CHAPTER VIII

THE MANAGEMENT OF LABOR

WHEN TO SEND FOR THE PHYSICIAN IN CONFINEMENT CASES--THE PREPARATION OF THE PATIENT--THE BEGINNING OF LABOR--THE FIRST PAINS--THE MEANING OF THE TERM "LABOR"--LENGTH OF THE FIRST STAGE OF LABOR--WHAT THE FIRST STAGE OF LABOR MEANS--WHAT THE SECOND STAGE OF LABOR MEANS--LENGTH OF THE SECOND STAGE--DURATION OF THE FIRST CONFINEMENT--DURATION OF SUBSEQUENT CONFINEMENTS--CONDUCT OF PATIENT DURING SECOND STAGE OF LABOR--WHAT A LABOR PAIN MEANS--HOW A WILLFUL WOMAN CAN PROLONG LABOR--MANAGEMENT OF ACTUAL BIRTH OF CHILD--POSITION OF WOMAN DURING BIRTH OF CHILD--DUTY OF NURSE IMMEDIATELY FOLLOWING BIRTH OF CHILD--EXPULSION OF AFTER-BIRTH--HOW TO EXPEL AFTER-BIRTH--CUTTING THE CORD--WASHING THE BABY'S EYES IMMEDIATELY AFTER BIRTH--WHAT TO DO WITH BABY IMMEDIATELY AFTER BIRTH--CONDUCT IMMEDIATELY AFTER LABOR--AFTER PAINS--REST AND QUIET AFTER LABOR--POSITION OF PATIENT AFTER LABOR--THE LOCHIA--THE EVENTS OF THE FOLLOWING DAY--THE FIRST BREAKFAST AFTER CONFINEMENT--THE IMPORTANCE OF EMPTYING THE BLADDER AFTER LABOR--HOW TO EFFECT A MOVEMENT OF THE BOWELS AFTER LABOR--INSTRUCTING THE NURSE IN DETAILS--DOUCHING AFTER LABOR--HOW TO GIVE A DOUCHE--"COLOSTRUM," ITS USES--ADVANTAGES OF PUTTING BABY TO BREAST EARLY AFTER LABOR--THE FIRST LUNCH--THE FIRST DINNER--DIET AFTER THIRD DAY.

WHEN TO SEND FOR THE PHYSICIAN IN CONFINEMENT CASES.--The physician should be notified just as soon as it is known that labor has begun. The adoption of this course is necessary for a number of reasons. It is only just that he should have an opportunity to arrange his work so that he may be at liberty to give his whole time to your case when he is wanted. He may not be at home at the moment, but can be notified, and can arrange to be on hand when your case progresses far enough to need his personal attention. It will relieve your mind to be assured that he will be with you in plenty of time. [Page 94]

Don't worry unnecessarily if he does not come immediately when you notify him, provided you notify him at the beginning of labor. There is plenty of time. You have a lot of work to do before he can be of any help. Many women entertain the idea that a physician can immediately perform some kind of miracle to relieve them of all pains at any stage in labor. This is a mistaken idea. No physician can hasten, or would if he could, a natural confinement. He waits until nature accomplishes her work, and he simply watches to see that nature is not being interfered with. If something goes wrong, as it does now and again; or if the pains become too weak, or if the proper progress is not being made, he may help nature or take the case out of her hands and complete the confinement. If it is thought best to do this, there will be plenty of time.

THE PREPARATION OF THE PATIENT AND THE CONDUCT OF ACTUAL LABOR.--It is assumed that the patient has adhered to the instructions of the physician given during the early days of her pregnancy. These instructions included directions as to exercise, diet, bathing, etc.

Having calculated the probable date of the confinement, it is the better wisdom to curtail all out-of-door visiting, shopping, social engagements, etc.,--everything in fact out-of-doors except actual exercise, for two weeks previous to the confinement date. The usual walk in the open air should be continued up to the actual confinement day. The daily bath may be taken, and it is desirable that it should be taken, up to and on the confinement day.

