CHAPTER XVI

THE NURSING MOTHER

Not infrequently the nurse remains with her patient after the end of the puerperium, and therefore she may have the care of the mother and baby for several weeks, or even months. The most valuable single service which she can perform in this capacity is to help in making it possible for the mother to nurse her baby at the breast. For both the nurse and the mother must realize that the breast-fed baby is much more likely to live through the difficult first year, and is markedly less susceptible to disease and infection than is the bottle-fed baby.

The first step is to convince the young mother of what it means to her baby and her obligation to try to nurse him, since, excepting under very rare and unusual conditions, she can nurse him if she wants to enough to make the necessary effort and sacrifice.

The important contra-indications for attempting breast-feeding are retracted nipples, tuberculosis, eclampsia, severe heart or kidney disease and certain acute infectious diseases such as typhoid fever.

It seldom happens that the mother who has had average prenatal care, followed by good care during and after delivery, is unable to nurse her baby if she orders her life in the way that is known to be necessary to promote and maintain lactation. The first essential is her real desire to nurse her baby; next, her appreciation of the continuous care of herself that is necessary and third, her whole-hearted willingness to take this care for her baby’s sake.

It is safe to say that if the doctor and the nurse and the patient all want the baby to nurse at the breast, and all do everything in their power to make this possible, they will almost invariably succeed. This assertion can scarcely be made too positively, and the nurse should never lose sight of the fact that if the baby is not breast-fed he is being defrauded, and in the vast majority of cases, because of insufficient effort on the part of the doctor, nurse or patient, or all three.

A favorable frame of mind and state of good nutrition in the mother are the two indispensable factors in establishing breast-feeding and in maintaining the secretion of an adequate supply of breast-milk. These conditions, in turn, are both affected by her general mode of living, as long as the baby nurses.

Women with happy, cheerful dispositions usually nurse their babies satisfactorily, while those who worry and fret are likely to have an insufficient supply of milk, or milk of a poor quality. And in addition to this sustained influence, the temporary effect of a fit of temper; of fright; grief; anxiety or any marked emotional disturbance is frequently injurious to the quality of milk that previously has been satisfactory. Actual poisons are created by such emotions and may affect the baby so unfavorably as to make it advisable to give him artificial food, for the time being, and empty the breasts by stripping or pumping, before he resumes breast feeding.

A mother’s lack of faith in her ability to nurse is so detrimental in its effect that she must be assured over and over, that she can nurse her baby if she will persevere. If the nursing does not go well at first she must not give up, but must continue to put the baby to the breasts regularly, as this is the best means of stimulating them to activity. His feeding should be supplemented with modified cow’s milk, if the breast milk is inadequate, either in amount or quality.

=Method of Nursing.= The baby should be put to the breast for the first time between eight and twelve hours after he is born. This gives the tired mother an opportunity to rest and sleep, and the baby, too, is benefited by being kept warm and quiet during this interval. His need for food is not great as yet, nor is there much if any nourishment available for him.

In preparing to nurse her baby, the mother should turn slightly to one side, and hold the baby in the curve of her arm so that he may easily grasp the nipple on that side. She should hold her breast from the baby’s face with her free hand by placing the thumb above and fingers below the nipple, thus leaving his nose uncovered, to permit his breathing freely. (Fig. 138.) The mother and baby should lie in such positions that both will be comfortable and relaxed, and the baby will be able to take into his mouth, not only the nipple but the areola as well, so as to compress the base of the nipple with his jaws as he extracts the milk by suction.

The nurse may have to resort to a number of expedients in persuading the baby to begin to nurse, for he does not always take the breast eagerly at first. He must be kept awake and sometimes suckling will be encouraged by patting or stroking his cheek. Or if his head is drawn away from the breast, a little, he will sometimes take a firmer hold and begin to nurse. Moistening the nipple by expressing a few drops of colostrum or with sweetened water may stimulate the baby’s appetite and thus prompt him to nurse.

