CHAPTER VI

PRENATAL CARE

The day is long since past when the obstetrician’s concern for his patient began when she went into labor. The obstetrician of to-day watches and cares for his patient throughout pregnancy, for he knows that by so doing he greatly increases her chances of surviving the ordeal of childbirth, and the baby’s prospect of living through that perilous first year.

Although many conditions that result in invalidism or death occur during labor or the puerperium, they have their beginnings during pregnancy. Their prevention, then, or early recognition, followed by prompt and efficient treatment, will avert many of the dreaded complications and emergencies associated with childbearing.

In order to prevent these disasters it is necessary to supervise the expectant mother and care for her from early in pregnancy—from the time of conception if possible—until the onset of labor, and this is prenatal care. It may be divided into instruction, examinations and observations, as follows:

1. a. Teaching the expectant mother the principles of personal hygiene, as especially adapted to meet her needs, and helping her to adopt them;

b. Describing to her the more apparent, normal changes of pregnancy which she is likely to notice and perhaps not understand, and also the common symptoms of complications which she may detect and should report;

2. The doctor’s preliminary examination, early in pregnancy, comprising a study of the size, shape and proportions of the pelvis, and later their relation to the size and mouldability of the baby’s head; a Wassermann test for syphilis; urinalysis and measuring the blood pressure. In addition to these, a complete physical survey is made, consisting of examinations of the heart, lungs, breasts, abdomen, a vaginal smear for gonorrhea, and the patient’s height, weight and temperature;

3. Constant watching for early symptoms of the complications of pregnancy, with speedy treatment of such symptoms when they appear, and relieving the common discomforts of pregnancy; making observations upon the presentation and size of the fetus, later in pregnancy, in order to plan ahead of time for the delivery, if the patient’s condition makes this advisable.

Prenatal care of this character is essentially preventive for both the mother and the new-born baby.

We gain a faint impression of what it may prevent when we learn that year after year, about 17,000 young women die in the United States from causes associated with childbirth, which are known to be largely preventable (during 1918 the number was 23,000); and that each year about 112,000 babies are born dead, and 100,000 of those born alive perish during the first month of life, also from causes which are largely controllable.

But 17,000 dead mothers and 200,000 dead babies, most of whom might have lived, are not all that enter into the annual erection of this national monument to neglect. There are also the unrecorded and uncounted victims of little or no obstetrical care who have had too much vigor to succumb completely and die, and who, therefore, live on through years of wretched invalidism. Sometimes, it is true, their disability is slight, so slight as to be uninteresting, and of no statistical importance. But to the woman herself, who must resume the functions of mother, homemaker, wife and general utility person, the disability may be enough to make life endlessly dreary and discouraging. And yet, she is perhaps only just below the physical level upon which she could live her life with joy and eagerness; and proper care when the baby came would have left her upon that level.

The effect of the mother’s impairment reaches far beyond her own invalidism, for such women are not as well able to rear and care for their children satisfactorily as are fresh, buoyant mothers. Whatever makes for good obstetrics, therefore, makes for a better race, and, as we shall see later, measures that tend to improve the health of the race tend to lessen the hazards of childbearing.

Ideal prenatal care, then, would really begin during the expectant mother’s own infancy, but we must be content here with a description of the care that is advisable, and desired, for expectant mothers from the beginning of pregnancy.

There is considerable difference of opinion among physicians concerning the stage of pregnancy at which it is desirable to see the expectant mother for the first time, and the frequency of subsequent observations. But the growing tendency is for the doctor to see his patient as early as possible, for the preliminary examination, and to follow a fairly uniform routine in the kind and frequency of subsequent observations, and in the personal hygiene which the patient is advised to adopt.

Thus, it has become generally customary to see the patient, take her temperature, pulse and blood pressure and make a urinalysis once a month during the first half of pregnancy, and then every two weeks until the onset of labor, or possibly once a week toward the end. These periodic examinations keep the physician constantly informed about his patient’s condition, and frequently disclose very early symptoms of a complication which is easily amenable to treatment at that stage, but which might prove serious if allowed to progress unchecked. Albumen in the urine, for example, or an increase in the blood pressure, in a woman who had no other symptoms, would suggest the advisability of watching for further symptoms of toxemia; while an elevation of temperature, even though the patient was not uncomfortable, might lead to the early discovery of tuberculosis, pyelitis or some other infection not otherwise apparent.

It is this stitch in time that means so much to the pregnant woman and her expected baby.

But the most painstaking obstetrician requires the co-operation of his patient in innumerable little ways, if she is to have the fullest benefits of his skill; for it is not so much what the doctor advises that counts as how the patient lives.

It is at this point that nurses are more and more being given opportunity for immensely gratifying service. A private patient who is in the care of an obstetrician is, of course, supervised and instructed by her doctor. But there are other patients—women who cannot afford this individual care, but who need care none the less. And it is these expectant mothers that nurses are helping the doctors to instruct in the principles of right living, and are watching for danger signs, through visiting nurse societies, out-patient departments of hospitals and through prenatal clinics.

The character and extent of the instruction and supervision given by the nurses is, of course, decided by the medical board of her organization, and is often affected by the conditions under which the work is conducted. The nurses in a rural community, for example, may take blood pressures and test urine for albumen, while in cities, rich in doctors and medical institutions, these observations might not be among their duties.

In addition to this definite relation to expectant mothers, nurses are meeting them, unofficially and informally, at every turn; women who are needing, but not receiving, care from a doctor or an organization; women who are puzzled or troubled over their condition, but do not know where nor how to obtain advice; women who could employ a physician but do not appreciate the importance of his care.

Every nurse should recognize it as her duty to advise an unsupervised, pregnant woman to place herself under medical care, no matter under what conditions she meets her.

In the discharge of her duties, the nurse will sometimes need no little ingenuity to adapt the routines of prenatal care, as prescribed by her organization, to the mentality, traditions and varied demands of the daily lives of her patients. But this will have to be done, for though in a general way the needs of all expectant mothers are the same, their circumstances and personalities are infinitely varied.

It may require undreamed-of tact and resourcefulness to convince a patient that details of care, which seem wholly unrelated to her or her baby’s welfare, will actually increase their chances for life and health. For this reason, it is of almost prime importance that the nurse win her patient’s friendship and confidence. She will then scarcely realize that she is being taught, but will do and continue to do as she is advised, because of an almost insensible reliance upon the judgment and sincerity of her counsellors.

