OBSTETRICS.

Puberty.—This is the period of transformation from childhood to adolescence. There is a marked development of the throat and chest, the breasts become fuller, more rounded, and there is also an enlargement of the pelvis. These outward signs are combined with certain internal changes, affecting especially the ovaries and the uterus, that are described under the terms of ovulation and menstruation.

Ovulation.—The ovaries produce ova that are retained in cavities termed ovisacs (Graafian follicles), which are scattered throughout the ovary. Sometimes an ovisac contains more than one ovum, but usually each ovisac contains but one. When the ovary becomes functionally active, some of the ovisacs in the deeper part of the organ increase in size and develop toward the surface. From time to time one of these ovisacs, having continued to increase in size so as to form a projection on the surface of the ovary, actually bursts and sets free an ovum. This frequently occurs in association with menstruation, but may take place at other periods. While this development of the ovisac has been taking place there is a special flow of blood to the pelvic contents, and the fringe-like processes of the Fallopian tube become more closely applied, so that a cup is formed by the fimbriated extremity of the Fallopian tube, into which the ovum drops. Eventually the ovum reaches the cavity of the uterus, and, unless it becomes fertilized or impregnated, it is in due course cast off from the uterus in the menstrual discharge and perishes.

When the uterus has become the seat of a fertilized ovum there is no further ripening of ovisacs. After the escape of an ovum from the ovisac the follicle is filled with blood, and this takes part in the formation of a structure known as the corpus luteum, which is formed within the burst ovisac. The corpus luteum varies in its development according as the ovum becomes fertilized or not. If pregnancy takes place it remains to its close, but if the ovum is not fertilized it disappears in about three months. The ruptured ovisac always contains the elements of a corpus luteum, but its development depends on the fate of the ovum. Ovulation has been said to commence before menstruation; ovisacs may sometimes ripen and burst in childhood. Conception may take place before menstruation has set in.

Menstruation.—The blood is derived from the mucous membrane of the uterus (endometrium) and not from that of the cervix. The endometrium becomes swollen and thickened prior to the commencement of the flow, and the blood-vessels are distended. With the beginning of the flow this swelling gradually diminishes. A few superficial cells of the endometrium are usually cast off during menstruation, and this is regenerated during the interval between the periods. The mucous membrane of the uterus is thus never at rest until menstruation ceases for good.

Conception.—Fertilization of the ovum may occur anywhere in its course from the ovisac to the uterus, but ordinarily it takes place in the uterus. Certain changes take place in the uterus preparatory to the arrival of the fertilized ovum. The whole organ enlarges, it contains more blood than before; the mucous membrane becomes soft, spongy, thickens greatly, and is thrown into folds which are called the decidua vera.

Decidua Vera.—The part of the decidua vera to which the ovum becomes attached and where the placenta afterward forms is called the decidua serotina. The presence of the ovum acts as an irritant to the spot where it lodges, and active growth takes place. At the same time the ovum burrows into the mucosa and gradually becomes embedded. The vera closes over the ovum. The decidua vera is a mold of the interior of the uterus. The external surface is rough where it has been torn from the underlying tissues of the uterus, and the internal aspect which is in contact with the ovum is smooth. It is thickest at the third month; after this time the membrane becomes thinner and thinner, until by the end of pregnancy it is very thin. It is to a considerable extent expelled at labor and forms part of the membranes.

Ovum.—As the ovum develops the decidua reflexa expands until it fills the decidua vera at the end of the second month, and by the end of the third month it has intimately united with the decidua vera to form one membrane. Until these two membranes have coalesced the ovum is not free in the uterine cavity, but is enclosed in the decidua reflexa.

Pregnant Uterus.—As pregnancy proceeds the uterus ceases to be a pelvic organ; it becomes rounded, and after the sixth month gradually assumes an ovoid shape. At the end of the third month it has reached to the brim of the pelvis. By the sixth month it is level with the umbilicus, and by the ninth it has reached to the tip of the sternum. During the last fortnight the organ sinks a little, and this relieves to some extent the shortness of breath which has been caused by the pressure on the diaphragm.

