University of Virginia Library

CHAPTER X.
THE CONFINEMENT.

Preparation for the Confinement; Signs of Approaching Labor; Symptoms of Actual Labor; the Confinement-bed; the Process of Labor.

Preparations for the Confinement.--The right time to engage the physician who is to take charge of the woman at her confinement is just so soon as the woman knows that she is pregnant. It used to be argued that, since giving birth to children was a physiologic process, there was no necessity for the woman to consult the physician until he was sent for when the labor pains began. Take the case of the woman who is for the first time pregnant; she is absolutely at sea; she has not the least idea how she ought to feel, what she ought to do or to leave undone; the result is that she often has a miscarriage which is the source of the greatest disappointment to her husband and herself, or she suffers very unnecessarily throughout the entire pregnancy, has a difficult labor, and perhaps gives birth to a sickly child.

The educated physician will explain to her what symptoms are normal and what are pathologic, and often he will be able to entirely cure the latter. It is now a well-established fact that the most serious complications of the pregnancy, and of the labor itself are caused by severe congestion or disease of the kidneys. The condition of the kidneys can only be determined by frequent examinations of the urine; during the early months of pregnancy these examinations are made once a month, and during the last month they are made every week. The amount of urine passed in the normal condition is three pints a day.

Nowhere, perhaps, is the constant vigilance of the physician so well rewarded as in the careful oversight of the pregnant woman. She goes through her entire pregnancy feeling well, and often the greatest discomfort that she suffers is due to her size; her labor and her lying-in are normal, and she gives birth to a healthy child.

Engagement of the Nurse.--This is generally left to the physician in charge of the case, since he is responsible for the safe delivery of the woman; but if the patient has any decided choice in the matter, it is acceded to unless there should be some very valid objections, and the physician always sends the nurse in view for that case to see the patient in order to ascertain if she is personally agreeable to the patient.

Choice of Room for the Confinement and Lying-in.--The room should be light, sunny, and well ventilated;

it should not be too near a water-closet. In the city as quiet a room as possible should be selected, and one that is well removed from the rest of the house, so that if necessary perfect quiet can be maintained. The room should be as cheery as possible.

The dress of the mother during the lying-in consists of a merino undervest, with high neck and long sleeves, and a nightgown, which shall be open all the way down the front. The gowns should be made of light muslin or of cambric; and there should be a sufficient number so that they may be changed every day.

Six abdominal bandages should be provided. These are made of light muslin, and they should be eighteen inches wide and long enough to go once and a third around the patient's hips at the sixth month of pregnancy, or about one yard and a quarter long; they may be made straight or to fit the patient at the sixth month. This bandage is fastened down the front; it is applied directly after the labor, and adds greatly to the patient's comfort during the lying-in.

The vulvar pads used during the lying-in are the antiseptic absorbent pads which can be obtained at any place where surgical dressings are sold; they are made of absorbent cotton, covered with cheesecloth, and sterilized.

There must be a sufficiently generous supply of sheets so that they can be changed every day, and the drawsheet as often as may be required. Nothing is so important to a good lying-in as to have a clean, well-ventilated

room, and plenty of fresh bed-linen. Cleanliness is the first requisite to antisepsis, and this is the secret of avoiding puerperal fever.

Articles to be provided for the confinement are:

• 1. An oblong douche-pan of agate-ware.
• 2. An agate bed-pan.
• 3. A bath thermometer.
• 4. Two pieces of rubber sheeting; one, one yard square, and the other two yards square.
• 5. Two sterilized bed-pads, 30 inches square by 3 to 4 inches thick.
• 6. Three dozen antiseptic absorbent pads.
• 7. One pound of sterilized absorbent cotton; twelve yards of cheese-cloth.
• 8. Six abdominal bandages, eighteen inches wide, preferably made to fit the figure at the sixth month of gestation.
• 9. Two hand-scrubs.
• 10. Four ounces of the tincture of green soap.
• 11. Bottle of corrosive sublimate tablets.
• 12. Four ounces of powdered boric acid.
• 13. Half a pint of good whisky.
• 14. Two ounces of aromatic spirits of ammonia.
• 15. Two ounces of aqua ammonia.
• 16. One pint of alcohol.
• 17. Two tubes sterilized white vaselin.
• 18. Plenty of large and small safety-pins.
• 19. Hot-water bag.

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• 20. New fountain syringe, to hold four quarts; with glass nozle.
• 21. One small basin for vomited matter.
• 22. Two very large agate basins or wash-bowls for washing doctor's hands and for antiseptic solutions.
• 23. Vessel for after-birth.
• 24. Three large pitchers; one for boiling water, one for cold boiled water, and one for antiseptic solution.
• 25. Tumbler for boric acid solution for washing baby's eyes, with fine old linen sterilized.
• 26. One dozen freshly laundered sheets, and two dozen towels.
• 27. Stocking-drawers, muslin.
• 28. Change of night-clothing warmed for the mother.
• 29. A warm blanket to receive the baby.
• 30. An infant bath-tub.
• 31. A large piece of oil-cloth to protect the floor.[1]

Baby's Outfit.--Four flannel bandages, to be made of fine, soft flannel, four inches wide, to go once and a third around the body. The edges may be pinked or whipped, but should never be hemmed; a tape is sewed on double, the ends passing around the body, and so the bandage is fastened without pinning.