It is not the single examination of a specimen of urine that counts, nor the exercise taken with pleasure and enthusiasm during the first few days of its novelty. It is not the rest, fresh air nor proper food, taken according to rule for a week or two, that will keep her fit. It is the aggregate and repetition of the infinite number of details that make up the expectant mother’s mental and physical life during twenty-four hours in each day, seven days a week, throughout forty long weeks, that grow longer and more monotonous as pregnancy advances; it is the mosaic that she makes out of the minutiae of her daily life that counts. And paradoxical as it seems, she must shape her days to meet her own and her baby’s needs with such steady persistence that she finally lives them almost unconsciously of what she is doing, and also without introspection.

Obviously, then, the expectant mother’s mental attitude is of considerable importance.

She should in general continue the diversions, work and amusements that she is accustomed to and enjoys, if they are not contra-indicated; cultivate a cheerful, hopeful frame of mind; guard against being self-centred and over watchful of symptoms, and at the same time not adopt the dangerous habit of uncomplainingly ascribing to pregnancy all of the discomforts and unfamiliar conditions which may arise. In short, to forget that she is pregnant in so far as that is consistent with the care that she should take of herself.

She should understand that childbearing is a normal function, but, like other normal functions, may become abnormal if neglected; and that a sick pregnancy is not a normal one.

In connection with the patient’s mental attitude and her anxieties, the nurse may be of great comfort in helping to dispel superstitions and the widely credited and depressing beliefs concerning maternal impressions.

After one has traced the development of the human body in the uterus, and even faintly understood its growth and method of nourishment, it is impossible to believe that the mother’s thoughts or experiences could in any way deform or mark her child, or alter its sex. That the mother’s “reaching up,” for example, could slip the cord around the unborn baby’s neck is manifestly absurd, as well as the previously mentioned superstitions about the eight-month baby’s slender chances for survival.

But superstitions are always fondly cherished, for, as Gibbon tells us, “the practise of superstition is so congenial to the multitude, that if they are forcibly awakened, they still regret the loss of their pleasing vision.” We can scarcely wonder however that even intelligent and educated people hold utterly improbable beliefs about pregnancy, for the most fanciful of them are quite as easy to believe as the thing that we know actually occurs—the development of a human body from a single cell.

These fanciful beliefs, however, are sometimes serious matters to the young woman who is traveling, day by day, toward a great and mysterious event, and they should not be laughed to scorn, but explained away seriously and with sympathy. She may be told quite simply, that after conception she gives her baby only nourishment; that the baby’s connection with her body is through the cord and placenta, in neither of which are there nerves; and that even if the blood could carry mental and nervous impulses, which it cannot, the maternal and fetal blood never come in actual contact with each other. A tale which she has heard about a woman who saw something distressing and later gave birth to a marked child may cease to worry her if she is reminded of the innumerable babies, beautiful and unmarked, which are born to women who have had equally shocking experiences. It is scarcely probable that any woman lives through the ten months of pregnancy without seeing, hearing or thinking things that would disfigure a baby if maternal impressions could produce such results, and yet newborn babies are very rarely blemished. Although the ultimate causes of marks and deformities of the fetus are not definitely known, they are probably to be found in faulty development very early in the embryonic life, and, therefore, are not preventable.

HYGIENE OF PREGNANCY

In coming to the expectant mother’s personal hygiene, we find that an understanding of the physiology of pregnancy almost of itself indicates what this hygiene should include. We shall take it up in detail, however, and describe what is at present considered a reasonable outline of the routine desired for the average pregnant woman, who is found by careful examination to be normal and free from complications, and needing only to keep well. But, as has been said, and must be oft repeated, the ideal routine cannot be deposited _en bloc_ upon all expectant mothers. It must be adjusted to the individual and to her circumstances.

EXCRETIONS. Although, as has been explained previously, the pregnant woman does not have to eat for two, she does have to eliminate the waste and broken-down products from two bodies, through her own excretory organs: the kidneys, skin, lungs and bowels. True, the amount of the baby’s ash is not great, but is of such a character that its elimination is important and increases the strain upon the maternal excretory apparatus.

=Kidneys.= One of the most important factors in prenatal care is promoting the function of the kidneys and watching their output. It is probably more true of the kidneys than of any other organs that a slight abnormality which would not give trouble at other times may, if neglected during pregnancy, produce very grave results. The amount of urine passed in twenty-four hours should be measured, and a specimen prepared, once a month during the first half of pregnancy and every two weeks afterward. If less than three pints are passed the patient should know, without further instruction, that she is not taking enough water and must take more. And so it is the nurse’s duty, in this connection, to convince her patient of the importance of drinking an abundance of water, and periodically measuring her urine and sending specimens to the doctor for examination.

She is very likely to follow such advice if she is told that by so doing she will help to prevent convulsions, for most women know of this complication and dread it.

In preparing a specimen, a covered or corked receptacle which is large enough to hold the voidings for twenty-four hours, must be thoroughly washed and scalded; in it should be collected the total amount of urine voided during twenty-four hours and kept in a place that is cool enough to prevent putrefactive changes. The additional precaution of putting a teaspoonful of chloroform into the receptacle is wise and does not injure the specimen. The patient should be instructed to empty her bladder at any designated hour, and then keep all urine voided from that time until the corresponding hour on the following day. The urine should be shaken so as to mix thoroughly the different voidings, and six or eight ounces poured into a bottle which has been washed and scalded, carefully corked and labelled with the date, patient’s name, address and the total amount for twenty-four hours.

If the nurse is called upon to test for albumen, either of the following will serve, unless the doctor specifies a test which he prefers:

_Heat and acetic acid test_: Fill a test tube about half full of urine and gently boil the upper part in a flame; add five drops of 2% to 5% acetic acid and again boil gently. The presence of albumen is shown by a white cloud in the upper part of the urine.

_Esbach’s test_: Fill a test tube half full of urine; add eight or ten drops of Esbach’s Solution. The presence of albumen is shown by a white flocculent precipitate in the upper part of the urine.

=Skin.= Under ordinary conditions, the skin serves as a protective covering for the body, helps to regulate the body temperature and acts constantly as an excretory organ. This last function is performed by the sweat glands which open upon the surface of the body, and we are told that there are some twenty-eight miles of these minute, tube-like structures in the skin. These glands should be, and usually are, constantly active and they daily pour upon the surface of the body an oily substance that lubricates the skin and something over a pint of water containing waste matter, that is inimical to health if retained in the body. We are not aware of this constant excretion of fluids, which, therefore, is termed “insensible perspiration,” but it continues even in cold weather and must not be interrupted if health is to be preserved. If the oil, dust, particles of dead skin and the waste material left by dried perspiration are allowed to remain upon the surface of the body, they will clog the pores and gland openings and thus interfere with their functions. The removal of this material, then, is an imperative health measure. This is done automatically, in part, for the fluid evaporates, and much of the solid matter is rubbed off on the clothing. But the most important aids to the skin’s activity are the drinking of plenty of water, deep breathing, exercise and warm baths; baths serving the double purpose of removing waste matter already on the surface, and stimulating the glands to increased activity in giving off still more.

