Maternity and child care

Front matter

Class _H20~4J Book__

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COPYRIGHT DEPOSIT.

Preface

Prevention is our watchword of today. To stamp out disease, we must prevent it. How? With knowledge. Knowledge is the cornerstone on which our life-saving stations must be built. Superstitions and wrong teachings must be thrust away with the discarded ideas of the past, for this is a new age of health.

Our National Conservation Commission reports that forty out of every hundred premature births can be prevented ; that forty out of every hundred cases of congenitally weak babies can be avoided ; and that seventy out of every hundred babies whose eyes are infected at birth can be saved this misfortune. This Commission reports that nearly half of the babies who do not survive the first year of life die from conditions existing before or at the time of their birth and that these conditions may be prevented if the mother can be reached and told what she should know, and what, in the vast majority of cases, she is anxious to learn.

Added to these figures of needless waste of child-life, are the appalling figures of the thousands of mothers whose lives are sacrificed annually through lack of knowledge and proper

PREFACE

care during the time when they are fulfilling their highest destiny, that of motherhood.

Read these figures and you have the reason why this book is written. It is written in the hope that it may carry the truths that make for safe motherhood; carry them in so simple a language that, wherever needed they may be plainly understood by every prospective mother. And thus, every child of the home into which this book goes may receive through its message more of the benefits that modern medical science has to offer.

Table Of Contents

CHAPTER PAGE

I The Story of Reproduction li

II The Embryo's Growth and Food 21

Chapter II The Embryo's Growth And Food

The fertilized ovum attaches itself to the swollen lining of the uterus by a remarkable process. The covering formed by the cells is well started by the time the ovum reaches the uterus. It secretes a substance which destroys or absorbs some of the cells in the lining of the uterus at one small spot. This forms a nest in which the ovum burrows. The rest of the lining grows gradually thicker and richer in blood vessels and actually grows over the ovum in its nest. This new, thickened membrane we call the decidua. In addition to the secretion which we have just mentioned the ovum throws out another secretion which prevents menstruation from occuring and washing out this new life.

Eight at the spot where the ovum attaches itself to the lining of the uterus, there develops that important membrane, the placenta, through which the embryo breathes and receives its food until birth.

The outer covering or shell for the embryo begins to develop as soon as impregnation occurs and the cells making up this covering grow so rapidly that the embryo is very shortly entirely surrounded by two complete layers or membranes. The outer layer is the chorion ; the inner layer, the amnion. The sac itself, made up of these two layers in which the tiny embryo is rapidly developing, is filled with a watery secretion called the amniotic fluid. This rapidly increases in amount as the sac grows, and forms what is known as "the bag of waters" at the time of birth.

This fluid serves four purposes: it forms a cushion of water around the fetus which protects it from injury through any jar or blow to the abdomen; through pressure from tight corsets or clothing; or through sudden changes of temperature, and it forms the "bag of waters " which is so important in dilating the mouth of the womb at the time of labor.

Now let us again turn attention to the outer envelope or the chorion. The cells which make up this layer begin to grow outward, projecting like fingers or the branches of a tree. There are thousands of these processes, called villi, and just where the little embryo has sunk into the lining of the uterus, they develop in great numbers and grow to greater length and size than the villi covering the rest of the sac. They extend right through the blood vessel walls of the membrane lining the uterus and are thus bathed in the mother's blood. This is the way in which

Cross Section of Pregnant Uterus {After Allen Thompson) This Diagram Shows the Relations of the Uterus, the Embryo, and the Embryonic Structures at the Second Month of Gestation. 1 — Wall of uterus. 2 — Beginning of fallopian tube. 3 — Placenta showing branches of villi. 4 — Umbilical cord. 5 — Fetus. 6 — Amnionic fluid or "bag of waters." 7 — Amnionic membrane. 8 — Chorionic membrance. 9 — Cervix or mouth of uterus.

the "mother cake," the placenta or "after-birth" as it is also called, is formed.

At this point within the sac the embryo is growing and becomes attached to the placenta by a tiny tubular membrane which becomes the navel cord. This navel or umbilical cord enters the body of the fetus at the center of the abdomen. Blood vessels are later formed within this cord, one of which carries the blood from the placenta to the fetus and two of which carry the blood from the fetus to the placenta. Before the blood vessels form, the embryo absorbs nourishment directly from the placenta.

You can readily see from the accompanying illustration just how the embryo lies within its sac suspended by the umbilical cord and surrounded by the amniotic fluid. You will notice that the sac at one point has grown solidly into the wall of the uterus connected by the villi or branches of the placenta. The sac hangs in the cavity of the uterus and grows with great rapidity, the water constantly increasing until by the third month the sac completely fills the uterus, becoming attached to the lining membrane on all sides.