Fetal Membranes.—Inside of the decidual membranes we find the chorion and amnion. Whereas the deciduæ are maternal structures, the chorion and the amnion are derived from the ovum. The chorion is the more external of the two fetal membranes; it early surrounds the ovum and throws out processes (villi) toward the decidua reflexa and serotina. These processes are at first formed equally all over the chorion, but those which lie in connection with the decidua serotina grow more rapidly in size and complexity, and remain to form the main part of the placenta. The membrane in which the fetus lies is the amnion. Contained within the amnion is more or less fluid, the liquor amnii, in which the fetus rests as in a water-bed. It permits free movements on the part of the fetus and protects it from violence from the outside; it equalizes the pressure on the uterine walls, preventing pressure on the cord and placenta; and during labor it assists in the dilation of the os uteri and lubricates the maternal passages. From it also the fetus derives its supply of water. Occasionally water may form between the three membranes, and during labor the chorion may rupture and not the amnion, and the waters between them be discharged. In like manner, water which has formed between the decidua and the chorion may come away. These, then, are two sources of fluid which may be discharged from the vagina in labor when the amnion is intact.

Umbilical Cord.—The organ by which the fetus is attached to the uterus is a whitish, glistening structure which springs from the fetus at the center of the abdomen, and passes to the internal aspect of the placenta. It contains two arteries and one vein surrounded by a gelatinous material (Wharton’s jelly), the whole being covered with a layer derived from the amnion. The vessels usually run tortuously in the cord, thus lessening the danger of compression, which might otherwise occur. This arrangement also tends to regulate and equalize the circulation of the blood through its vessels.

Placenta.—The “after-birth” is a spongy cavernous organ and has a circumference of from 20 to 24 inches. It is made up of two elements, fetal and maternal, chiefly the former. The fetal surface, to which the umbilical cord is attached, is formed by the amnion. External to the latter is the chorionic tissue, consisting mainly of finger-like processes of villi, many of which extend to the decidua. These villi are mostly vascularized. The vascular villus is made of a capillary loop, lying embedded in a connective tissue, the blood-vessels being derived from the umbilical vessels. The villi are surrounded by maternal blood, which circulates in the intervillous spaces. The maternal part is represented by the decidua serotina. Its surface is rough and irregular, being broken up into segments or cotyledons. It is made of two layers: (a) The deep or spongy layer, and (b) the compact, or layer to which the villi are attached. The decidua serotina contains large cavities or sinuses, which are formed by a dilation of the blood-vessels in the wall of the uterus. They communicate with the intervillous spaces of the placenta, and it is through the maternal blood circulating in them that nutriment is conveyed to the fetus through the medium of the villi. An interchange takes place between the fetal and maternal bloodstreams, though, of course, there is no direct continuity between them. The placenta thus has a two-fold function in acting both as an organ of circulation and of respiration. It is through the walls of the villi that this interchange of gases and fluids takes place; nourishment and oxygen passing through them to the fetus, and carbonic-acid gas and waste materials passing through them to the mother. There is no direct communication between the fetal and the maternal blood. The placenta, normally, is attached to the contractile part of the uterus, and on its separation the blood-vessels are closed by the contractions of the uterine wall. The placenta may be divided into two or more portions, or one or more of its cotyledons may be detached from the rest of the organ and have their own vascular supply. The importance of this lies in the fact that after the placenta is expelled these isolated masses may be left and give rise to hemorrhage or blood-poisoning.

SYMPTOMS OF PREGNANCY.

Suppression of the Menses.—The cessation of the periods may be due to other causes, but it is usually the first indication of pregnancy. Conception may take place and menstruation yet continue. It usually occurs but once or twice, and then only where conception took place immediately before an expected period.

Morning Sickness.—Nausea and vomiting continued for any length of time is almost a certain sign of pregnancy. It may begin as soon as conception takes place and last for many months; sometimes it may occur toward the end of pregnancy, or occasionally not at all.

Salivation.—The excessive secretion of saliva often accompanies the morning sickness. The secretion is tenacious and difficult of expectoration. Heartburn, abnormal appetite, longing or loathing for particular articles of food, toothache and the like may be present.