THE MEANING OF THE TERM "LABOR."--By labor is meant, the task or work involved in the progress by means of which a woman expels from her womb the matured ovum or child. After the child has been carried in the womb for a certain time (estimated to be 280 days) it is ripe, or fully matured, and is ready to be born. The womb itself becomes irritable because it has reached the limit of its growth and is becoming overstretched. Any slight jar, or physical effort on the part of the patient, or the taking of a cathartic, is apt to set up, or begin the contractions which nature has devised as the process of "labor" by which the womb empties itself. [95]

THE BEGINNING OF LABOR.--When the first so-called pains of actual labor begin they are not always recognized as such. The explanation of this seeming paradox is that the "pains" are not always painful. A woman will experience certain undefined sensations in her abdomen; to some, the feeling is as if gas were rumbling around in their bowels; to others, the feeling is as if they were having an attack of not very painful abdominal colic; while others complain of actual pain. The fact that these sensations continue, and that they grow a little worse; and that the day of the confinement is due, or actually here, impresses them that something unusual is taking place; then, and not till then, does the knowledge that labor is really approaching dawn upon them.

In due time one of these new sensations, which constitute the first stage of labor, will be more emphatic; there will be a little actual pain so that she will feel like standing still, holding her breath and bearing down. That is the first real labor pain and marks the beginning of the second stage of labor, and may be the first absolute sign that will leave no doubt in her mind that labor has begun.

The nurse will now inquire into the condition of the patient's bowels. If they have not already moved freely that day, she will give the patient a rectal injection of one pint of warm soap suds into which one teaspoonful of turpentine is put. After the bowels have been thoroughly cleansed, the patient will be made ready for the confinement. The clothing necessary consists of dressing gown, night gown, stockings and slippers. These are worn as long as the patient is out of bed, when all but the night gown will be discarded. The entire body of the patient, from the waist line to the knees, should be thoroughly cleansed, paying particular attention to the private parts; first with warm water and castile soap, and then rendered aseptic by washing with four quarts warm boiled water into which has been put one teaspoonful of Pearson's Creolin. A soft napkin is then wrung out of water that has been boiled and cooled to a suitable temperature, and laid over the genital region, and held in place by a dry clean napkin, [96] and allowed to remain there until the physician takes personal charge of the case.

LENGTH OF THE FIRST STAGE OF LABOR.--There is no definite or even approximate length of time for the first stage of labor,--that, you may recall, was the more or less painless stage, or as it has been termed, the "getting-ready" stage. Inasmuch as it is an unimportant and practically painless stage, most patients do not mind it. They continue to be up and around and work as usual.

The first stage of labor is utilized by nature in opening the mouth of the womb.

The second stage of labor is utilized by nature in expelling the child into the outer world.

LENGTH OF THE SECOND STAGE OF LABOR.--After the second stage has begun, the length of time necessary to end the labor, assuming everything is normal, depends upon the strength and frequency of the pains. The stronger and more frequent the pains, the quicker it will be over. First confinements necessarily take longer, because the parts take more time to open up, or dilate, to a degree sufficient to allow the child to be born. In subsequent confinements, these parts having once been dilated yield much easier, thus shortening the time and the pains of this, the most painful, stage of labor. The average duration of labor is eighteen hours in the case of the first child, and about twelve hours with women who have already borne children. The time, however, is subject to considerable variation, in individual cases, as has been pointed out.

CONDUCT OF THE PATIENT DURING THE SECOND STAGE OF LABOR.--She should remain up, out of bed, as long as she possibly can. The object of this is because experience shows that the labor pains are stronger, and more frequent, when in the upright position. Even though this procedure would seem to invite more constant suffering, it must be remember that labor is a physiological, natural process, that there is nothing to fear or dread; and if the patient is in good health, it is to her advantage to have it over soon, rather than to encourage a long drawn out, exhausting labor. When the pains come [97] she should be told to hold on to something, to hold her breath as long as possible, and to bear down. A good plan is to roll up a sheet lengthwise, and throw it over the top of an open door and let her grasp both ends tightly and bear down; or she can put her arms over the shoulders of the nurse and bear down. Instruct her to hold her breath as long as she can, bearing down all the time, and when she can't hold it any longer, tell her to let up, and then take a quick deep breath and bear down again, repeating this programme until the pain ceases. Tell her specifically to be sure to keep bearing down till the end of the pain, because the most important time, and the few seconds during which each pain does most of its work during the second stage of labor, is at the very end of each pain. When a woman understands that these instructions are for her good, and that they are given with the one purpose of saving her pain, and shortening the length of labor, she will try to obey. Each pain is intended by nature to do a certain amount of work, and each pain will accomplish that work if the woman does not prevent it; and if she does prevent it, she is only fooling herself, because the next pain will have to do what she would not allow the former to do, and so on according to how she acts.