During this time the fetus and the entire womb have steadily grown larger. Until the entire lining of the uterus is covered by the sac, some blood may make its appearance at the regular menstrual periods. This is rare, however, as menstruation normally ceases entirely when pregnancy occurs.

Any bleeding that may be noticed after the third month probably comes from the place where the placenta is attached and must be heeded. It may mean that contractions of the uterus have slightly loosened the placenta and there is possible danger of miscarriage.

Of the blood vessels which develop in the umbilical cord, two are veins and one an artery. These pass directly from the placenta to the body of the fetus, entering at the navel. The circulation of blood begins as soon as the heart in the developing fetus starts to beat. These heart beats can be heard as early as the fourth month, but it must be remembered that actual life in the embryo begins at the time of conception.

The villi are covered by a thin flat layer of cells and these cells separate the mother's blood from the blood of the placenta, and through them the food and oxygen needed by the fetus for life and growth are filtered. Thus, the blood of the mother does not flow directly into the blood of the fetus, or the blood of the fetus into that of the mother. After the food and oxygen in the mother's blood has been filtered through those cells and have been taken up by the blood of the placenta, they are collected in those converging blood vessels at one point, emptied into the artery in the umbilical cord, carried to the arteries which have formed in the fetus and thence circulated by the pumping of the fetus heart to all the organs.

With growth of any kind there is waste matter. After the baby is born it gets rid of this waste through the lungs, kidneys, bowels and skin. While the fetus is growing in the uterus this waste is collected into the baby's veins and these veins, converging, empty into the two veins of the umbilical cord. Thus the waste is carried out through the placenta to the villi where it seeps back into the mother's blood through the same cells, just as the nourishment was filtered in.

The placenta also takes the place of lungs as no air is received into the baby's lungs until birth.

The waste is gotten rid of through the mother's skin and lungs and bowels but mostly through the kidneys. Remember this as it explains why so much attention must be given to the kidneys during pregnancy.

It is difficult for the mother to transmit actual disease to the baby in her uterus, because no solid substance can pass through the layer of cells which separate the blood of the fetus from that of the mother. Bacteria circulating in the mother's blood, such as the germs of tuberculosis and typhoid fever, cannot pass through these cells so long as they remain intact.

GROWTH

Now that we have learned the way in which the ovum starts its growth, how it is protected and nourished, let us determine how it takes its shape and the rate of its development.

During the first six weeks of its life the fertilized ovum is known as the embryo. At the end of the fourth week, the embryo is about the size of a pigeon's egg; at the end of the second month it is the size of a hen's egg and human shape can be discerned without the aid of a magnifying glass if the embryo is expelled at this time. At the twelfth week the embryo is slightly larger than a goose egg and the sex can be distinguished.

After the sixth week it is proper to drop the term embryo ancl name the developing life, the fetus. After the twentieth week growth is very rapid. The rate is the same in all mothers regardless of physical characteristics.

APPROXIMATE GROWTH OF FETUS mths

Length in

Weight in

Inches

Pounds

3V> to 4

6V 2 to 8

The first baby is usually smaller than subsequent children. The average birth weight approximates seven pounds and three ounces.

but full term babies commonly range in weight from six to ten pounds. Exceptional cases are reported where babies have weighed more and even less than these figures.

The mother who is overworked and poorly nourished is very liable to have a baby whose N weight is below the average. This is also true of small women. The mother who exercises little and eats heartily is prone to have a baby weighing eight or nine pounds or even more.

Throughout pregnancy the uterus keeps up the gentle contraction and expansion and while this is mild it is sufficient exercise to keep up the strength and tone of the muscles, which qualities are so necessary at the time of labor. As the uterus enlarges it rises slowly out of the pelvis and by the fourth month it can be felt just above the pelvic bones. At about the middle of the fourth month or a little later, the woman pregnant for the first time, feels life. Oftentimes this first movement is not recognized. When it is noticed the mother describes it as a slight fluttering and it becomes more pronounced until the "little kicks " can be felt and seen against the side of the abdomen. In a second or later pregnancy life is usually recognized earlier than in the first pregnancy.

By the fifth month the physician's practiced ear can hear the heart beat faintly and this is very distinct by the sixth month. The heart of the fetus beats about twice as fast as that of the mother.