This explains the importance to the expectant mother of thorough and regular bathing, and of keeping her body evenly warm. Most doctors advise a warm, not hot, shower or tub bath every day, with soap used freely over the entire body, followed by a brisk rub. The best time for this warm, cleansing bath, as a rule, is just before retiring, as it is soothing and restful and tends to induce sleep. Very hot baths are fatiguing, particularly during pregnancy, and should never be taken except with the doctor’s permission; but cold baths usually may be continued throughout pregnancy if the patient is accustomed to them and reacts well afterwards. Under these conditions the morning cold plunge, shower or sponge is beneficial, as it stimulates the circulation and thus promotes the activity of the skin. Some doctors forbid tub bathing of any kind after the seventh month, on the ground that as the patient sits in the tub her vagina is filled with water, which may contain infective material. Should labor occur shortly afterward an infection might result. As the patient is heavy and somewhat uncertain on her feet, there is also the danger of her slipping and falling while getting in or out of the tub.

Other doctors permit tub baths throughout pregnancy, up until the onset of labor; while as to hot foot baths, there seems to be no reason for or against them at any time during the nine months.

Bathing in a quiet stream or lake is apparently harmless, but sea bathing, if the surf is rough, is inadvisable because of the impact of the waves upon the abdomen and the general violence of the exercise.

The importance of keeping the body evenly warm throughout pregnancy cannot be overemphasized, for a sudden chilling or wetting may so check the excretory function of the skin as to throw a greater burden upon the kidneys than they can meet, in their effort to eliminate the skin’s share of the body waste. Accordingly, a single chilling will sometimes be enough to precipitate an eclamptic seizure. This may be one reason why we see eclampsia more frequently during cold weather or after a sudden drop in the temperature after warm or mild days.

=Bowels.= The bowels, also, eliminate a certain amount of toxic material and if they do not move thoroughly at least once a day, deleterious substances are absorbed into the system and an extra tax is placed upon the kidneys in an attempt to excrete them.

Unhappily, a large proportion of pregnant women suffer from constipation, particularly during the later weeks, though women who have always had a tendency of this kind may have trouble from the very beginning of pregnancy. Sluggish peristalsis, due to pressure by the enlarged uterus upon the intestines, is probably the prime cause, though impaired tone of the stretched abdominal muscles also may be a factor.

The bowels should move regularly every day, and to this end the patient should regularly attempt to empty them, immediately after breakfast usually being the best time. The importance of regularity in making the attempt cannot be overemphasized, even though the bowels do not always move.

Exercise, the intake of an abundance of fluids, eating fresh fruit, coarse vegetables and bulky cereals, such as bran, to stimulate peristalsis, and drinking a glass of hot or cold water upon retiring and arising are all laxative in their effect. As the regular use of enemata only tends to lessen intestinal tone, they should not be employed unless ordered by the doctor; nor should the patient take cathartics without the doctor’s order. But she may safely increase the amount of her fluids and the bulk of her food, in order to regulate her bowels, and may also take senna and prunes cooked together. A simple way of preparing prunes for this purpose is to pour a quart of boiling water over an ounce of senna leaves and allow it to stand for about two hours. A pound of well washed prunes should soak over-night in this infusion, which has been strained, and the combination cooked until tender. They may be sweetened with two tablespoons of brown sugar, and the flavor improved by adding a stick of cinnamon or slice of lemon while they are cooking. Half a dozen of these prunes, with some of the syrup, may be taken at the evening meal to start with, and increased or decreased in number as necessary.

CLOTHES. The chief purpose of clothes under all conditions is to aid in keeping the body warm, thus helping to preserve an even circulation and the activity of the sweat glands. As has been pointed out, this is of especial importance during pregnancy. The expectant mother’s clothes should be not only sufficiently warm, but they should be equally warm over the entire body. They should be light and porous, and fairly loose, so as not to interfere with the circulation or other body functions. There must be no pressure on chest or abdomen; no tight garters, belts, collars or shoes.

The patient’s clothes, like every other detail in her care, will have to be adapted to her environment and mode of living. If her house is well and evenly heated during the cold months, she may quite safely dress lightly while indoors; if it is not, she should be advised to wear underwear with high neck, long sleeves and drawers, both indoors and out, except when the weather is warm enough to induce free perspiration. At all times, however, the warmth of her clothing must be adjusted to the temperature of the home, the climate and to the state of the weather.

Bearing in mind the importance of diversion and amusements, it becomes apparent that in addition to the hygienic qualities mentioned, the expectant mother’s clothes should be as pretty and becoming as is consistent with her circumstances. She is much more likely to go about and mingle with her friends if she is fortified with the consciousness that she is becomingly and well dressed. Which, of course, is not peculiar to pregnant women.

The expectant mother’s clothes should be so made that their weight will hang from the shoulders instead of from the waistband.

And that brings us to the question of _corsets_, one of the most discussed garments in her wardrobe. Women who have not been accustomed to wearing corsets will scarcely feel the need of adopting them during pregnancy, except perhaps during the later weeks when the heavy, pendulous abdomen needs to be supported for the sake of comfort. This is particularly true of women who have borne children and whose flaccid abdominal walls give but poor support to the uterus.

Women who have been wearing comfortable, well-fitting corsets probably will not feel the need of making a change until the third or fourth month. By this time the uterus has pushed up out of the pelvis into the abdomen and accordingly the corsets must be so constructed that they will accommodate themselves to an abdomen that is steadily increasing in size and also changing in shape; will provide support for both abdomen and breasts and still not compress nor disguise the figure. To be entirely satisfactory in their adjustability, the maternity corsets must be made of very soft material and have elastic inserts and side, as well as front or back lacings. They should extend well down in front and fit snugly over the hips. The upper part may be fitted with adjustable shoulder-straps that will support the breasts and help to suspend some of the abdominal weight from the shoulders; but at the same time will not interfere with the development of the breasts nor compress the nipples. Many women find great comfort in wearing a short-waisted maternity corset and a brassiere.

The front-lace corset is usually found to be the most satisfactory, for the patient may lace it from below upward while lying on her back. This enables her to draw it in snugly about the hips, below the abdomen, and adjust the garment to the abdominal curve so as to really support, without compressing the uterus. Other excellent corsets lace both front and back and are capable of very comfortable adjustments. If the nurse clearly understands the purpose of a maternity corset, she will be able to explain to her patient why the same style as she ordinarily wears, no matter how large, will not be satisfactory during pregnancy, and may be even harmful.