The young mother must be prepared to find very discouraging the early attempts to induce the baby to nurse, but if the nurse will help her to persevere in making regular attempts she will almost certainly succeed.

During the first two or three days the baby obtains only colostrum, while nursing, but the regular suckling is extremely important, not alone for the sake of getting him into the habit of nursing but for the sake of stimulating the breasts to secrete milk.

Moreover, the irritation of the nipples so definitely promotes involution of the uterus that this process goes on more rapidly in women who nurse their babies than in those who do not. If the nipples are not sufficiently prominent for the baby to grasp them, a shield will have to be used while they are being brought out. But the shield should be discarded as soon as possible for it is the baby’s suckling that produces the physiological effects. If a shield is used, it should be washed and boiled after each use and kept, between nursings, in a sterile jar or a solution of boracic acid.

The length of the nursing periods and the intervals between them have to be adjusted to the needs and condition of each baby; his weight, vigor, the rapidity with which he nurses, the character of his stools and his general condition, all of which will be considered in connection with the care of the baby. The intervals between nursings are measured from the beginning of one feeding to the beginning of the next, and are fairly uniform for babies of the same age and weight. The length of the nursing period itself is usually from ten to twenty minutes.

The average baby nurses about every six hours during the first two days, or four times in twenty-four hours. According to one schedule he will nurse every three hours during the day for about three months, beginning with the third day, and at 10 p.m. and 2 a.m., or seven times in twenty four hours. From the third to the sixth month he nurses every three hours during the day and at ten o’clock at night, or six times in twenty-four hours, and from that time until he is weaned he should nurse at four hour intervals during the day and at ten o’clock at night, or five times daily, as follows:

─────────────────────┬──────────────────────────────────┬───────────── │ Day │ Night │ │ First and second days│ 6 12 6 │ 12 First three months │ 6 9 12 3 6│ 10 2 a. │ │ m. Third to sixth month │ 6 9 12 3 6│ 10 After the sixth month│ 6 10 2 6 │ 10 ─────────────────────┴──────────────────────────────────┴─────────────

It is becoming more and more common to omit night feedings after 10 p.m., even during the first three months, with the average baby who is in good condition. When this practice is adopted the baby not only seems to do as well as he normally should, but to benefit by the long digestive rest during the night. Certainly the mother profits by the unbroken sleep which this makes possible.

As a rule the baby should nurse from one side, only, at each nursing, emptying the breasts alternately, but if there is not enough milk in one breast for a complete feeding both breasts may be used at one nursing. Neither the mother nor the baby should be permitted to sleep while he is at the breast, but he should pause every four or five minutes to keep from feeding too rapidly.

After the mother sits up, she may occupy a low, comfortable chair while nursing the baby. She should lean slightly forward and raise the knee upon which the baby rests by placing her foot on a stool, supporting his head in the curve of her arm, and holding her breast from his face, just as she did while in bed. (Fig. 139.) She should nurse him in a quiet room where she will not be disturbed nor interrupted and where the baby and her breasts will be protected from drafts or from being chilled. Many women prefer always to lie down when nursing the baby.

Before the nurse leaves her patient she should teach her how to care for her nipples, including the preparation of boric solution; the importance of washing her hands before bathing her nipples, and of keeping the breasts covered with clean gauze between nursings.

PERSONAL HYGIENE OF THE NURSING MOTHER

The personal hygiene of the nursing mother should be virtually a continuation of that which is advisable during the latter part of the puerperium; a normal, tranquil kind of life which is unfailingly regular in its daily routine.

But this is not quite as easy as it sounds, for during the puerperium the young mother is still something of a patient and is regarded as such, while during the months that follow she is simply a nursing mother, who must live sanely and moderately for her baby’s sake, and at the same time take her place among people who are not under compulsion to place any special restrictions upon their daily lives. It is much easier to take precautions and follow directions for a few days or weeks, while the situation is novel, than it is to persist month after month without help or encouragement. The young mother’s family often fails to appreciate the difficulty of her problem and for this reason she is sometimes unable to care for herself, as she should, with the result that she cannot nurse her baby successfully.