By the fifth month the uterus has risen up halfway between the pelvic bones and the navel ; by the seventh month it is three or four fingers above the navel; and by the eighth month it has risen as high as the cartilage at the end of the breast-bone. The last two weeks of pregnancy the uterus begins to sink. This movement is described by the mother as ' ' settling. ' 9

When the full term has been reached the uterus has assumed the shape of an immense egg. The walls of the sack containing the baby are attached to the entire lining of the uterus except at one point directly over the mouth of the uterus where the sac is simply stretched across. At the place where the ovum first nested itself, the lining has become greatly thickened. Here is attached the placenta which has grown to the circumference of a dinner plate and about an inch in thickness. It is about one-sixth of the weight of the baby.

The sac in which the baby floats is now fully distended with the amniotic fluid or "bag of waters.' J The umbilical cord is now about twenty-four inches long. The fetus is usually found lying with the head down, and flexed so that the chin touches the chest. The back is bent forward, the arms are crossed just below the chin, the knees doubled up in front of the abdomen, and in this position the fetus is ready to be delivered.

SEX

Nothing can be done to influence sex, nor is there any way of telling the sex, before the baby is born. The theory has been advanced that the rate of the heart-beat is a determining factor, but this is in no way reliable. The most plausible theory is that the male element is the determining factor. It is maintained that part of the male cells contain the female germ plasm and part the male germ plasm, these cells being equally divided in the male generative organs. Based upon this theory the births of males and females would be equal. Statistics bear this out with a slight variation.

TWINS

In approximately one out of every ninety pregnancies, twins occur. Heredity seems to have a decided influence in the birth of twins. Records show that twins appear in the same family for several generations. We have traced twt> causes for twin births. One is the case of two ova being impregnated at the same time by two different male elements, and by this double fertilization we may get twins of both sexes, a boy and a girl born at the same time. The other case is of the single fertilized ovum that divides into two separate groups of cells, giving us twins of the same sex closely resembling each other.

A

Chapter III Signs Op Pregnancy

Pregnancy is a perfectly normal condition and there is no occasion for alarm or apprehension when the first signs make their appearance. The first and most important thing to be done is to place yourself at once in the care of your physician. This is because the troubles that develop during pregnancy and at the time of confinement have, as a rule, very small and many of them early beginnings. So slight are the beginnings of these troubles that only the practiced eye of the physician can detect them at the start. He can set about their immediate correction.

The early signs of pregnancy are known to nearly every woman and she can usually tell when she is pregnant before seeking the advice or examination of her physician. Mistakes are many times made, however, because signs which are associated with pregnancy and are usually considered infallible may be the indications of other conditions entirely foreign to this.

The first group of signs can only be called probable or presumptive signs. The second group is made up of the positive signs and do not make their appearance until after the first signs.

Of the probable signs there are four: the cessation of menstruation, the changes in the breasts, morning sickness and the frequent or painful urination.

The stopping of menstruation is always the first symptom of pregnancy to attract attention if it happens during the child-bearing period. There are other conditions, however, which are in no way associated with pregnancy which may cause temporary cessation of menstruation. While pregnancy may occur at any time during the month, it more often takes place just before or just after the menstrual period.

The conditions which cause menstruation to cease temporarily are most often known to a woman and she is not apt to confuse them with a sign of pregnancy.

The change of life, or menopause, usually begins with irregularity of the monthly periods. This is quite frequently mistaken for a sign of pregnancy, but rarely does pregnancy occur at this time. Any acute or chronic disease of the ovaries or womb may suppress menstruation for an indefinite period. When an operation is performed for the removal of both ovaries menstruation permanently ceases. This does not follow the removal of one ovary.

Anaemia, the condition in which the blood becomes thin or impoverished, will produce irregular and scanty menstruation and oftentimes cause it to cease temporarily. Great anxiety, serious shock, worry, or severe physical or mental strain may cause menstruation to cease for a time.

The nursing mother, in whom menstruation has not become re-established, thus becomes pregnant at times without being aware of it. She has neither the sign of cessation of the monthly periods nor the change in the breasts to be guided by.

You readily see the importance of consulting your physician at the first probable signs of pregnancy, as the cessation of menstruation due to any of these other conditions demands his advice and attention.

A slight bleeding may sometimes occur at the regular menstruation periods for two or even three months after pregnancy, but this is much less in amount and of short duration. Any considerable loss of blood that appears after pregnancy has been determined indicates a threatened abortion, or miscarriage, which is especially liable to happen at the menstrual period, and should be immediately brought to the physician's attention.