THE CARRIERS OF HERITAGE

THE FORMATION OF A NEW LIFE

HOW A WILLFUL WOMAN CAN PROLONG LABOR.--For a certain time, during the second stage of labor, a willful, unreasonable woman, can work against nature and save herself a little pain by prolonging the issue; but there will come a time when, the head having reached a certain position, the expulsive pains will be so great that she won't be able to control them and nature then seems to take her revenge. So if a woman holds back, and begins to cry, and scream, when she feels a pain coming, she renders the pain to a large degree negative, she prolongs her labor, adds to the total number of pains, exhausts herself, and endangers the life of her child. It must, however, be remembered in all justice that this is a time when it is much easier to preach than to practice.

Every confinement is a new experience; no matter how many a physician may have seen, there are no two alike. It is one of the interesting [98] psychological problems in medicine to observe the conduct of women during their first confinement.

Some are calm, exhibiting a degree of self-control that is admirable. They are willing to be instructed, and they recognize that the advice is given for their benefit. They conscientiously try to obey suggestions, and they make praiseworthy efforts to keep themselves under control. They are stoics.

Others collapse at once; they go to pieces under the slightest excuse, and frequently without as much as an excuse. As soon as the pain begins, they willfully ignore all the instructions given and desperately and foolishly try to escape what they cannot escape. In this unreasonable selfishness they resent advice, and at the same time they implore you to "do something" for them. There is absolutely no excuse for this kind of conduct; and any prospective mother who, because of a willful trait in her disposition, refuses to profit by the kindly professional advice of her physician or nurse, should at least have some consideration for her unborn babe. It may seem unkind to criticise the conduct of any woman at such a time. It is not prompted by a lack of patience or justice however. These women permit, in spite of every assurance to the contrary, an unreasonable fear to overwhelm them; and because of this fear they refuse to be guided into a path of conduct that will save them suffering and shorten the pains which they complain of. It is our conviction that if a woman would try to follow the advice of the physician at this time, at least half of all the seeming suffering would be avoided. We are glad to be able to truthfully state that this type of woman is vastly in the minority.

When the second stage has advanced far enough, the patient will decide to go to bed. It may be necessary to put her in bed earlier, if her pains are very strong, as there is always a possibility of suddenly expelling the child under the influence of a strong pain. She will, as previously stated, discard all clothing, except her night gown, which can be folded up to her waist line and let down as far as necessary after the confinement is over. The obvious advantage of this arrangement is that the gown remains [99] unsoiled, and saves what would be needless trouble if it proved necessary to change the night gown at a time when the tired-out patient needs rest. Much aid may be afforded the woman at this stage by twisting an ordinary bed sheet and putting it around one of the posts or bars of the foot of the bed. The patient may then pull on the ends during the pain; she may also find much comfort and aid by bracing her feet on the foot of the bed while pulling. It is desirable to instruct the nurse to press on the small of the back during these pains. Some women appreciate a hot water bottle in this region. If the pains are hard the patient may perspire freely; it is always refreshing occasionally to wipe the face and brow off with a cloth wrung out of cold water. Cramps of the limbs may be relieved by forcibly stretching the leg and pulling the foot up toward the knee. From this time until the child and after-birth are born the physician will take active charge of the case.