As long as the nurse remains with her patient, therefore, she must try to impress upon both the patient and the members of her household that the most important single factor in the care of the new baby is the sustained and regular care which the nursing mother should take of herself. For it must be remembered constantly that it is not alone breast feeding, but _satisfactory breast feeding_ that nourishes and builds and protects the baby. Unsatisfactory breast milk may be positively injurious, and irregularity and thoughtlessness in the mother’s mode of living will usually produce milk of this character.

Therefore, for ten or twelve months after the baby is born, the mother should discharge her responsibility and obligation to him by regulating her own life to meet his needs.

=Diet.= Throughout the entire nursing period the mother’s diet must be such that it will nourish her and also aid in producing milk which will meet the baby’s needs. His needs are that the daily demands of his growing body shall be supplied and that he shall be given those materials which will build a sound body, with resistance against disease and infection.

So important is this matter of nutrition, and the principles upon which it rests, that it is discussed at considerable length in the succeeding chapter. At this point, however, it may be stated briefly that the most valuable article in the nursing mother’s dietary is milk, and that to this should be added eggs and the vegetables which are designated as “leafy,” and fresh fruits, particularly oranges. These foods are rich in the materials which are essential to the baby’s nutrition, good health, and resistance.

She should have a generous, simple, nourishing mixed diet, then, consisting largely of milk, eggs, and leafy vegetables. She must steadily guard against indigestion for if her digestion is deranged the baby is almost sure to suffer. Rich and highly seasoned foods must be avoided, as well as alcohol, strong tea and coffee or any articles of food or drink that might upset her.

It becomes apparent that although the expectant mother does not have to “eat for two,” the nursing mother does, in certain respects. She should augment the nourishment provided by her three regular meals, by taking a glass of milk, cocoa or some beverage made of milk, during the morning, afternoon and before retiring.

The morning and afternoon lunches had better be taken about an hour and a half after breakfast and luncheon, respectively, in order not to impair the appetite for the meals which follow.

It is very important that the nursing mother shall take her meals with clock-like regularity and enjoy them, but at the same time she must guard against overeating, for fear of deranging her digestion. She must drink water freely, partly for the sake of promoting intestinal activity.

=Bowels.= The nursing mother’s bowels must move freely and regularly every day, but she should not take cathartics nor even enemata without a doctor’s order.

She will usually be able to establish the habit of a daily movement by taking exercise, eating bulky fruit and vegetables, drinking an abundance of water and regularly attempting to empty her bowels, every day, preferably immediately after breakfast.

=Rest and Exercise.= The nursing mother will not thrive, nor will the baby, unless she has adequate rest and sleep and takes at least a moderate amount of daily exercise in the open air. She should have eight hours sleep, out of the twenty-four, in a room with open windows, and as fatigue has an injurious effect upon the character of the milk, the average mother should lie down for a while every afternoon.

Her exercise will have to be adjusted to her tastes, customary habits, circumstances and physical endurance, for it must always be stopped before she is tired. Walking is often the best form of exercise that the nursing mother can take, though she may engage in any mild sports that she enjoys. Violent exercise is inadvisable because of the exhaustion that may follow.

=Recreation.= Part of the value of exercise lies in the pleasure and diversion which it gives, for a happy, contented frame of mind is practically indispensable to the production of good milk. In addition to some regular and enjoyable exercise, therefore, the mother needs a certain amount of recreation and change of thought and environment. If her life is monotonous and colorless, the average woman is likely to become irritable and depressed; to lose her poise and perspective; to worry and fret, and then, no matter what she eats nor how much she sleeps, her digestion will suffer, her milk will be affected and the baby will pay. This, of course, goes back to the question of her mental state and the condition of her nerves as being determining factors in the young mother’s ability to nurse her baby successfully.