Quickening.—The first feeling of fetal life felt by the mother is usually between the fourth and fifth months, but may be experienced occasionally as early as the third month, or be deferred until the sixth. Quickening occurs as soon as the uterus comes in contact with the abdominal wall. Improper elimination of the bowels, causing gastro-intestinal trouble, may produce movements not unlike this indication; therefore, this symptom is not reliable.

Enlargement of the Breasts.—The breasts grow larger toward the end of the second month. In some cases the enlargement is very marked, but in others there is scarcely any increase in size during the whole term of pregnancy.

Pigmentation.—Coloring of the skin takes place in different parts of the body. The face may show brownish spots. The skin darkens in the axilla and in the areola of the breasts. A dark line presents itself down the middle of the abdomen. The vagina takes on a violet tint, the cervix becomes purple, the various colors becoming more marked with the progress of pregnancy.

Changes in the Abdomen.—The abdomen grows larger gradually, and with it the gait and carriage of the woman change, to counterbalance the weight of the abdomen. It enlarges symmetrically unless the uterus is displaced by adhesions, or by a tumor in the uterus or external to it. The tearing of the under layer of the skin of the abdomen while distended produces streaks (stria), first pink and then white, which remain after the form resumes its natural shape; any other enlargement of the abdomen, especially when caused by a tumor, may produce the same result. The various conditions mistaken for pregnancy, due to changes in the abdomen, are fibroid in uterus; metritis; swelling of the tubes and ovaries, distended bladder, a pendulous belly; excessive fat; extra-uterine pregnancy; and inflammatory conditions, such as peritonitis. Pregnancy and any of the conditions named may coexist, and the former may be overlooked, while the latter is recognized.

Fetal Heartbeat.—The heart sounds are generally audible between the fourth and fifth months. The rate is from 120-140 a minute, being double that of the mother’s pulse. About midterm is heard the uterine souffle, a blowing sound, quite unlike the fetal heart, and its origin is the rushing of the blood through the enlarged and twisted arteries.

Ballottement.—In normal cases there is no pain on palpation. The uterine wall varies in consistence, being alternately soft and firm. The fetal parts may be felt through the abdominal wall in the late months.

Lightening.—In the last two weeks, especially in primiparæ, the child’s head sinks into the pelvis, and its body falls a little forward. The uterus sinks down and forward with the child. The waist-line lowers, the stomach region is flatter, the navel more prominent. The patient breathes easier, but does not walk as well.

Duration of Pregnancy.—Average time is 280 days; protracted, 314; a short term about 245 days. There is no positive period.

Prediction of the Date of Labor.—Count 9 calendar months from the beginning of the last menstruation and add 7 days. An error of 2 or 3 weeks, however, is possible. (See Table on page 178.)

Premonitory Symptoms of Labor.—(1) Lightening.—Dropping may be attended with slight pains similar to labor pains.

(2) False Pains.—These vary in nature and quality. They may be short and sharp, or long and continuous, or irregular. As a rule, they are marked by irregularity. They are mostly abdominal, rarely like true pains beginning in the sacral region and moving around to the region of the pubes. They may be caused by cramps in the abdominal wall, intestines, or in the distended bladder. They may be due to old inflammatory areas within the abdominal and pelvic cavities. They are frequent in cases in which there is marked bowel irregularity, and in conditions of over-fatigue. Some authors believe that they may be produced by irregular contractions of portions of the uterine wall. One important test is the condition of the uterine body during the pain. If there is no genuine contraction, the uterus will not become hard when pain is felt. This indication is not always reliable, however, since palpation may be unsatisfactory on account of the woman’s nervousness, her sensitiveness, or the thickness of the abdominal wall. If the cause be contractions of the uterus, partial hardening may be felt.

TABLE FOR CALCULATING THE PERIOD OF UTERO-GESTATION.

January 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

October 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 1 2 3 4 5 6 7 Nov.

February 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28

November 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 1 2 3 4 5 Dec.

March 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

December 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 1 2 3 4 5 Jan.

April 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30

January 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 1 2 3 4 Feb.

May 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

February 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 1 2 3 4 5 6 7 Mar.

June 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30

March 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 1 2 3 4 5 6 April.