THE MANAGEMENT OF THE ACTUAL BIRTH OF THE CHILD.--Near the end of the second stage of labor it will be observed that the pains have grown strong, expulsive, and more frequent. Very soon the advancing head will begin to push outward the space between the front and back passage; the rectum is pushed outward and the lips of the vagina open. If an anesthetic is to be used these are the pains that call for it. A few drops may be dropped singly on a small clean handkerchief held up by the middle over the nose, its ends falling over the face. A few drops will just take the edge off the pains, and render them quite bearable. As soon as the pain is over the patient should rest, relax completely, and not fret and exhaust herself worrying about the pains to come. It is astonishing how much actual rest a woman can get between pains if she will only try; and it is astonishing how much concentrated mischief a willful, unreasonable woman can do in the same time. She will not try to rest, but cries and moans and pleads for chloroform, until she succeeds in giving everyone except the physician and nurse the impression that she is suffering unnecessarily. Her husband or her mother, whichever is present, gets nervous; they begin to wonder [100] if the physician is really trying to help; assume a long, sad, serious face! forget their promise to look cheerful, and mayhap offer sympathy to the woman. It is a trying moment and needs infinite patience and tact. The physician attends strictly to his duty, which will now be to guard the woman against exerting too great a force during the last few pains. About this time, or before it in many instances, the "waters will break." This means simply that the bag or membrane in the contents of which the child floated burst because of the pressure of a pain. This is a perfectly natural procedure and should not cause any worry: simply ignore it as if it had no bearing on the labor in any way. As soon as the oncoming head has dilated the passage sufficiently, so that the edges of the entrance to the vagina will slip over the head without tearing, the physician allows the head to be born. It takes some time to do this, and he must hold the head back until just the right moment. It is best not to let the head slip through at the height of a pain, or rupture is sure to occur. Wait till it will slip through as a pain is dying out, and if you have waited long enough and handled the head skillfully, the conditions will be just right at a certain moment to permit this without tearing the parts. There are some cases where a tear, and a good tear, is impossible to guard against. It is not a question of patience, or tact, or skill; it is a combination of conditions which patience, tact, and skill are powerless against.

POSITION OF WOMAN DURING BIRTH OF CHILD.--The position of the woman is a matter of choice and is not contributory to the results at all. She can lie on her back, which is the ordinary way, or on her side, as the physician or the patient prefer. As soon as the head is born the physician should see that the cord is not round the child's neck; if it is, release it. The shoulders will most likely be born with the next or succeeding pain. The physician will permit the lower shoulder to slip over the soft parts first; this is done by retarding the upper shoulder by pushing it gently behind the pubic bone of the mother. When the shoulders are through, the rest[101] of the body of the child slips out without effort.

DUTY OF NURSE IMMEDIATELY FOLLOWING BIRTH OF CHILD.--As soon as the child is born the nurse should sit by the side of the mother and hold the womb until the after-birth is expelled. The womb can be easily felt in the lower part of the woman's abdomen as a hard mass. It feels about the size of an extra large orange. The object of holding it is to prevent the possibility of an internal hemorrhage. It can be readily appreciated that the interior of a womb, immediately after a child is born, is simply a large bleeding wound. So long as the womb remains firmly contracted there is very little chance for an extensive bleeding to take place. As a rule the womb remains sufficiently contracted to preclude a hemorrhage until the after-birth is out. After the after-birth is expelled, the womb usually closes down firmly and the liability to bleed is very much reduced. Because there is a distinct chance or tendency for the womb to bleed freely during the time the after-birth remains in, it is customary, as stated above, to watch it closely and to hold it securely. It is best held with the right hand. The fingers should surround the top of the womb and exert a slight downward pressure. Should it show any tendency to dilate or fill with blood, get it between the fingers and the thumb and squeeze it, pushing downward at the same time.

EXPULSION OF AFTER-BIRTH.--The after-birth is usually expelled in about twenty minutes after the child is born. Great care should be experienced in its expulsion. It should not be pulled at any stage of its expulsion. If it does not come easily give it a longer time,--it takes time for the womb to detach itself from the after-birth; and some after-births are very firmly attached. Eventually it will come out with a little encouragement in the way of frictional massage of the womb through the abdominal walls. If the membranes remain in the womb after the body of the after-birth is out, do not pull on them. Take the after-birth up in the palm of your hand and turn or twist it around, and keep turning it around gently, thereby loosening the membranes from the womb instead of pulling them, which would surely break them, leaving the broken ends in the womb, and, as a result, the[102] chance of developing serious trouble.

The patient should now be given one teaspoonful of the fluid extract of ergot, which should be repeated in an hour. Should there be an excessive flow of blood after this period it may be again repeated at the third hour.

CUTTING THE CORD.--As soon as the child is born, and of course long before the after-birth is expelled, the physician will tie the cord. This is best done at two places, one about two inches from the child, and the other two or three inches nearer the mother. Cut the cord about one-half inch beyond the first ligature, which will be between the two ligatures. The cord should be tied with sterile tape made for the purpose, or heavy twisted ligature silk, or a narrow, ordinary, strong tape, previously boiled. It should be tied firmly and inspected a number of times within one hour of its birth. It is possible for a baby to lose enough blood from a cord badly tied to cause its death. A very good way to ensure against such an accident is to cut the cord one inch from the ligature nearest the baby, then turn this inch backward and retie with the same ligature, thus making a double tie at the same spot. Cut the cord with scissors that have been boiled and reserved for this purpose.