For the sake of giving her an opportunity to go out, mingle with her friends or enjoy some music or a play, it is often a very good plan to replace one breast feeding, some time in the course of each day, with a bottle feeding. The freedom which this long interval between two nursings gives the mother for diversion and amusement, will usually affect her general condition so favorably that the quality of her milk is better than it otherwise would be, and the baby is benefited as a result. This single supplementary feeding cannot be regarded lightly, however, for it must be prepared with the same cleanliness and accuracy as an artificial diet.

=Weaning.= One advantage in giving the baby a supplementary bottle, once a day, is that it paves the way for weaning, when the time comes to make this change. Under ordinary conditions, the mother begins to wean her baby about the eighth or tenth month. Having started by replacing one breast feeding, daily, with a bottle feeding, she should gradually increase the number of daily artificial feedings until all of the breast feedings are discontinued by the time the baby is eleven or twelve months old. There are exceptions to this general rule, of course, and under any conditions the weaning should always be directed by a doctor, for the baby will suffer unless it is skillfully done.

If the mother’s milk is satisfactory and the baby is doing well, it is often considered wiser not to discontinue the breast feeding entirely, during the hot summer months, even though the weaning falls due at this time.

It was formerly deemed advisable to wean the baby for any one of several reasons, but at present the only indications for this step which are generally accepted by the medical profession, are: pulmonary tuberculosis, acute infectious diseases in the mother, and pregnancy. Menstruation, which is normally suspended during lactation, was long regarded as incompatible with satisfactory nursing, but it is now known that if the mother is taking proper care of herself and is in generally good condition, the effect of menstruation upon the milk is usually for the duration of the periods only. It may be necessary to supplement the breast feeding with suitably modified cow’s milk during menstruation, but the baby should be put to the breast regularly, just the same, for if the stimulation of the baby’s suckling is discontinued, the temporary reduction in the amount of milk secreted will probably be permanent.

The state of pregnancy, however, is different, for though some women nurse the baby satisfactorily for some months after becoming pregnant, it is not considered advisable to subject a woman to the combined strain of pregnancy and nursing. Moreover, the mother’s milk is usually impoverished during pregnancy and the nursing baby suffers in consequence.

=Drying up the Breasts= used to be a great bugbear. Lotions, ointments and binders were employed and often a breast pump as well. Various drugs were given by mouth and the patient was more or less rigidly dieted. It is true that some of these measures are still employed and are followed by a disappearance of the milk. But at the same time, the breasts dry up quite as satisfactorily when none of these things is done, provided the baby does not nurse. It is not known what starts the secretion of milk in the mother’s breasts but certain it is that absence of the baby’s suckling prevents it.

If the drying up of the breasts is left to the nurse, as it so frequently is, her wisest course will be to do nothing beyond applying a supporting bandage if the breasts are heavy enough to be uncomfortable. She may rely absolutely upon the fact that the baby’s suckling is the most important stimulation in promoting the activity of the breasts and if this stimulation is not given, or is removed, the secretion of milk will invariably subside in the course of a few days. It is true, that the breasts may be engorged and very uncomfortable for a day or two, and in addition to a supporting bandage the doctor may order sedatives, but the discomfort subsides as the secretion disappears. This is true whether the reason for drying up the breasts is that the baby is still born or has died, or a live baby’s nursing is discontinued.

Naturally, the nurse will not press her patient to drink an extra amount of milk if it is not desirable to promote the activity of the breasts, but, unless otherwise ordered, there is no necessity for placing any other restrictions upon her patient’s diet.

In thinking over the period of lactation, as a whole, it is apparent that the most valuable service which the nurse can offer to the nursing mother, is assistance in planning and living a simple, normal, tranquil life; helping her to eat, sleep, bathe, and exercise and to nurse her baby with unfailing regularity—all for the sake of providing her baby with adequate nourishment. This must be the chief end and aim of her existence.

Normal breast-milk is the ideal baby food and there is no entirely satisfactory substitute. It greatly increases the baby’s chances of living through the first year, and protects him from many diseases.

Quite evidently, breast-feeding is every baby’s right and the nurse can and should help him to secure it.