July 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

April 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 1 2 3 4 5 6 7 May.

August 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

May 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 1 2 3 4 5 6 7 June.

September 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30

June 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 1 2 3 4 5 6 7 July.

October 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

July 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 1 2 3 4 5 6 7 Aug.

November 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30

August 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 1 2 3 4 5 6 Sept.

December 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

September 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 1 2 3 4 5 6 7 Oct.

Explanation.—Find in top line the date of menstruation, the figure below will indicate the date when confinement may be expected, i.e., if date of menstruation is June 1st, confinement may be expected on March 8th, or one day earlier if leap year. (Dr. Ely.)

(3) True Pains.—The contractions of the uterus as they become stronger, in the great majority of cases, cause the woman pain. For this reason “true pains” is used synonymously with “uterine contractions.” With their appearance the woman becomes restless, likes to sit down, to bend forward and to press on the sacrum. “True pains” are felt in the sacral region, gradually moving around toward the pubes. They begin slowly, increase in intensity, and slowly pass away. The pains are involuntary, and the woman tries to complain or cry out. Differences in this largely depend upon the nervous temperament of the patient, though they are also related to variations in the physical factors. “True pains” must be distinguished from “false pains.”

(4) The Show.—Within twenty-four hours before labor really begins there is a discharge from the vagina of thick mucus, more or less stained with blood. This is called the “show,” and is the plug of mucus which fills the cervical canal during pregnancy. Sometimes the show is absent or appears after labor has been in progress for awhile. If there is much pure blood with the discharge it is unusual, and the physician should be notified.

LABOR.

First Stage.—The first stage extends from the time of the labor pains to the complete dilatation of the os uteri. It may come on very slowly or act quickly. Slow dilatation occurs normally in a woman over thirty years of age; and it may be due to inflammatory conditions or appear in cases where the membranes lining the uterus are adherent. On examining the vagina there is found a bulging (which is a main factor in dilatation of the cervix) and a discharge of mucus tinged with blood. The dilatation increases until it is 4 in. across, and the bag of membranes bulges like a saucer. In abnormal cases it comes down into the vagina in the shape of a tube. When the os is fully dilated the membranes rupture, a rush of water escapes down the vagina, and the first stage of labor is ended. Not all of the water comes away, for the head comes down and acts as a plug. It is very important for the nurse to recognize the true rupture and not mistake it for incontinence of urine.

Second Stage.—This comprises the period from the time of complete dilatation of the cervix to the end of the expulsion of the child. The patient has some relief after the first stage, and when the second stage comes on she holds her breath and contracts the abdominal muscles as much as she can in making expulsive efforts. The pains become of longer duration and more frequent; and upon examining the vagina the head is found down, the tissues bulge, the rectum becomes stretched, the majora and minora separate, and then, while the pain is on, there is some change in the position of the head as it recedes and advances again. Nature brings it slowly, for if the head plunged down it might produce complete laceration of the perineum. If the head is delayed too long there is swelling of the scalp. The most painful period is when the head passes the perineum. Then there comes a marked change in the position of the fetus, and it lies in that position for some time; following, comes a rotation to one side, the shoulders turn, and birth occurs. The cord is still in the vagina, and the third stage begins with a flushing of amnii fluid. The placenta is still in place in the uterus. The child may cry, and the pulsation may continue in the cord for as long as fifteen minutes, but ordinarily for about five minutes, while a new circulation is established in the infant and more blood is drawn from the placenta.

Third Stage.—The patient has a rest for some minutes. Then the contractions of the uterus continue until the membranes and placenta are expelled. The pains begin again; the uterus is smaller, firm, yet will recoil; it is rounded, and the fundus lies even with the umbilicus. If the fundus is above the umbilicus something is wrong. Painful contractions of the uterus follow and cause a squeezing off of the placenta. There is a flow of blood, the placenta follows, passes out of the vagina, dragging the membranes after it. The fundus sinks, and the uterus, hard, contracted and firm, lies in the pelvis. In some cases it becomes soft, rises up and then relaxes. If it becomes too soft, the relaxation which follows may induce hemorrhage. The uterus should be carefully massaged until it hardens.