Even a properly fitting maternity corset may become uncomfortable during the last few weeks of pregnancy, and have to be replaced by an abdominal supporter of linen or rubber. And when this stage is reached, even the woman who has worn no corsets may be made more comfortable by adopting such a support, particularly at night. There are many admirable binders on the market, or the nurse and patient may fashion some such an one as is shown in Figs. 34, 35, 36 and 37. Comfortable and inexpensive stocking supporters, which meet all practical requirements, may be made by the patient from tapes or strips of muslin. (Figs. 38 and 39.)

The expectant mother’s _shoes_ also merit considerable attention and thought. Her feet are larger than usual because they are likely to be somewhat swollen during the latter part of pregnancy, and the increased weight of her body tends to spread them. This added weight also increases the strain put upon the arch and flat foot is a not infrequent result, unless the arch is well supported. Another reason for the need of proper shoes is that, as pregnancy advances, the body’s centre of gravity changes. The pregnant woman becomes unstable on her feet and needs low, broad, firm heels. They need not necessarily be flat at first, if the patient has been accustomed to wearing moderately high ones, for the sudden lowering of the heels may injure her arches. High French heels, of course, should be avoided because they not only increase the difficulty and discomfort of walking but cause backache, as well, by forcing a posture that adds to the pressure on the lower part of the abdomen. They also increase the risk of turning the ankles, tripping and falling.

The patient’s shoes should be an inch longer than those she ordinarily wears; they should have broad toes and fit snugly over the instep, in spite of being large. If her shoes are not comfortable the expectant mother will tire easily and tend to take less exercise than she should.

DIET.—It is advisable for both nurse and patient to understand, and keep clearly in mind, the purposes which are served by the food intake of the expectant mother, and what foods and practices will defeat, and what will accomplish these purposes. Her food should provide nourishment, as under ordinary conditions; it should promote the functions of her skin, kidneys and bowels, because of the waste from her own and her baby’s body which she must excrete; it should be adequate to build and nourish the baby’s body without drawing materials from the mother’s own tissues. Moreover, proper food during pregnancy is an essential factor in preparing the mother to nurse her baby, which is as important as nourishing the fetus _in utero_.

In order to accomplish these various ends the patient must not only eat suitable food, but she must digest and assimilate it. This requires that she sedulously guard against overeating, constipation and indigestion of any kind. Indigestion may be avoided during pregnancy exactly as it is at other times, by eating proper food; by cultivating a happy frame of mind; by exercise, fresh air, adequate rest and sleep.

If accustomed to a fairly simple, well-balanced, mixed diet, the average expectant mother will need to make little or no change, excepting to make her evening meal light if it has been a hearty one; for she uses her nutritive material with surprising economy and does not have to “eat for two,” as is so commonly believed. It is a safe general principle that an amount and kind of food that keeps the expectant mother, herself, in a state of health and good nutrition, is favorable to satisfactory development of the fetus until the latter part of pregnancy.

She will probably be able to understand why this is true if it is explained that her baby gains nine-tenths of his weight after the fifth month, and one-half of his weight during the last eight weeks of pregnancy; also that if she takes too much food, the excess is stored up in both her own and the baby’s tissues; if too little, the fetus is nourished and her body deprived.

It is very unwise for the mother to diet with the idea of keeping the child small, and thus make labor easy, unless she is so ordered by her physician. In general, it is the size of the fetal skull that makes labor easy or difficult, and not the amount of fat distributed over the child’s body. And if the patient cuts down the minerals in her diet to make the fetal bones soft, and thus increase the compressibility of the skull, the fetus will extract lime from her bones and teeth, so that the only effect is upon herself.

The expectant mother’s meals should be taken with clock-like regularity, eaten slowly and masticated thoroughly. Three meals a day will usually suffice during at least the first half of pregnancy. The possible need for slight additional food after that may be supplied more satisfactorily by lunches of milk, cocoa or broth and crackers or toast, between meals and upon retiring, than by taking larger meals. But if the patient has a tendency to nausea, early in pregnancy, she will often be able to control it by taking a little food regularly five or six times daily, instead of the usual three meals.

In general the expectant mother should eat an abundance of fruit and vegetables, taking at least some uncooked fruit and a green salad, daily, and making sure that her food contains a good deal of residue, such as is provided by fruit and coarse vegetables. This residue increases the bulk of the intestinal contents, which stimulates peristaltic action and thus helps to overcome the tendency toward constipation. As fat is less easily digested, and more likely to cause nausea during pregnancy, than carbohydrates, it is better for the patient to eat no more fat than usual, but to supply the additional energy needed after about the sixth month, by taking a little more starch. But after all, only a slight increase is needed, and this chiefly during the last three or four weeks.

It is of the greatest importance that every pregnant woman drink an abundance of fluid, to act as solvent for her food and waste material, and stimulate the activity of her kidneys, skin and bowels. She needs about three quarts daily, and most of this should be water, the remainder consisting of milk, cocoa, soup, and other liquids.

Alcohol should not be taken under any circumstances, except upon a doctor’s order, while tea and coffee, if taken at all, should be used with moderation. The patient should be advised to avoid fried food, pastry, rich desserts, rich salad-dressings and any other food which would ordinarily disagree with her. In fact any article of food that disagrees with her in a non-pregnant state should be avoided during pregnancy, no matter how valuable it may be as nourishment to the majority of people.

On the other hand, it sometimes happens that an article of food which is likely to disagree with other people will be easily digested by the pregnant woman, and if it adds to the pleasure of her meals should not be taboo, for the enjoyment of one’s meals promotes digestion. So-called “cravings” are not as common in fact as they are in rumor, but the expectant mother may have a capricious appetite and display strange likes and dislikes for certain dishes, possibly because of her tendency to be nauseated.

The average pregnant woman with no symptoms of complications will be able to supply her needs, and at the same time keep within the bounds of safety if she selects her diet from such groups as the following:

ANIMAL FOODS.—Milk and eggs are the most satisfactory, but for the sake of variety, and to tempt her appetite, she will usually be allowed to have fish, the various kinds of shell fish, beef, lamb, chicken or game rather sparingly, preferably only once a day. Pork, veal, and goose should be avoided as a rule, and particularly by women with whom they ordinarily disagree.

SOUPS.—Thin soups and broths have little food value, but, because of their appetizing flavor and aroma, are an aid to digestion, and frequently will stimulate a flagging appetite and prompt the patient to eat and assimilate more than she would without them. Cream soups and purées obviously have a high food value, and, like thin soups and broths, also supply a definite amount of fluid which the patient must have.