WASHING BABY'S EYES AND MOUTH IMMEDIATELY AFTER BIRTH.--As soon after birth as is practicable, wash the baby's eyes with a saturated solution of boracic acid.

Immediately after the eyes have been washed the physician will drop into them a solution of silver nitrate, three drops of a two per cent. solution in each eye, or argyrol, three drops 20 per cent. solution. This precaution is taken against possible infection during labor and, as explained elsewhere, it is a preventive against certain diseased conditions which, if present, would result in blindness.

The physician should then wind a little sterile cotton round his moistened little finger, dip it in the boracic solution, and holding the baby up by the feet head down, insert this finger into the throat, thus clearing it of mucus. The tongue and mouth may be gently washed with the same [103] solution.

After the baby has cried lustily as an evidence of life and strength, he should be wrapped up in a warm blanket quickly, and immediately put in a cozy basket in a warm place, and left there undisturbed, with his eyes shaded from the light until the nurse is ready to attend to him. The baby should be laid on his right side.

CONDUCT IMMEDIATELY FOLLOWING LABOR.--As soon as the physician is satisfied that the patient is well enough to be left in care of the nurse or attendant, every effort should be made to favor a long, refreshing sleep. Nothing will contribute to the patient's well-being so much as a quiet, restful sleep after labor. The nurse will therefore take the baby into another room, fix the mother comfortably, and give her a glass of warm milk,--draw the shades or lower the light and tell the tired-out mother to go to sleep. As a rule she will sleep easily, as she is sore and exhausted.

AFTER-PAINS.--In women who have had children the womb does not as a rule contract down as firmly as after the first confinement. This condition permits of slight relaxation of the muscular wall, at which times there is a slight oozing of blood. This blood collects and forms clots in the uterine cavity which acts as irritants, exciting contractions in the effort to expel them. These contractions cause what are commonly known as "after-pains." These pains last until the womb is free from blood-clots. They may be severe the first twenty-four hours and then gradually die out during the following two or three days. Ordinarily in uncomplicated confinements they rarely annoy the patient longer than a few hours. It is a rare exception to observe them after the first confinement.

REST AND QUIET AFTER LABOR.--Sometimes the birth chamber is the rendezvous for all the inquisitive ladies in the neighborhood. No one should be permitted in the lying-in chamber until the patient is sitting up, except the husband and the mother. This should be made an absolute rule in every confinement. This is a period that demands the maximum of uninterrupted rest and repose. The world and all its concerns should remain a blank to a woman during the whole period of her confinement. This is the only successful means of obtaining mental rest. The husband and mother [104] should be instructed to present themselves just often enough to demonstrate their interest in the welfare of the patient and the baby.

POSITION OF THE PATIENT AFTER LABOR.--After delivery a woman should be instructed to lie on her back, without a pillow, for the first night. On the following morning she may have a pillow, but she must remain on her back for the first week. Sometimes an exception may be made to this rule by letting the patient move around on the side, with a pillow supporting the back, on the fourth day. These exceptional cases are those whose womb has contracted firmly, as shown by the quick change in the amount and color of the lochia. Women should be told why they must remain on their backs as explained in the chapter: "How long should a woman remain in bed?"

THE LOCHIA.--The discharge which occurs after every labor is called the lochia. Its color is red for the first four or five days; for the succeeding two or three days it is yellow; for the remainder of its existence it is of a whitish color. It lasts from ten days to three weeks.

The odor of the lochia is at first that of fresh blood; later it has the odor peculiar to these parts. If at any time the odor should become foul or putrid it is a danger signal to which the nurse should immediately draw the physician's attention.

If the amount of the lochia should be excessive it should be investigated.