Period of Labor.—Fourteen hours is a normal range. First stage usually lasts about twelve hours; second stage about one hour, and the third stage from fifteen to thirty minutes.

Complications of Labor.—Labor may be brought on by extreme mental anxiety. The child may be born without any actual pain. It may be expelled while the patient has an evacuation of the bowels, especially if the bowel movement has been induced by enemata or a purgative. Children may be born without the usual progression of labor, yet with all normal conditions present. In cases where the mother dies during labor the uterus continues to contract until the child is born about fifteen minutes later. The child in such cases is sometimes saved by a Cesarean section.

CARE OF THE OBSTETRIC PATIENT.

Diet.—Diet should be regulated and consist of light, nutritious and predigested foods. Milk should be prepared in various ways palatable to the patient. Wine and fruits and vegetables in season may be included. For malnutritious patients, malt and beef extracts may be added. Starches prepared in fat, and rich pastries should be avoided.

Elimination.—The bowels must move regularly, and laxatives may be given if necessary. Alkalies should be given before bedtime, and effervescent powders in the morning. Enemata should not be resorted to unless absolutely necessary, as the sudden expulsion of the contents may produce abortion. The kidneys may be regulated by giving simple diuretics; plenty of pure water is the best. The condition of the kidneys is a most important factor in pregnancy. The urine should be clear and of sufficient quantity. Meats should be eaten but sparingly, as they over-produce albumin.

Baths.—Daily bathing in tepid water is very essential to encourage the elimination through the skin and to promote cleanliness. A cold sponge is stimulating and very agreeable to some patients.

Exercise.—Exercise should be moderate. Light work about the home may be encouraged, care being had to avoid over-lifting, over-reaching, etc. Walking should be insisted upon, to maintain correct carriage and posture of the body. Outdoor enjoyments may be had if indulged in with discretion. Tiredness may be overcome by the patient lying down on an incline, the head lower than the body, thereby relieving all tension of the muscles and nerves. Any recumbent position for comfort is beneficial.

Breasts and Nipples.—Plenty of room should be given to permit full growth and to encourage the nipples to prominence. Their inversion or depression may be remedied by massage and manipulation. No alcohol or other strongly astringent washes should be used. The nipples must not be hardened, but should be kept soft and pliable; cocoa-butter or other healing ointments may be applied. Cracks and fissures not only render nursing difficult or impossible, but may lead to mastitis and subsequent abscess formations. There should be perfect cleanliness, to promote pure secretion and prevent sepsis.

Pelvic Organs.—Pelvic organs do not, under normal conditions, require douches. The normal vagina cleanses itself, and a hot douche may induce abortion.

LYING-IN PERIOD.

Confinement Room.—A quiet room should be selected, in which there has been no recent sickness and which is not in proximity to any sewerage. The room should be well ventilated, with no draughts, and at a temperature from 65°-75° F. The furnishings should be plain and few as possible. They should consist of a table or two, a few chairs, and a narrow iron bed of medium height. If the bedspring is soft, a few boards may be placed under it to make it firm. If the patient is to be delivered in bed, it should be made up as follows: (1) Long rubber sheet; (2) long muslin sheet; (3) rubber draw-sheet; (4) muslin draw-sheet; (5) a large pad, 3 ft. square and 3 in. thick. All sheets should be fastened with large safety-pins, and the pad left free to draw the patient to either side, if the bed is of the low-and-wide variety commonly used in many homes. The ideal way is to deliver the patient on a settee, or on two tables, covered with a small mattress; the physicians and nurses have less work to do and they work to a better advantage. Moreover, when the patient is carried from the table to her clean, warm bed she gets immediate comfort and avoids the usual disturbance and uncleanliness attending the clearing away of soiled linen, etc.

Preparatory Treatment for Patient.—The patient should have a warm bath, and the genitals should be scrubbed thoroughly with soap and water. Shaving the parts is much to be desired if the patient has no objection, then an antiseptic pad should be applied. The nurse must be sure the bladder is empty; it is very important that a dribbling from an over-distended bladder should not be mistaken for frequent urinations; this is to prevent the danger of ruptured bladder from the constant pressure of a contracting uterus; also a distended bladder makes labor hard by interfering with the passage of the head.