VEGETABLES.—The group of vegetables usually designated as “leafy” are of even greater importance to the expectant mother than they are to the average person. Of these, she may safely eat onions, asparagus, celery, string beans, spinach, and make a point of taking a green salad, such as lettuce, cress, or romaine, at least once daily. Sweet potatoes, white potatoes, rice, peas, Lima beans, tomatoes, beets and carrots may also be eaten with safety as a rule, but cabbage, cauliflower, corn, egg-plant, Brussels sprouts, parsnips, cucumbers, and radishes should be taken with great caution and avoided altogether if they cause flatulence or any kind of distress.

FRESH FRUITS.—A necessary part of the diet is fresh fruit, and among those fruits which are both beneficial and harmless are apples, peaches, apricots, pears, oranges, figs, cherries, pineapple, grapes, plums, strawberries, raspberries, blackberries, and grapefruit. These are more likely to be laxative if eaten alone, as before breakfast and at bedtime. Cooked fruits are also valuable articles of diet, but are probably less laxative than raw fruit. Some of the citrus fruits, oranges, grapefruit and lemons, should be taken daily because of their antiscorbutic properties.

CEREALS.—For their nourishing and laxative qualities, cereals are important, and their food value is increased by the milk and cream which are usually taken with them. Cooked cereals should invariably be cooked longer than the usual directions suggest. Bran, eaten alone, as a cereal or in combination with other grains, is an excellent laxative.

BREADS.—Graham, cornmeal, whole wheat and bran bread are all good. In general the expectant mother will be on the safe side if she eats sparingly, if at all, of very fresh or hot breads and hot cakes.

DESSERTS.—Desserts are very important for they add to the attractiveness of most people’s meals, and if wisely chosen and properly made, may supply a good deal of easily digested nourishment. They may include, in addition to fresh and cooked fruits and preserves, ice-cream, a wide variety of custards, creams and puddings made largely of milk, eggs, and some ingredient to give substance and firmness, such as gelatine, cornstarch, rice, tapioca, farina, arrow-root and similar materials.

FRESH AIR AND EXERCISE. If the nurse has become aware of the value of promoting all of the normal physiological processes of the pregnant woman, she already realizes how important are fresh air and exercise to the patient and her expected baby.

The average individual uses every minute the oxygen contained in four bushels of air, and since the pregnant woman takes in through her lungs the oxygen for both herself and the baby, she must have an adequate quantity of constantly changing air to supply at least this amount. She should spend at least two hours of each day in the open air. If the weather is so stormy or severe as to make it undesirable for her to go out from under cover, because of the danger of getting wet or chilled, she may wrap up well and take her airing on a protected porch or in a room with all of the windows wide open. But this is only a part of it, for the air in her house, or rooms, must be kept fresh all day by being constantly changed; this requires a steady inpouring of fresh air and outpouring of stale, vitiated air.

A very good way to accomplish this is to have one or more windows open slightly, top and bottom, all the time. But there must be no sudden changes of temperature, nor drafts, for fear of chilling the patient’s skin. At night she should sleep in a room with the windows open, taking care to be well protected by light, warm coverings.

Each detail of the expectant mother’s daily routine seems to be more important than the last. And so when we come to the question of regular outdoor exercise we almost think that whatever else may be neglected, this is indispensable, since it promotes digestion, stimulates the functions of the skin and lungs; steadies the nerves, quiets the mind and promotes sleep. And more than that, walking, which is probably the most satisfactory form of exercise, also strengthens some of the muscles that are used during labor. But exercise is downright injurious if continued to the point of fatigue, no matter how little has been taken. Each woman must be a law unto herself in this matter, therefore, and must be impressed with the importance of stopping before she is tired. She should start by walking only a short distance, increasing gradually until she is able to walk possibly as much as an hour in the morning and an hour in the afternoon, if she can do so without fatigue.

All violent exercises and sports are of course to be avoided, particularly swimming, horseback riding, and tennis. While motoring and carriage riding are pleasant diversions, they cannot be classed as exercise. They should be taken only in comfortable vehicles and over smooth roads, so that there will be no jarring nor jolting, and the patient should not do the driving herself.

A certain amount of exercise, in the shape of light housework, may be taken indoors. It is distinctly beneficial, if not continued to the point of fatigue, both because of the exercise which it provides, and also the diversion and interest, for these promote mental and physical health. But this indoor exercise must not interfere with, nor to any degree replace, the daily exercise out of doors; nor must it include heavy work, such as washing, sweeping, heavy lifting, running a sewing machine by foot nor much running up and down stairs. However, the amount and kind of work which a woman may comfortably and safely do are so related to what she has been accustomed to, that it is not possible to offer more than general suggestions, which will help in the planning for each individual. All patients will do well to moderate their activities at the time when they would ordinarily menstruate.

There are patients to whom massage and gymnastics are beneficial during pregnancy, when for some reason the out-of-door activities are contra-indicated. This might be true of a patient with heart trouble, for example, or one who is being kept in bed to avert an abortion, and accordingly is a matter which must be entirely in the doctor’s hands.

REST AND SLEEP. When we studied the bony structures of the female body, we found that as the abdominal tumor of pregnancy increased in size and weight, the body’s centre of gravity changed and the pregnant woman was required to make a constant, though unconscious effort to stand upright. This is probably one reason for the fatigue which expectant mothers so often feel without apparent cause, and for the fact that they are likely to tire rather more easily than usual.

Accordingly, the patient may have to rest frequently during the day, in order to avoid the ill effects of fatigue. She should work and exercise in short periods rather than long, always lying down when tired, and for an hour or two after the noon meal. She must be particularly careful not to be over-active, nor to overexert herself at the time when menstruation would occur were she not pregnant, for fear of bringing on an abortion. This precaution is particularly important during the first four months, the period when abortions occur most frequently.

Since eight hours’ sleep is usually considered necessary to keep the average person in good condition, the pregnant woman cannot expect to progress satisfactorily with less. In fact, it is so important to her general well-being that she should be taught and persuaded to do everything in her power to secure it.

Fresh air during the day and open windows at night; prudent eating; a comfortable bed furnished with warm but light bedding; warm baths; a hot water bag to the feet and a hot drink upon retiring are all conducive to sleep.

But in addition to these, and perhaps of even more import, are cheerfulness and a tranquil, untroubled state of mind. It is well for the nurse to make a mental note of that intangible but influential fact, for she can usually exert a great deal of influence in shaping her patient’s or patients’ moods.

BREASTS.—Breast feeding is the most urgent single need of the baby, for whose coming we are making preparation, and practically every mother, excepting those with definite physical disability, can supply this need of her baby’s, if she gives herself proper care both before and after its birth. It is true, that everything that promotes her general health helps to prepare her to nurse the baby, but there is need also for care of the breasts and nipples themselves, to make the nursing satisfactory, and to prevent sore nipples and possibly even breast abscesses.

Briefly, this local care consists of supporting heavy breasts, but avoiding pressure; bringing out flat or retracted nipples and toughening the skin which covers the nipples.