THE EVENTS OF THE DAY FOLLOWING LABOR.--We will assume that the patient enjoyed a long sleep and wakes up refreshed, and with a thankful feeling that all is over and that baby is safely here. She will want to see and caress baby, of course. Lay the baby down in bed beside her and let her love and mother it. Tell her not to lift it, for the strain might injure her, then quietly steal away for ten or fifteen minutes, for these are precious, sacred moments. Motherhood--that angel spirit, whose influence every human heart has felt--that guards and guides the world in its sheltering arms--is born in its divine sense, into the heart of every woman for the first time, as she gazes in ecstasy and wonder at her [105] first-born. She feels that she has begotten a trust,--a trust direct from her Creator, and she makes a silent resolve, as she gently and timidly feels the softness of baby's cheek, that she will watch over it, and guide it, and do all a mother can for it, with God's help. It is good for the race that mothers do feel this way: and it is good for all concerned that they be given the opportunity to be so inspired.

Just as gently take the baby away at the expiration of the allotted time. Take it with a cheerful, smiling word, and do not comment upon mother's happy, thoughtful face, she will quickly collect herself and enter into the spirit of quiet congratulation that should now permeate the home.

THE FIRST BREAKFAST AFTER LABOR.--If the patient has passed a comfortable night, feels well, and is free from temperature, and has a normal pulse, breakfast will consist of a cup of warm milk, or a cup of cocoa made with milk, a piece of toasted bread, and a light boiled egg; or if preferred a cereal with milk and toasted bread. This will be the breakfast for the two following days also. The milk, or the cocoa (whichever is taken), must be sipped, while the attendant supports the patient's head. The cereal, or the egg (whichever is taken), must be fed to the patient out of a spoon. The patient must not make any physical effort to help herself; she must remain relaxed. Even when she sips her milk, or cocoa, she must not make any effort to raise her head; the nurse must support its entire weight. This will be the absolute routine of every meal until the physician gives permission to change the procedure. It is a waste of time to formulate rules only to disobey them.

Shortly after breakfast the patient's toilet should be attended to. She should have her hair combed, and her face and hands washed. The hair on the right half of her head should be combed while the head rests on the left side, and vice versa. The water used for washing the hands and face should be slightly warmed. It is best to keep the hair braided and to consult the wishes of the patient as to the frequency of combing it. [Page 106]

THE IMPORTANCE OF EMPTYING THE BLADDER AFTER LABOR.--An effort should be made now to have the patient urinate. This is very important at this time, as it is not an uncommon experience to find that the abdominal muscles are so worn out and overstrained with the fatigue of labor that they refuse to act when an effort is made to urinate. As a consequence the bladder becomes distended and may have to be emptied by other means. This condition is a temporary and a painless one, and will rectify itself in a day or two; meantime, if this accident has occurred, it is essential that the bladder should be emptied from time to time until the patient can do it herself. To test this function place the patient on the bed pan into which a pint of hot water has been put, and give her a reasonable time to make the effort to pass her water. Should she fail, take an ordinary small bath towel and wring it out of very hot water, just as hot as she can tolerate, and spread it over the region of the bladder and genitals: if there is running water in the room, turn it on full and let it run while the towel is in position as above. If the bladder is full, there is a peculiar, irresistible desire to urinate when one hears running water. If this effort fails, report the fact to the physician when he makes his daily call; he will draw the urine and it will be part of his daily duty to give specific instructions regarding this function until nature reëstablishes it.

No particular attention need be paid to the bowels for the first two days. On the morning of the third day, if they have not acted of their own accord, the physician will give the necessary instructions to move them. The means necessary to accomplish the first movement after a confinement is a matter of choice. The old-time idea was to use castor oil, and while other remedies are now more or less fashionable, castor oil is still an excellent agent. Enemas are frequently used, but their use is questionable in this instance, inasmuch as a movement has not taken place for three days, the object is to clean out the whole length of the intestinal tract, and an enema is limited to part of the large intestine only,--according to how it is given. If the small intestines are not thoroughly emptied, [107] particles of food may remain there, and if so, they will putrify and the patient runs the risk of developing gas,--sometimes to an enormous extent. This affliction is painful, and dangerous, and nearly always unnecessary. It is always, therefore, more safe, and more desirable, to use some agent by the mouth, and we know of no better one than castor oil; and as castor oil can be so masked as to be practically tasteless at any drug-store soda fountain there can be small objection to it. My custom is to send the nurse or husband with an empty glass to the drug store to have the mixture made there and brought back ready for use. We have frequently obtained it in this way and given it to the patient without her knowing what it was. The best time to give castor oil is two hours after a meal, and two hours before the next meal--i.e., on an empty stomach. It works quicker and does not nauseate when the stomach is empty.