During the First Stage.—The patient may be out of bed and encouraged to take exercise. She should not walk about too freely before the head is engaged, lest this induce a malpresentation or malposition. The patient’s crying should not be prevented, and she should be told not to press down. She may have a cup of hot water or tea, but no stimulant, as an anesthetic may become necessary.

During the Second Stage.—All clothing should be removed but the night-dress. Pin the gown up under the arm, put on perineal drawers, and a sheet around the body, then place the patient in bed. The pain in the back may be relieved by pressure over the sacrum, and the patient should be encouraged to hold her breath. The nurse should now use tact to quiet the patient, having hitherto managed, if possible, to encourage calmness. For cramps in the limbs, the muscles may be moved and firm pressure applied. A handkerchief bound tightly around the affected part may relieve it. A sheet may be tied to either side of the bed, for the patient to grasp, and a block placed at the foot of the bed for a brace for her feet.

Patient After Labor.—The soiled skin should be gently and quickly bathed with warm solution, the vulva and perineum carefully cleansed and an antiseptic pad applied. The binder should be pinned firmly about and below the hips, allowing freedom over the upper part of the abdomen. If there is any anxiety that the uterus may relax after kneading it, a tightly folded towel may be placed over the fundus, and kept in position by the binder. A vaginal douche is never given without orders from the physician. External douches of lysol, 1 or 2 per cent., are given three or four times daily until the lochia becomes scant. The patient should be watched during the first few hours for symptoms of hemorrhage. The room should be kept quiet and dark, and light, warm covering be used on the bed. The patient may have a cup of hot water or milk to induce sleep and relieve thirst.

Diet.—During the first twelve hours the patient should be kept on liquid diet. On the second day, butter toast, milk toast, oyster stew, and chocolate may be added. On the third day, if the bowels move freely, soups, with rice or barley, and cereal foods may be given. Stewed fruits (omitting those strongly acid) may be included. After the fourth day, fresh fish, a chop, chicken, and pigeon may be given. Even after ordinary diet is ordered, heavy meats and rich pastry should be avoided for a while.

Bowels.—The bowels are usually constipated for the first few days. A dose of castor oil may be given, to be followed in six hours by a saline enema. The patient should be encouraged to drink freely of pure water, to secure proper elimination of the kidneys. If the patient can not urinate, after the different methods to produce urination have been tried, she may be catheterized. The urine should be measured for some days to ascertain if the quantity is sufficient.

Colostrum.—The first secretion in the breasts contains no nourishment, but is a laxative for the child. The baby should be put to the nipple as soon as the mother has had some sleep and feels rested. Nursing assists the uterine contractions, preventing hemorrhage from the torn placental vessels and cleansing the organs from secretions still being discharged at intervals.

Breast and Nipples.—The nipples should be cleansed after each nursing with warm boric solution. If they are cracked and sore a lubricating ointment should be applied and a nipple shield should be used. If the breasts become distended they should be massaged gently every two or three hours, and they may be pumped if necessary. In this state the patient must not have regular liquid diet, and the bowels must be kept freely open with saline laxatives. A compressed binder is comforting and beneficial. If the child, for some reason, does not nurse, the secretion may be dried by an application of belladonna in the form of a plaster, permitting the nipples to protrude through an opening cut into the center of it. The belladonna ointment is good but very unclean. Atropin may be given internally.

Conditions During which the Child Should Not Nurse.—Depressed or cracked nipples; inflammation of the breasts; poor health of the mother; marked anemia; kidney or heart disease; nervous or general febrile afflictions; tuberculosis; syphilis.

Menstruation.—If the return flow of the menses occur during the nursing period the milk becomes impure, and the child may suffer from the effects of it. If menstruation takes place normally and the child does not become ill, it is because the mother is strong and can endure the drain upon her system with no other bad result than losing flesh. In such a case it is best to wean the baby, especially after it is nine months old.

CARE OF THE BABY.