Six merino shirts, with high neck and long sleeves, made to button down the front.

Cotton diaper napkins, not too large; old soft ones are preferable.

Long merino stockings which can be pinned to the napkin.

Flannel petticoats, not too long; these may be made on muslin bands, which are held up on the shoulders by means of straps. The essential in all the clothing is that it should be sufficiently loose.

Dress-slips should not be so elaborate that they cannot be washed and changed with sufficient frequency; and not so long that the baby's feet will be hampered in their movements by them. All of baby's clothes but the dress should be fastened by safety-pins.

Baby's basket should contain:

• 1. One outfit of clothes.
• 2. One tube of sterilized tape.
• 3. A pair of blunt-pointed scissors.
• 4. Large and small safety-pins.
• 5. Pieces of fine old linen; old handkerchiefs are the best.
• 6. A soft hair-brush.
• 7. A powder box and puff, with talcum powder.
• 8. Two tubes of sterilized white vaselin.
• 9. Two soft towels.
• 10. Castile soap.
• 11. Single-bulb syringe; so-called "eye and ear syringe."
• 12. A woolen shawl or wrap.

If there is no nurse available before the labor sets in, and it is necessary for the patient to see to the sterilizing of the above articles, she should first scrub off all pitchers, basins, and other utensils, as well as the douche-pan, fountain syringe, and rubber sheeting, with a brush and hot soap-suds; the hand-scrubs are to be well washed; then each article should be pinned separately in coarse towels, and put to boil for half an hour in an ordinary wash-boiler. The articles so boiled are then dried without removing the towels, put away, and not opened till the time of the labor.

The abdominal bandages must be laundried and pinned up in separate towels until they are needed. The cheese-cloth must be laundried and then sterilized.

The vulvar pads should be pinned in an old napkin, in packages of half a dozen each; and one package is sterilized at a time by placing it in the oven until the outer covering is scorched. The linen for the baby's eyes and the cheese-cloth are treated in the same way; they are to be cut up into small pieces and sterilized as needed.

Signs of Approaching Labor.--About two weeks before labor there is a sinking of the womb. At the beginning of the ninth lunar month this was at the end of the breast-bone; it now descends to a point midway between this and the navel; the abdomen becomes smaller, the pressure on the lungs is relieved, and the woman breathes more freely. But at the same time

that the woman is relieved of the pressure on the chest, she experiences increase of the troubles in the lower extremities. There is an increase of the bladder symptoms, with a desire for frequent unrination. Constipation becomes more troublesome, and there may be hemorrhoids; the veins of the lower extremities may become greatly enlarged.

There is an increased fullness of the external genitals and a greatly augmented amount of mucous discharge. There is a feeling of anxiety and nervousness, with depression of spirits.

During the last two weeks of pregnancy patients are apt to have cramp-like pains in the lower part of the abdomen. These are often mistaken for labor pains. True labor pains are characterized by starting in the back, extending around the abdomen and toward the pubes and down the thighs; they come at more or less regular intervals of half to three-quarters of an hour, and increase in intensity with a decrease in the intervals. A strong pain is apt to be followed by two weaker ones. The so-called false pains are irregular in their occurrence.

Symptoms of Actual Labor.--First is generally the show; this is a discharge of mucous tinged with blood; at the same time the true labor pains set in. When the patient or nurse is in any doubt as to the character of the pains, or when the show appears, the physician should be summoned at once. Other symptoms are

frequent desire to empty the bladder and bowels, and a sensation of shivering.

The Confinement-Bed.--A single bed is much more convenient, but it is rarely found in a private house. The double bed is arranged as follows: The hair mattress is covered with a large rubber sheet, which is pinned with safety-pins at the corners and tucked well under the mattress; the rubber sheet must not be drawn too tightly for fear of tearing. Over this comes the sheet, and over the upper half of the bed, the draw-sheet; this is a sheet folded four double, which goes across the bed so as to come under the hips of the patient, and is tucked under the mattress at both sides. The object of this is so that it may be frequently and easily changed without disturbing the patient. The sheet, blanket, and spread which are to serve as a covering after delivery are folded back and placed on the left side of the bed.

The lower right-hand corner of the bed--the right side of the bed is that side which is toward the right hand as one stands facing the foot-board--is arranged for the confinement; on this is fastened the smaller rubber sheet, and over this the sheet is folded, and both are fastened down with safety-pins. The pillow for the patient should be placed at the upper and inner corner of the square. After the delivery the patient is lifted to the upper part of the bed and the temporary dressing is removed. A sheet and blanket are used for a covering during the confinement.

Before the labor begins it is well to fasten up the vest and gown, so that they will not be soiled, as it is important that the patient shall be moved as little as possible after the labor, as all movements tend to increase the bleeding.