INSTRUCTING THE NURSE IN DETAILS.--The nurse will attend to the patient's discharges by changing the napkins frequently. The bruised parts should be washed twice daily, for the first three or four days. If the nurse is a trained graduate nurse a few directions will suffice. If she is not a trained nurse the physician should be explicit in his instructions. It would be better if he actually showed her just how he wanted this work done. The best way to cleanse the vulvæ or privates is to take an ordinary douche bag at the proper height (about three feet) and allow the solution (1 to 2,000 bichlorid) to run over the parts into the douche pan, but do not touch any part of the patient with the nozzle of the douche bag. While she is directing the water with the left hand she should have a piece of sterile cotton in the right hand with which she will gently mop the parts. This method ensures disengaging any clotted blood and is aseptic. Dry the parts afterwards with a soft sterile piece of gauze and apply a clean sterile napkin.

DOUCHING AFTER LABOR.--A nurse should never give a vaginal douche without instructions from the physician. Douches are not necessary in the convalescence of ordinary uncomplicated confinement cases. When it is [108] necessary to give vaginal douches after a confinement, there are good reasons why they should be given, and it is therefore absolutely essential that they should be given properly, and with the highest degree of aseptic precautions. If these rules are not observed, the danger of causing serious trouble is very great, and as the physician is directly responsible for the conduct of the case, he should in justice to himself and his patient, do the douching himself.

HOW TO GIVE A DOUCHE.--The proper way to give a vaginal douche after a confinement, when the parts are bruised and lacerated, and when, as a consequence, the possibility of infection is very great, is as follows:

Instruct the nurse to boil and cool about two quarts of water and have another kettle of water boiling. Boil the douche bag and its rubber tubing and the glass douche tube (do not use the hard rubber nozzle that comes with the ordinary douche bag). Drain off the water after it has boiled for ten minutes, but instruct the nurse not to touch the bag or tube, to leave them in the pan, covered, till the physician uses them. When the physician calls, place the patient on a clean warm douche pan while he is sterilizing his hands and making the solution ready. While he is douching the patient the nurse will hold the bag. The bag should not be held higher than two feet above the level of the patient.

ADVANTAGES OF PUTTING BABY TO THE BREAST EARLY AFTER BIRTH.--The patient can now take, and will likely be ready for, an hour's nap. After the rest it is desirable to put the baby to the nipple, first carefully cleaning the nipple with a soft piece of sterile gauze dipped in a saturated solution of boracic acid. The reasons for this are as follows:

1st. There is in the breasts of every woman after confinement a secretion known as "colostrum" which has the property of acting as a laxative to the child, in addition to being a food.

2nd. It is advisable that the child's bowels should move during the first twenty-four hours and the colostrum was put there partly for that purpose.

3rd. The act of suckling has a well-known influence on the womb, in [109] that it distinctly aids in contracting it, and thereby expelling blood-clots and small shreds of the after-birth which might cause trouble if left in.

4th. By nursing the colostrum out of the breasts, it will favor and hasten the secretion of milk.

5th. It is frequently easier for the baby to get the nipple before the breast is full of milk, and having once had the nipple it will be easier to induce him to take it again when it is more difficult to get.

THE FIRST LUNCH AFTER LABOR.--Lunch will be next in order, and that should consist of a clear soup,--chicken broth, mutton broth, beef broth with a few Graham wafers or biscuits, and a cup of custard or rice pudding. This will be the lunch for the two following days also. The same precautions are to be observed in giving this as were observed with breakfast and as will be observed with all other meals as clearly stated before, and repeated again, so that no mistake may be made. In the middle of the afternoon the patient can take a cup of beef tea or a cup of warm milk.

THE FIRST DINNER AFTER LABOR.--Dinner will consist of more broth, or a plate of clear consomme with a dropped egg, or a cereal, a little boiled rice with milk, and stewed prunes, or a baked apple.

After the bowels have moved, on the third day, and provided the temperature and pulse have been normal since the confinement, the patient can be put on an ordinary mixed diet, particulars regarding which are given on page 121 under the heading "Diet for the nursing mother."

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