Changes in the Breasts. — Many sensations may occur in the breasts early in pregnancy. These include the sense of fullness ; extreme tenderness, so marked sometimes that no pressure may be bourne over them. They also include throbbing and tingling; and by the second month the nipples increase in size and stand out more prominently; the circular area around the nipples grow darker in color. This color is much deeper in brunettes. At the base of the nipples are tiny glands which begin to enlarge and can be seen standing out just underneath the skin. By the fourth month a white watery substance which is known as colostrum, can be seen if the nipples are gently compressed. In the later months this turns to a yellowish color and is less watery. This is not milk and it disappears the third or fourth day after the baby is born.

The woman who has recently nursed a baby may find some milk secreted in the breasts for quite a time after weaning and this is not an indication of another pregnancy.

Morning Sickness. — Soon after the first menstruation is missed morning sickness usually makes its appearance. It is generally most pronounced soon after rising and in most instances passes away after the third month. This sickness may amount in some women only to a slight nausea, and in others be so serious that actual vomiting takes place. It may pass away in one or two hours, or it may persist for half a day and in rare cases last throughout the day.

Severe and persistent nausea and vomiting must not be ignored, as they often point to an accumulation of poisons in the system which must at once be brought to the physician's attention.

Disturbances of Urination. — Pregnancy usually causes frequent urination often accompanied by some pain and difficulty in passing the urine. This is simply due to the pressure of the enlarging uterus upon the bladder. By the fourth month the uterus has risen so high that the pressure on the bladder is relieved and these disturbances disappear. In the latter weeks of pregnancy, when settling occurs, these symptoms may again return as the uterus again presses against the bladder.

Because of the frequency of urination, the prospective mother must not cease drinking plenty of liquids, as the extra supply of water and other liquids is absolutely essential to her health and that of the baby's throughout the entire period of gestation.

The Positive Signs. — The first positive sign of pregnancy is determined by your physician's examination. It is the enlargement of the uterus. The pregnant uterus enlarges in a characteristic way, quite different from the enlargement due to other causes such as tumors. The first positive sign noticed by the mother is movement, or as it is commonly called, "quickening." This comes some time between the eighteenth and twenty-first week. This comes as a fluttering sensation or as gentle taps and grows stronger as the time progresses, usually being most noticeable at night. It is even so pronounced at times as to interfere with sleep and later the taps or " kicks ? * as they are called can be plainly seen against the abdominal wall. When movement has become established and then a period occurs in which no movement is felt for two or three weeks you must not fail to call this to your physician's attention.

The next positive sign of pregnancy is the fetal heart-beat. This your physician can hear through the walls of your abdomen by the latter part of the fourth month or early in the fifth. The heart-beat is 150 to 160 a minute or about twice that of the mother. This is a most valuable sign because where the baby has been quiet for some time, movement not being noticed by the mother, the physician can reassure the mother that everything is all right by listening to the fetal heart-beat through his stethoscope or by placing his ear against the abdomen.

THE DATE OF CONFINEMENT

If the positive date of conception were known, the time of confinement could be estimated to take place 275 days from that date, or in approximately thirty-nine weeks. However, the date of conception is rarely known, therefore, the method of calculation is to estimate the time from the last menstruation. Experience has led us to count two hundred and eighty days from the first day of the last menstruation as the average period of pregnancy up to the date of confinement. This corresponds to the nine calendar months, the time commonly referred to which comprises ten lunar or menstrual months of 28 days each.

Rarely does delivery occur before the estimated time. If you count forward two hundred and eighty days from the first day of the last menstruation, you are as near as you can come to the approximate date of your confinement. Another simple method of calculating this date is to count backward three months from the first day of the last menstruation, and then add seven days. This gives exactly the same number of days. This estimate is based on the assumption that pregnancy occurred right after menstruation, which is most usual, but pregnancy may have occurred later in the month so that the estimate would vary several days.

If the date of the last menstruation is not known the only method of calculation is to estimate from the day the first movement or "quickening' 9 is felt. As this usually occurs about the eighteenth week we add to this time twenty-two weeks. This is not nearly so accurate, for quickening may not be felt until later than the eighteenth week. If the date of the first movement is not known the only method left is the very inaccurate one of estimating the number of months of pregnancy by examining the size of the womb.

Second pregnancies are, as a rule, a few days longer than the first. Delicate and sickly women and women who overwork are liable to be confined a few days before the estimated time. Women who are inactive are very prone to go over the estimated date. The sex of the child has no influence upon the date of confinement. Twins are liable to be born before the calculated date.

The mother who has made the estimation of two hundred and eighty days should not worry if she goes one or two weeks over this time, but if she passes the third week her physician will induce labor if he is reasonably sure that she has not miscalculated the time.