The floor oilcloth must be spread at the side of the bed which is made up for the confinement, and should extend slightly under the bed.

A bureau in the room should contain the mother's and baby's clothing, bed-linen, towels, and any other articles which will be needed, all properly arranged.

The clothing for the mother and baby will be placed where it will keep warm, and the infant bathtub will be in readiness in case of sudden need for it.

All water used about the confinement must have been carefully sterilized in advance. The best way to sterilize the water is by boiling it in a large wash-boiler; whatever vessel is used must be scrupulously clean, and ought to be new. The vessel is covered over, and the water is allowed to boil for half an hour; it is then, still covered, set aside to cool. There should be three gallons each of sterilized hot and cold water; since in case of an emergency there must be plenty of water ready for use.

The various articles ordered in the confinement outfit will be at hand ready for use. It is the duty of the nurse to have everything ready for the doctor before his arrival. The patient should have a full warm tub-bath, fresh night-clothes put on, and an enema should

be at once given to unload the bowels, and this even though there may have been a bowel movement only a few hours previously. The patient should remain in bed until the arrival of the doctor. After an examination has assured the latter that all is right, she may be allowed to go around the room, with a wrapper thrown on over the night-gown.

Conveniently near the bed should be a small table, covered with one or two freshly laundried towels. This table should have on it a wash-basin, a hand-brush, soap and hot water, an antiseptic solution, scissors, a ligature for the navel, and a suitable aseptic lubricant for the hands.

The Process of Labor.--The process of labor is divided into three stages. The first stage is that of dilatation; by which is meant the stretching of the mouth of the womb so that the child may pass through. At the first confinement this stage lasts about fifteen hours; at subsequent labors the length of this stage is much shorter, the average time being eight hours. The pains during this stage are sharp and cutting, and they are accompanied by a slight show of blood. The patient is fretful and nervous

The second stage of labor is called that of expulsion, because in this stage the uterus contracts down together with the abdominal muscles to expel the child from the womb and the vagina into the world. The duration of this stage in the first confinement is about an hour and a half.

The third stage of labor includes the time from the expulsion of the child till the coming away of the after-birth; the average length of this stage is from twenty minutes to half an hour.

The average length of time for the first labor is seventeen hours; and for subsequent labors from eight to eleven hours.

The bag of waters is the sac of membranes in which the child is inclosed. It contains a liquid in which the child floats; the object of the water is to protect the child from sudden shocks or any kind of injury during pregnancy. During labor this membrane with its contained water serves as a dilating wedge to assist in the opening of the womb, and it also protects the child from the direct contraction of the uterus upon it. When the waters break prematurely, the labor is much longer and more tedious; normally this should not occur before the mouth of the womb is fully dilated.

The pains of the second stage of labor are of a bearing down character, and constantly increase in force and frequency; the climax being reached as the head passes through the vulvar orifice.

A child usually lies in the womb with the head downward; the reason of this is that there is more room in the upper part of the uterus, and as the small parts of the child as it is folded upon itself take up the most space, they occupy this position, while the head lies just above the pubes. The normal position of the child is: the head is flexed on the chest, the legs on the thighs

and the thighs on the abdomen, and the hands are folded across the chest. And so the child is usually born head first.

During the stage of expulsion the head of the child is forced down slightly during each pain, to recede a little during the intervals between the pains; in this way the vagina and its external orifice are gradually stretched so that the head of the child may pass through without tearing the parts. If the head is allowed to pass through suddenly, or where the labors are rapid, as in the case of women who have given birth to several children, much mischief may be done by tearing the soft parts.

After the birth of the head there is a short interval of rest, when the shoulders are born; the rest of the body easily slips out; and with the expulsion of the after-birth the labor is over.

At the very beginning of labor the patient should be given a full warm tub-bath, and make an entire change of linen. She will usually prefer to be dressed in her night-clothing, over which during the first stage she may wear a loose wrapper; a sterilized napkin should be worn over the vulva during this stage. During the first stage, as a rule, the patient should not be confined to bed until the dilatation is well advanced; she is generally more comfortable if she is allowed to move around the room, and the pains are thereby advanced.

The only way in which the physician can determine whether labor has begun is by making an internal examination;

and this will enable him to decide as to whether it is necessary to remain or not.

The nurse should always wear a wash dress in the confinement and lying-in room.

If the labor is long, nourishment in the form of beef-tea, broths, and milk may be given. No stimulants should be given without the direction of the physician. The frequent taking of cold water is permissible.

At the beginning of the labor the family and friends must be excluded from the room, and it must be kept as quiet and as cheerful as possible.

Toilet of the Patient.--The newly born child is received in a small blanket, is well wrapped, and laid in a warm place. The nurse then turns her attention to the mother; the external genitals and soiled parts of the body are cleansed with sterilized cheese-cloth wrung out of an antiseptic solution; if the body-linen has become soiled, it is also changed, and all blood-stained articles are removed from the bed. The patient is then carefully lifted up on the permanent bed, and the vulvar pad and the abdominal bandage are applied; after which the patient is allowed to rest.