all napkins and cloths used to protect or wipe the woman. must be wet in one of these solutions, or otherwise disinfected. Every examination by the physician or nurse must be made only after thorough scrubbing of the hands with soap and some disinfectant. The napkins used may either be wrung out of these solutions, or steamed an hour before using.
By such precautions we may expect to avoid blood poisoning. The nurse must always wash and disinfect her hands before giving a douche or handling the patient's private parts. The douche is always a source of vexation to nurses, and the matter may here be thus stated: unless there has been given an order by the physician to the contrary, never use a douche after the baby is born.
Remember the principle of always keeping surgically clean, i. e. germ free, all objects which come in contact with the lying in woman.
The Presentation. An examination with the finger is to be made to learn the presentation, that is, to learn which part of the child comes first into the mouth of the womb.
Head Presentation. If the head present, the labor will probably go on without the need of medical aid. But in all labors there is a liability to dangers from unforeseen accidents, which renders the attendance of an intelligent physician highly prudential.
Breech or Feet Presentation. If the feet or breech present, it is desirable to have the first part of the labor proceed slowly, so that the passage may become well dilated, and prepared for a more rapid delivery of the head. If the breech present, do not pull down the feet; let the child come double; it will make more room for the head. If the feet present, let there be no pulling upon them to hasten the birth of the breech.
After the feet and breech have fully cleared the external orifice, the delivery may be judiciously hastened for the purpose of preventing the death of the child from pressure on the umbilical cord, before its head is brought to the air, and the act of breathing thus permitted. For after the pulsations of the cord cease, the child must either breathe or die.
In this kind of presentation, therefore, the child's life is in great danger. After the birth of the lower half of the body, the cord experiences severe pressure, sufficient to interrupt if not wholly prevent its pulsations. It then becomes necessary to hasten the birth of the upper extremities and head by all prudent means. Violence is never in order in midwifery; but considerable force, skillfully directed, may sometimes be safely used. After the shoulders are delivered, the passage of the head may be facilitated by carefully pulling down the arms. Then, as soon as possible, introduce the finger into the mouth of the child. This will serve the double purpose, perhaps, of permitting a little air to make its way into the child's lungs, and of furnishing a hold by which its head may be gently drawn along into the world.
If there is much delay at this juncture, perhaps in some cases the child's life may be preserved by inserting into its mouth one end of a male catheter, thus furnishing an open tube for the passage of air, until more vigorous pains shall introduce it into the full liberty of the atmosphere. While the head is yet undelivered, great care should be used to keep the child's body warm by covering it with flannel, and also to keep it in a correct relative position with the head. If the body be incautiously turned round, of course the neck will be twisted; and the child's subsequent delivery with a broken neck will be the miserable result, bringing confusion to the medical attendant, and unhappiness to all concerned.
Arm or Shoulder Presentation. If the arm or shoulder present, the child will probably have to be turned. In case this cannot be effected, its chest must be opened and emptied of its contents, that there may be room to bring down the head. It is barely possible to avoid a resort to art in this presentation.
Flooding or Hemorrhage, occurring to an alarming extent, is happily one of the rare incidents or consequences of labor. But when it does occur, it demands the most serious and prompt attention.
Profuse bleeding from the womb is most commonly owing to a partial separation of the placenta, or afterbirth, from its attachment to the internal cavity; and it has been’ observed that the flow proceeds more rapidly from the detached portion of the afterbirth than from the corresponding exposed surface of the womb. A knowledge of this fact has an important practical bearing; for if, in severe cases of flooding, the partially detached afterbirth can be entirely separated, the bleeding will often be speedily arrested.
The most dangerous floodings occur in cases of placenta previa, when the afterbirth is over the mouth of the womb. In such cases, when the labor commences, and the womb begins to open itself, the afterbirth of course must be partially separated. These cases, unless promptly relieved by art, may prove fatal in a few minutes. Yet there is ordinarily sufficient time, if it be improved, calmly to choose and pursue the proper treatment. If the flooding be immediately dangerous to life, the child must be turned and delivered, or the tampon or plug be applied, as directed under the head of abortion. This expedient is used when, through rigidity of the mouth of the womb, the delivery is inadmissible.
Before Delivery. In all cases of flooding, we prescribe quiet, the recumbent posture, cold applications to the abdomen and to the external genitals and to the internal administration of astringents and anodynes (152)
After Delivery, our object is to promote contraction of the womb by cold applications and frictions externally, or, if necessary, by the introduction of the hand into the womb, for the purpose of removing the afterbirth, clearing out clots, or stimulating it to shut itself up for the expulsion of the offending substance. Until this contraction is secured, the plug should not be used, lest internal bleeding into the enlarged and expanded womb should be profuse, and fatally exhaust the patient.
After the Child is Born, our first duty is, if possible, to see that it breathes. In the vast majority of cases, the well known cry which salutes the ear gives proof that the duty is unnecessary. But sometimes we do not hear the welcome sound. The umbilical cord may be once or repeatedly wound around the child's neck, and must be immediately removed to prevent strangulation; or, the child's mouth may be filled with phlegm, or some sticky mucus, which must be poked out with the finger, and its exit favored by turning the face downward; or, after tedious labors, the child may be born in a very feeble state, and may need the stimulus of cold water thrown suddenly, in small quantities, upon its chest and body, with considerable rubbing, and perhaps the inflation of its lungs with air blown into its mouth.