Upon Birth.—As soon as the eyes are cared for, by flushing them with warm boric solution (the physician may use Credé’s method—1 to 2 per cent. nitrate of silver solution, followed by weak salt solution), the baby should be wrapped in a warm, soft, sterile cloth (cotton flannel), and placed in a warm crib until the mother has been attended to. After that the baby should be anointed with warm olive oil, especially in the groin, axilla, in the folds of the neck and behind the ears. The nurse should then wash and sterilize her hands to dress the cord. Apply alcohol, 95 per cent., and then boric acid powder or any other antiseptic dressing the physician may order; it may be kept in place by a thin flannel binder, going around the abdomen but once and be fastened in the back (not too tightly) by sewing it together. Pins of any kind should be used only where absolutely necessary. The baby should be dressed in as few garments as possible.

Bathing.—Until the umbilicus is healed the child should not be put in the full bath. The face, hands, and head may be sponged daily with tepid water. Gently massaging the body every day with warm olive oil, and rubbing with a soft towel, will not only keep the baby clean, but prove beneficial. The genitals should be washed well once daily and sponged after each evacuation of the bowels. During the first few weeks a little oil rubbed into the parts is better than powder; in most cases powder will dry the skin too quickly and rub off the delicate epithelium.

General Care of the Baby.—The eyes, the mouth, and navel should be given the usual daily attention. The bowels, if constipated, should be encouraged by small doses of castor oil given with a medicine dropper. If the urinations are not clear and of sufficient quantity the baby may have warm water, about 1 oz. at a time, three or four times daily. Leave the infant with the mother only during the nursing period.

Nursing the Baby.—Practical experience is daily upsetting the theory that a set of rules and regulations can be laid down and followed for the nursing of all babies; that nursing must be done at certain hours and after certain intervals. While babies are alike in nearly every respect, speaking physiologically, there are only a few who can be awakened at regular intervals to be nursed by the mother or fed by the bottle. Some babies can not be awakened sufficiently for nursing, even after four or five hours’ sleep. Others will nurse for twenty minutes (the rules say it should not be longer than ten minutes) at two- or three-hour intervals during the day and then sleep all night.

Of course, where the child can be fed regularly, this helps the mother to regulate her own habits, and is comforting to all concerned. Therefore, nurses should not lack in determination to encourage such a system. But no such regularity should be insisted upon where both baby and mother suffer during the interval when nursing is denied; the former, hungry and crying lustily, and the mother under a nervous strain that is harmful to both. Let there be no hard-and-fast rules. Babies who feed as often as they feel like it (being allowed proper, though not necessarily long, intervals for digestion) generally suffer no ill effects and are healthy and strong. Mother’s milk, the natural feeding, should always be given, rather than any artificial food, when the supply is sufficient and good.

OBSTETRIC SUPPLIES.

Solutions:

Antiseptic solutions.

Normal salt solution.

Spiritus frumenti.

Fluid extract of ergot.

Plenty of sterile water (hot and cold).

Articles:

Rubber sheeting.

Plain roll of absorbent cotton.

Abdominal binders.

Vessel to receive placenta.

Large drainage-pan.

Large- and medium-sized safety-pins.

Sterilized Accessories:

One half-dozen sheets.

One dozen towels.

One night gown.

One doctor’s gown.

Accouchement pad.

Two dozen vulva pads.

Receiving pad for baby.

Maternity leggings.

Gauze sponges.

Cotton pledgets.

Applicators.

Tape for the cord.

Rubber and glass catheters.

Douche points.

Douche bag.

Vaselin.

SUPPLIES FOR BABY BASKET.

Blunt-pointed scissors.

Needle, thread and thimble.

Medium-sized and small safety-pins.

Rectal and bath thermometer.

Bar of pure mild soap.

Jar of pure olive oil.

Wide-mouthed bottle of alcohol, 95 per cent.

Wide-mouthed bottle of boric solution.

Sterile gauze to dress the navel.

Sterile applicators.

Two slips.

Two shirts.

Abdominal binders.

Diapers and old soft cloths.

BABY SLEEP.

A young baby sleeps eighteen hours out of twenty-four. At six months of age a baby sleeps about sixteen hours. A one-year-old child sleeps about fourteen hours, and at two years of age at least twelve hours. Daytime naps should be continued as long as possible.