PREGNANCY IN THE FALLOPIAN TUBE

In very rare cases the impregnated ovum may be caught in the fallopian tube before being swept into the uterus, and, attaching itself to the wall of the tube, may begin to grow. The opening in the fallopian tube is very small and with the growing ovum serious trouble results. The ovum may be violently detached by the natural contraction of the muscles in the tube and thrown off completely before it has attained much size.

A comparatively small amount of bleeding occurs in this case. Again, the little villi may grow right through the wall of the tube and slow bleeding occur around the tube outside of the womb. The embryo may also grow and fill the tube until it actually bursts through, producing sudden severe hemorrhage with shock and collapse.

A woman who has such a tubal or ectopic pregnancy usually passes her menstruation period, although frequently a slight bleeding occurs at the regular time and lasts for a few hours. Commonly the menstruation period is several days late and then the bleeding is also very slight, but this is usually accompanied by considerable pain in the right or left side, depending upon which tube the pregnancy has taken place in. The small amount of bleeding from the uterus may come at irregular intervals, several days of cessation and then slight bleeding again. The pain in the side increases at these times of bleeding, becoming severe in the nature of a colic. Women often think this is a threatened miscarriage. Whenever these suspicious symptoms occur you should notify your physician without fail and at once.

Following suspicious symptoms of this description if there develops a sudden sharp pain followed by great faintness, dizziness and collapse, not a moment should be lost in getting into immediate communication with a competent surgeon as an instant operation is necessary.

It is a strange fact and one that must be carefully noted that after a pregnancy has once occurred in the tube, normal pregnancy may later occur again, but there is great danger of a second pregnancy occurring in the other tube. For this reason physicians emphasize the importance of avoiding pregnancy for at least two years after the tubal or ectopic pregnancy has taken place.

Women with tubal pregnancies rarely experience morning sickness, there is practically never any change in the breasts, and the womb does not enlarge.

Chapter IV Diet In Pregnancy

The Expectant Mother's Weight. — In the early months of pregnancy the mother's weight remains about the same. Sometimes there is a slight loss, sometimes a little gain. But in the last three months there is an average monthly gain of three and a half to five and a half pounds. At birth there is the natural loss to the mother of ten to fifteen pounds, and a little later the tissues which have been stimulated by pregnancy return to their normal condition and there is a further loss of weight. However, after a normal confinement, most mothers remain a little heavier and generally better nourished than they were before pregnancy.

Thus, the mother does not require extra food for the child's growth until the sixth month.

The Use of Her Foods. — The body is constantly calling for the carbohydrates and fats to supply body fuel and yield heat and energy. The carbohydrates are starch and sugar, and we are all familiar with the common foods that we must provide to give the needed supply of fats, sugar and of starch, which is turned into

DIET IN PREGNANCY 43

sugar in the process of digestion. Besides the cane sugar which is our regular table sugar we get sugar in grapes and other fruits, in corn, in onions and in other vegetables. Fat we get in abundance in cream and butter, cocoa and chocolate, and the fatty meats.

Again the body is continually calling for the protein element in our food. We get our animal protein in meat, milk, eggs and cheese. If we eat too little protein food our tissue-building suffers. If we eat too much meat, which is our principal protein food, there is increased putrefaction in the intestines and extra work for the kidneys which are the organs most occupied with ridding our bodies of the waste products of protein. Many people supply the protein needs of the body by a purely vegetarian diet, but the majority have found a mixed diet of both animal and vegetable protein most advantageous.

The other constant call of the body is for water and mineral material. Two or three quarts of water is being used in the daily process of living. This loss must be supplied by the water in our foods and principally by the water we drink. Except for our table salt, the mineral material which, with the water, assists in building new tissue and repairing worn-out tissue, is provided in' the other food-stuffs. For example; we get iron (which is so essential to the blood)

from apples, spinach, lettuce, potatoes, peas, carrots and meats. We get lime (the material that makes the bones hard), in bread, milk, eggs and vegetables. Other mineral constituents of the body, such as magnesium, potassium, sulphur and phosphorus, occur in other foods.

The Needed Extra Food. — After the fifth or sixth month there comes a demand for more of the heat and energy-giving and the tissue-building food-stuffs and one of the best means of taking this extra supply is- by drinking milk between meals and at bed-time. About a quart of rich creamy milk can be taken in this way by most mothers. If it tends to cause a little indigestion, put a pinch of baking soda in each glassful. Some cscnnot take "this extra milk and they can supply the needed between-meal nourishment by taking a light broth or soup with a graham or oatmeal cracker or a cup of cocoa.