After they become heavy and uncomfortable the breasts may be supported by brassieres, which are snug below the breasts, loose over the breasts themselves and suspended from shoulder straps; or by some such binder as is shown in Figs. 34, 35, and 36, which answers the same purpose.

If the patient’s nipples are flat or retracted, she should begin about the fifth month to make them more prominent in order that the baby may grasp them easily. There are several ways of accomplishing this, all of them in the nature of massage, but whatever is done must be done regularly and persistently. One simple and effective method is to grasp the nipple between the thumb and forefinger, draw it out, hold it for a moment, then release it and allow it to retract. This should be done over and over, two or three times daily. Or the unstoppered opening of a warm bottle may be placed over a flat nipple and held in place until the nipple is drawn up into the neck of the bottle as it cools and forms a vacuum.

The toughening of the nipples should be begun eight weeks before the baby is expected. There are two general methods which seem to give about equally satisfactory results; one is to harden the skin with astringents and the other is to soften it with ointments. In either case, the nipples should first be scrubbed gently with a soft brush or cloth, warm water and soap, for about five minutes night and morning. They may then be rubbed with lanoline, cocoa-butter or vaseline and covered with a piece of clean soft cloth or gauze, to protect the clothing; or they may be bathed with a wash consisting of equal parts of a saturated solution of boracic acid and 95% grain alcohol. Tannin, benzoin and a great variety of astringents are also used, and with satisfactory results. But the essential is to decide upon some method of preparation, of proved value, and then persuade the patient to employ it with faithful regularity.

CARE OF THE TEETH. It is important that the pregnant woman give her teeth excellent care, for in addition to the conditions with which we all have to cope, she must combat the effect of her tendency to have an acid stomach. And her teeth are prone to decay and crumble, since the fetus extracts lime salts from her bones and teeth, unless she is careful to take in through her food a supply which is adequate to meet the fetal needs. It is therefore advisable for her to place herself under the care of a dentist, as soon as she knows of her pregnancy, and have any necessary work done at that time, as delay may be serious.

Some physicians think it advisable to have an X-ray examination of the teeth made as a routine, in order to discover any existing pockets of pus at the apices of devitalized teeth. They feel, that because of the somewhat unstable condition of the pregnant organism, these localized infections are more of a menace to the expectant mother than to the ordinary individual, and that in some cases they should be drained.

As to daily care of the teeth, the patient should use dental floss and brush her teeth after each meal, and use an alkaline mouth wash several times daily, particularly after vomiting and before retiring. Much damage may be done by the acid secretions in the mouth if they are allowed to bathe the teeth through the long night stretches. Common cooking-soda, lime-water or milk of magnesia make excellent mouth washes.

TRAVELING. In this day, when people travel so much and so easily, it is common to hear discussions as to its advisability for the prospective mother. Like many other details of prenatal care, this point cannot be settled once for all women, nor for all stages of pregnancy. Each patient’s general condition must be considered; her tendency to nausea; the length of the journey and the ease with which it may be made, and whether or not she has ever had, or been threatened with an abortion. In general, traveling is less hazardous for the expectant mother to-day than it was formerly, to just the extent that it causes less strain, discomfort and fatigue. But as a rule it is considered wise for her to avoid traveling during the first sixteen and the last four weeks of pregnancy, and at the times when menstruation would ordinarily occur. Obviously, then, in the interests of prevention, a journey should not be undertaken at any time without a physician’s approval.

The _marital relation_ is usually considered inadvisable in all cases after the eighth month of pregnancy, and among women who have had abortions or miscarriages it is best omitted throughout the entire period of gestation. This is particularly true of elderly primiparæ.

COMMON DISCOMFORTS DURING PREGNANCY

There are many minor disturbances which overtake the pregnant woman, and though not serious in themselves, her comfort is greatly increased by having them relieved, and this promotes her general welfare. The relief of these discomforts, when they are slight or only temporary, sometimes resolves itself into little more than a question of nursing. When long continued or severe, however, they constitute complications which the doctor treats accordingly.

=Nausea and vomiting= are probably the commonest disturbances of pregnancy and vary from the slightest feeling of nausea when the patient first raises her head in the morning, to persistent and frequent vomiting which then assumes grave proportions and is termed “pernicious vomiting.” Although it is possible that even the slightest nausea is due to a mild toxemia, there can be no doubt that in many instances the patient’s mental attitude is an important factor.

Dr. Slemons makes the interesting observation, that women who are unaware of their pregnancy for several months are seldom troubled with nausea, while those who erroneously believe themselves to be pregnant will suffer from this well-known symptom of pregnancy, until convinced of their mistake. The nausea then subsides.

As there is a marked tendency toward nausea during early pregnancy, it may be brought on by slight causes which would not produce it under ordinary conditions. Anxiety, grief, fright, shock, incessant worrying, fits of rage, introspection, brooding, or any great emotional stress may cause nausea when the diet is entirely satisfactory. But indiscretions in diet, rapid or over-eating also may cause nausea and vomiting in the expectant mother.

We seem to get back to the principles of personal hygiene as preventives of nausea during pregnancy, for simple, light food, taken in small quantities five or six times daily, eaten slowly and masticated thoroughly; the cultivation of a happy frame of mind; exercise and fresh air all tend to avert this very uncomfortable condition. Its prevention is of great importance, as the habit of vomiting is easily acquired but broken with difficulty. The common causes of nausea, and their prevention, should therefore be explained to the average patient, for she will then be able to help herself in warding it off.

Should “morning sickness” occur, however, it may be relieved in many cases, by eating two or three hard, unsweetened crackers or pieces of toast, with nothing to drink, immediately upon awakening and then lying still afterwards for half or three quarters of an hour. The sufferer should then dress slowly, sitting down as much as possible while doing so, and eat her regular breakfast. Lying flat, without a pillow, and keeping very quiet for a little while after meals, or whenever feeling the slightest premonitory symptom, will frequently prevent, and also relieve nausea, and sometimes comfort is derived from the use of either hot or cold applications to the abdomen. Some patients are relieved by having hot coffee or even a full breakfast before arising.

=Heartburn=, so called, which is experienced by many pregnant women, has nothing to do with the heart. It is caused solely by an excess of hydrochloric acid in the stomach, and is usually described as a burning sensation first in the stomach, then rising into the throat. It may be prevented, as a rule, by taking a tablespoonful of olive oil, or a cupful of cream or rich milk, fifteen or twenty minutes before meals, and avoiding fat and fried food at the meals immediately following.

This apparent inconsistency in treatment is due to the facts that fat taken into the empty stomach tends to inhibit the secretion of acid, while fat and fatty foods taken with meals tend to prolong their stay in the stomach and this in turn stimulates the secretion of hydrochloric acid, the thing to be avoided.