Tying the Cord. When breathing is established, a piece of narrow tape or common twine is to be tied tight around the navel string, about two inches from the child's navel, and the cord is then to be cut off, with a pair of sharp scissors, from half to three quarters of an inch outside the place where it is tied. The child is then to be delivered to the nurse.
The cord should be tied twice; the first about two inches from the child's body and again an inch and a half farther away. The cord is then cut between the two places. The object of the first tie is, of course, to prevent the child bleeding to death. The second is to prevent the blood from the after birth or placenta soiling everything about the bed.
Washing the Child. The child is now, while the physician is at,. tending to the mother, to be washed and dressed by the nurse. Its skin is at this time covered with a suet like substance, called the vernix caseosa. To remove this, a coat of warm sweet oil or lard may be lightly rubbed and mixed with this substance and then washed off with warm water and castile soap. It is not material that this coating should be absolutely all removed at the first washing; but the soap and water should be again gently applied in eight or ten hours from their first use. It is improper to use spirits for this cleansing. All rough rubbing must be avoided as injurious to the delicate skin of so tender an infant. Washing with cold water would lower the temperature to a dangerous degree, and should in no case be allowed.
Removal of the After Birth. The woman having rested fifteen or twenty minutes, a little gentle soliciting or pressure on the womb will generally bring away the after birth. If, however, any serious obstacle prevent its expulsion, it may be slowly and cautiously taken away by the hand introduced.
Cleansing the Bed, and Applying the Swathe. Upon the removal of the afterbirth, a disinfected napkin is immediately applied to the external organs, a drink of water or tea administered, and another rest of an hour or more allowed. The swathe may consist of a towel pinned snugly around the body, or of a cloth, cut and fitted exactly for the purpose. Its object is to afford a firm and steady support to the contracting womb.
The Dressings for the Child's Navel should be so fixed that the navel string or cord will not be left in contact with the healthy skirl To effect this, make a hole large enough to admit the cord in the centre of a piece of linen cloth four inches square; pull the cord through this hole, leaving the cloth lying flat upon the child's belly; then, having bandaged the cord down to the belly, fold the cloth over it, and apply the belly. band. The interposition of these dressings will thus keep the cord, which is dead and in process of decomposition, from irritating, and perhaps excoriating the living flesh, with which it must otherwise be in close contact. To wrap the stump of the cord in fresh absorbent cotton is another neat, dry, and practical method of treating it.
Never try to hasten the dropping of the cord if it occurs within a reasonable time, and from four to ten days may be expected to elapse before this event takes place. If pus appears, it shows that infective germs have gained entrance since the birth of the child, and a mild antiseptic dressing must be kept on or inflammation may strike in and the child die of blood poison.
Nourishment of the Child, etc. After being dressed, the child should be kept next the body of the mother or nurse, that it may receive the natural warmth thus to be derived. Its nourishment should be obtained exclusively from the mother's breast. If it is hungry, be sure and keep it so. There is nothing more appropriate than a hungry child all ready to take hold and exhaust the full and almost bursting breast on the third day, when the milk has come. Alas! How many children have been fed on sweetened water, and on milk and water, till they have lost all instinctive idea of, and an appetite for, nursing I and how many bowel complaints and broken breasts have been the miserable consequence I But meddlesome friends are afraid the 11 little dears " will starve ; and therefore they must first be made sick by unnatural diet, and then for their cure be treated to that fifthly, harsh, and indecent substitute for medicine, chamber lye and molasses!
But it maybe asked, “must not the child be fed at all, if it is hungry, and cries a great deal, and there is nothing in the mother's breast for it?" Such cases will be exceedingly rare, if the breasts have been properly solicited from the first by a hungry child. When they do occur, being themselves exceptions, their treatment must be exceptional; but, even then, only so far as is absolutely necessary. If fed at all, the child should not be fed to satiety, but as little as the circumstances will possibly permit. The great rule remains: keep the child as hungry as possible till the milk comes. When it has to be fed, imitate the mother's milk as nearly as possible in the preparation of the artificial diet. A little sweet cream, warm water and sugar, should be so mingled, that in warmth, richness, and sweetness, the mixture may closely resemble human milk. (See page 486.)
Diet of the Mother. For the first few days after confinement., the most appropriate diet for the mother is gruel, cocoa, rice water, crust coffee, or some similar liquid nourishment. Different constitutions, however, need somewhat different management.
A woman naturally robust, and of full habit, should confine herself more strictly, and for a longer time, to this light diet, than one who is more slender and feeble. In some cases, weakly women require the juice of meat, and even wine or ale, as early as the second or third day. If she be subject to canker, or nursing sore mouth, a generous diet is particularly serviceable. After the first week, she may gradually return to her customary diet.
Costiveness may be treated with the usual remedies. It was an old rule to give a dose of castor oil on the third day, when there is a little increase of excitement in the system, from the filling of the breasts. This is not always necessary, and in most cases an injection would be far better. The mother should stay in bed from three to four weeks, according to the state of her general health. A little time now is a great gain later.
The Perpendicular Position. During the first month, let the woman avoid being often or long on her feet. This is a very essential caution to avoid prolapsus, or falling of the womb, with all its attendant. weaknesses and pains, and to ensure a good 11 getting up," with a sound womb, in the right place, and subsequent months of health and enjoyment,
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