A patient with a tendency to heartburn will be wise, therefore, if she generally eliminates oils, fats and fatty foods from her meals, and definitely avoids them when the burning occurs. Since the painful, burning sensation is directly due to an excess of acid in the stomach, the obvious step toward relief is to take an alkali at once. A tablespoonful of lime-water is often satisfactory; a teaspoonful of sodium bicarbonate in water; a small piece of magnesium carbonate may be nibbled by itself, or any alkaline water that the patient fancies may be taken.

=Distress.= There is another form of discomfort, often vague and ill-defined, commonly called “distress” and occurring after eating. It may be neither heartburn nor pain, but resemble both and make the patient very miserable. It is usually seen in women who eat rapidly, do not chew their food thoroughly or eat more at one time than the stomach can hold comfortably. The prevention, naturally, lies in taking small amounts of food slowly and masticating thoroughly.

=Flatulence= may or may not be associated with heartburn, but it is fairly common and rather uncomfortable. It is usually due to bacterial action in the intestines, which results in the formation of gas. As has been previously explained, the pressure of the enlarged uterus upon the intestines and absence of pressure by the abdominal muscles, retards normal peristalsis, with the result that gas sometimes accumulates to a very uncomfortable extent. It is clear, therefore, that a daily bowel movement is of prime importance in preventing and relieving flatulence, and also that foods which form gas should be carefully excluded from the diet. The chief offenders are parsnips, beans, corn, fried foods, sweets of all kinds, pastry and very sweet desserts. Various intestinal disinfectants are employed, as in non-pregnant states, and also yeast cakes, cultures of Bulgarian bacilli and artificially fermented milk containing bacteria that are antagonistic to the gas-producing forms.

In the opinion of some doctors, flatulence is sometimes an early symptom of toxemia.

=Diarrhea.= Although diarrhea is not one of the commonest disturbances of pregnancy, neither is it infrequent, and must be borne in mind in connection with digestive troubles. Of course, a pregnant woman may have an attack of diarrhea from the same causes that produce it in any one else, and its relief would be obtained by the usual methods, chiefly the correction of dietetic errors. But on the other hand, it may be due entirely to the uterine pressure on irritable intestines. Like flatulence, it is regarded by some doctors as a possible symptom of toxemia.

PRESSURE SYMPTOMS. Under the general heading of pressure symptoms are several forms of discomfort resulting from pressure of the enlarged uterus on the veins returning from the lower part of the body, thus interfering with the flow of blood back to the heart. As both the cause and relief of these symptoms are associated with the force of gravity, the nurse will usually know what to do in mild cases without further explanation. In general the heavy abdomen should be supported by a binder or properly fitting corset, the patient should keep off her feet as much as possible and elevate the swollen part.

The commonest pressure symptoms are swollen feet, varicose veins, hemorrhoids, cramps in the legs and shortness of breath, and though they may appear at any time during the last half, of pregnancy, they grow progressively worse as pregnancy advances.

=Swelling of the feet= is very common, and when very slight may not be serious nor particularly uncomfortable. The edema may be confined to the back of the ankle, which grows white and shining, or it may extend all the way up the legs to the thighs and include the vulva. Sitting down, with the feet resting on a chair, or lying down with the feet elevated on a pillow will naturally give a certain amount of relief. If the swelling and discomfort are extreme the patient may have to go to bed until they subside, but very often she will secure adequate relief by elevating her feet for even a little while, several times a day. But while employing these harmless, and clearly indicated measures, to make her patient comfortable, the nurse must be keenly alive to the fact that while edema of the feet, legs and vulva may be of solely mechanical origin, they are also symptoms of toxemia, about the most dreaded complication of pregnancy. And as recognition of the earliest signs of toxemia is among the triumphs of prenatal nursing, even the slightest swelling must be reported to the doctor and immediate steps taken to have the urine measured and examined.

=Varicose veins= are not peculiar to pregnancy, but are among the pressure symptoms which frequently accompany this condition during the later months, particularly among women who have borne children. The superficial veins in the legs will often be equal to the tension put upon them the first time, but will give way as the strain is repeated during subsequent pregnancies. The distension of the veins is not serious as a rule, but may be very uncomfortable; this, coupled with the unsightly appearance, sometimes has a bad mental effect. Varicose veins may occur in the vulva, but they are usually confined to the legs, and both legs are about equally affected. But as the position of the child _in utero_ may exert greater pressure on the right than on the left side, the veins on that side may be more distended; or the right side alone may be affected.

Relief is obtained by keeping off the feet, and particularly by elevating them and also by the use of elastic bandages. When a woman finds it difficult or nearly impossible to sit or lie down for any length of time, she may accomplish a great deal in a few moments by lying flat on the bed with her legs extended straight into the air, at right angles to her body, resting against the wall or head board, as shown in Fig. 40. This right-angled position for five minutes, three or four times a day will accomplish wonders in reducing varicose veins.

In addition to posture, a spiral elastic bandage will give relief and help to prevent the veins from growing larger, if applied freshly after each time that the leg is elevated. The most satisfactory bandages, from the standpoint of expense, comfort and cleanliness, are of stockinette or of flannel cut on the bias, measuring three or four inches wide and eight or nine yards long. If made of flannel, the selvedges should be whipped together smoothly so that there is neither ridge nor pucker at the seam. The bandage should be applied spirally with firm, even pressure, starting with a few turns over the foot to secure it, and leaving the heel uncovered, carried up the leg to a point above the highest swollen vessels. As a rule, it may be left off at night.

There are satisfactory elastic stockings on the market, but they are expensive, often cannot be washed and seem to offer no advantage over the bandages.

Engorged veins in the vulva may be relieved by lying flat and elevating the hips, or by adopting the elevated Sims’ position for a few moments, several times a day. (Fig. 41).

=Hemorrhoids= are virtually varicose veins which protrude from the rectum, but, unlike those in the legs, are extremely painful. As it is the straining incident to constipation that causes these engorged veins to prolapse, this condition constitutes one more reason for preventing constipation. A pregnant woman whose bowels move freely every day rarely has hemorrhoids.

Should hemorrhoids appear, the first step is to have them gently pushed back into the rectum. The patient can usually do this for herself, quite satisfactorily, after lubricating her fingers with vaseline or cold cream. Lying down, with the hips elevated on a pillow; the application of an ice bag, cold cloths or witch-hazel compresses to the anus will almost always give relief. When the condition is severe, the physician may prescribe medicated ointments, lotions or suppositories, but operation is seldom resorted to during pregnancy, for fear of bringing on labor prematurely. Sometimes the hemorrhoids are worse during the first few days after labor, but as a rule they disappear with the removal of the cause, which in this case is pressure made by the enlarged uterus.

=Cramps in the legs=, numbness or tingling may be caused by the pressure of the large, heavy uterus upon nerve trunks supplying the lower extremities. The recumbent position; applying heat and rubbing the painful areas will often give comfort.

=Shortness of breath= is sometimes very troublesome toward the end of pregnancy, and, as may be easily seen, is due to the upward, and not downward pressure of the uterus. For this reason it is aggravated by the patient’s lying down and relieved by her sitting up or being well propped up on pillows, or a back rest.

=Vaginal discharge.= The normal vaginal discharge is greatly increased during the latter months of pregnancy, as was pointed out in Chapter V, so that ordinarily the moderately profuse yellowish or white discharge at this time has no particular significance. Its existence should be noted, however, and brought to the doctor’s attention, for a very profuse discharge is likely to be regarded as a possible evidence of gonorrhea. For this reason a smear is usually made, when the discharge is excessive, to establish or eliminate this diagnosis; if it is positive, it indicates the necessity for treatment to safeguard both mother and baby.

As the normal vaginal discharge has antiseptic properties, it should not be removed by douches, which many patients are eager to take; but if it is irritating and causes itching or burning the patient may be made entirely comfortable by avoiding the use of soap and by bathing the vulva with a solution of sodium bicarbonate or with olive oil.

=Itching of the skin= is a fairly common discomfort, and is possibly a result of irritating material being excreted by the skin glands and deposited upon the surface of the body. The local irritation usually may be allayed, if not very severe, by bathing the uncomfortable areas with a solution of sodium bicarbonate, or a lotion consisting of a pint of lime-water, half an ounce of glycerine and thirty drops of carbolic acid. It is a good plan, also, for the patient to increase the amount of fluids which she is taking, in order to promote the activity of the skin, kidneys and bowels, and thus dilute the material that may be responsible for the itching and increase its elimination through all channels. In other words the itching may be due to a mild toxemia.

Some women complain of discomfort caused by the stretching of the skin over the enlarged abdomen, which becomes so tense it feels as though it might tear apart. There is a very old and widely current belief that this sensation may be relieved by rubbing the abdomen with some kind of an oil or ointment. And, moreover, that such oiling will not only increase the elasticity of the superficial layers of the skin, but the deeper layers as well, and that by this means striæ may be prevented. There seems to be little foundation for the fear that the skin will tear, or belief in the efficacy of the oiling, but if a woman fancies that she is safer and more comfortable after oiling her abdomen, there is certainly no reason why she should not do so.

EARLY SIGNS OF COMPLICATIONS OF PREGNANCY

It is evident that by teaching the principles of personal hygiene to the expectant mother so convincingly that she will adopt them, and sometimes, by employing simple nursing procedures to relieve the various discomforts of pregnancy, much will be accomplished toward promoting the welfare of both the patient and the expected baby. But this is not enough. The nurse must also be on the alert to detect and report the early symptoms of complications, for there may be times when she will be the first one to see the patient after a symptom has developed.

The principal complications of pregnancy which are amenable to preventive or early treatment are the toxemias, premature terminations of pregnancy and hemorrhage.

The causes of these conditions and the details of treatment and nursing care are so inextricably associated with each other that they are discussed together and at some length in another chapter. But their most conspicuous, early signs are briefly noted here, since watching for them constitutes a part of routine prenatal care.

The =toxemias= are apparently caused by disturbed metabolism and impaired or inadequate excretory processes. Their prevention is to be accomplished largely by observing the principles of personal hygiene previously described, and in quickly treating early symptoms. One of the commonest of these symptoms is headache, sometimes persistent and very severe. Others are disturbed vision, dizziness and more persistent or severe vomiting than could reasonably be called “morning sickness”; puffiness under the eyes, or elsewhere about the face, or of the hands; anything more than very slight swelling of the feet and ankles; high or increasing blood pressure; mental depression; albumen in the urine, amounting to more than a trace, and epigastric pain, are all possible symptoms of toxemia. A patient in whom even one of these symptoms appears is usually placed under close observation; frequently put to bed and her diet restricted to milk, or even water, until the symptoms subside.

The common symptoms of =premature termination of pregnancy=, (an abortion, miscarriage or premature labor) are bleeding, with or without pain in the small of the back, followed by cramp-like pains in the abdomen. Bleeding or a bloody discharge, therefore, irrespective of pain should be regarded as a symptom of pending labor and the patient should be put to bed promptly, and kept quiet. Preventive treatment, after pregnancy has begun, consists largely of rest, particularly at the time when menstruation would ordinarily occur; avoidance of physical shocks and of overwork during the later weeks. Prolonged failure on the part of the patient to feel fetal movements or of the nurse or doctor to hear the fetal heartbeat after they have once been manifest usually indicates the death of the child and precedes its expulsion.

=Bleeding=, or a sudden increase in the size of the uterus with a rapid pulse or general symptoms of shock, may be the symptoms of hemorrhage caused by placenta prævia or premature separation of a normally implanted placenta; upon the appearance of any one of these signs the patient should be put to bed and kept absolutely quiet.

To sum up, we find that the following symptoms may be forerunners of serious complications, and therefore should be watched for and reported to the doctor immediately upon their discovery:

1. Persistent or severe vomiting.

2. Persistent or severe headache.

3. Dizziness.

4. Disturbed vision or the appearance of black spots before the eyes.

5. Puffiness under the eyes, or elsewhere about the face.

6. Swelling of the feet, ankles or hands.

7. Sharp pains, particularly in the epigastric region.

8. Prolonged failure to feel fetal movements after they have once been felt.

9. Cessation of the fetal heartbeat, or a marked change in its rate or rhythm.

10. Bleeding, or a bloody discharge.

11. Pain in the lumbar region, followed by cramp-like pains in the abdomen, before the expected date of confinement.

12. Albumen in the urine.

13. High, or increasing blood pressure.

14. Unwarranted mental depression, anxiety or apprehension.

These are generally accepted as the cardinal danger signs of pregnancy, any one of which, alone or in combination with one or more of the others, is of significance and should be reported to the doctor at once.

When all is said and done, our wish for the expectant mother is for little more than that she shall live a normal, wholesome life; that she shall be willing, and also be able to weave into her every day life the principles of personal hygiene which every one should adopt; that she shall be carefully watched for complications throughout the entire period of pregnancy, and that these complications shall be speedily treated.

Adoption of personal hygiene, then, and prevention of complications by their early detection and treatment—these we want for every woman who is looking forward to motherhood.

For lack of these things there are sick and blind and maimed babies and invalid women; there are lonely, motherless children and bereaved mothers in every corner of our land.