CHAPTER X

THE BIRTH OF THE CHILD

The Cause of Labor—The Course of Labor—The Stage of Dilatation—The Stage of Expulsion—The Placental Stage—The Effect of Labor upon the Child—Meddling—Justifiable Intervention—Management of Birth without the Doctor—Methods of Reviving the Child.

The birth of a child is an act of nature, an act generally performed as satisfactorily as any other bodily function. Birth has, however, so deep a meaning for the mother, as well as for her family and her friends, and is, above all, so vital to the future of the race, that it has naturally become the subject of many impressive superstitions. Primitive peoples have invariably embodied in their religion their views of the origin of life and the phenomena of its inception. With these mysteries Greek and Roman mythology dealt extensively, as did also the myths of the Phoenicians, the Egyptians, the Chinese, and the people of ancient India. No race, indeed, has lacked its own interpretation of childbirth, and no phase of the process has failed to have attributed to it a supernatural significance. A number of these superstitions still distress women on the eve of motherhood. To correct exaggerations and to deny many utterly false impressions of childbirth there is no better way than to give a frank account of what does actually occur.

I shall adhere to a purely physiological description of the event, for, although I appreciate fully the fact that its sociological and sentimental aspects are perhaps equally important, these are not, in my opinion, pertinent to a medical discussion.

In a scientific sense the act of birth may be described as a series of muscular contractions which widen the birth-canal and expel the contents of the pregnant womb. Since the process requires an expenditure of energy, it has come to be called labor. Intrinsically, labor does not differ from many other physiological acts. The heart drives blood into the arteries; the bladder empties itself; the intestine moves its contents and finally expels the undigested residue. All these acts strongly resemble that of birth; but they also differ from it, for the head of the fetus is a hard body which resists being molded to the shape of the passageway through which it enters the world. To this resistance the pain which accompanies delivery is largely due. And yet even in this respect the act of birth is not unique; certain circumstances lead to painful contractions of the muscle fibers in the intestine and less frequently of those in other organs.

It is natural to ask what purpose is served by the pain associated with labor; and a moment's reflection will make it clear that one reason for the discomfort is the warning which it gives of the approach of birth. If the mother were not thus cautioned, she might be delivered under very awkward circumstances, and even under such conditions that occasionally the infant would perish the instant it was born. All mammals suffer in giving birth to their young, though with quadrupeds the period of suffering is shorter, for the upright posture of man has changed the shape of the pelvis, rendering birth somewhat more difficult. Anyone who observes the lower animals preparing for delivery will be convinced that they also are responding to pain, the most compelling call of nature.

That the suffering is at all essential to the mother's love for her child I cannot believe. Under certain circumstances, as for example when the Cesarean operation is performed before the onset of labor, the delivery is painless; yet I have never known a mother less devoted to her child on that account. Biology throws no light upon the relation of the "curse of Eve" to present-day confinements.

THE CAUSE OF LABOR.—It is evident that, in a general way, the muscular contractions of the womb cause the birth of the child; but before we thoroughly understand the act, science must discover what stimulates the muscle to contract. Although careful research has thus far failed to disclose the source and character of the stimulus, it has taught many properties of the contractions themselves. Their force has been measured and found to increase as the end of labor is approached; the pressure they exert varies between nine and twenty- seven pounds. We also know that the patient can neither hasten nor delay the contractions voluntarily. Strong emotions are believed to accelerate them at times, and we find a very extraordinary illustration of this effect recorded in I Samuel, IV, 19, where we read: "Phineas' wife was with child, near to be delivered; and when she heard the tidings that the ark of God was taken, and that her father-in-law and her husband were dead, she bowed herself and travailed; for her pains came upon her." On the other hand, and much more familiarly, excitement checks the contractions after they have begun.

Every obstetrician has heard patients say that with his arrival the pains died down. Yet such an influence is never permanent; the contractions soon reappear, and labor advances as though no interruption had occurred.

For the artificial induction of labor, the physician has at his disposal means that resemble the method sometimes employed by nature. Suitable appliances introduced into the womb provoke contractions, and labor proceeds step by step as if the stimulus were a normal one. Nature does not, however, ordinarily employ mechanical irritation to start the uterine contractions. The initial factor is more remote and, as I have said, is not yet well understood.

Since, as everyone admits, delivery occurs with conspicuous regularity about the end of the fortieth week of pregnancy, and pregnancy corresponds, therefore, to ten menstrual cycles, some have been led to believe that labor and menstruation have a common basis. The truth of this supposition, however, must be doubtful until we know the cause of menstruation. Yet it is a matter of common observation that the uterus becomes unusually irritable about the time when the tenth menstrual period would be due. Strong purgatives administered with other drugs on or after the calculated date frequently bring about delivery, whereas previous attempts of this kind prove unsuccessful. To account for this peculiar irritability of the uterus about the fortieth-week of pregnancy, microscopical changes in its tissues have been suggested but sought in vain. Nor will the distention of the organ explain it.

A great many theories have been offered to explain the causation of labor, but they have now only an historical interest. To-day we are just beginning to learn the correct methods of studying the problem. The experience of ages has firmly established the fact that the fetus is expelled when ready to enter the world, or as we say, when it has become mature. But how does the fetus assert its maturity? There is the kernel of the matter; that is the real problem, a problem for the solution of which, happily, we possess better facilities than have heretofore existed. One solution that has been suggested assumes that the fetus loses ultimately its power to assimilate the nourishment provided through the mother's blood. In consequence, it is argued, the material which previously enabled the fetus to grow now collects— in the maternal circulation, stimulating the womb to contract.

A part of this explanation, namely, that the material which stimulates the muscle fibers, whatever it may be, is a chemical substance and that it circulates in the mother's blood, is almost certainly true. There are, however, very weighty reasons for believing that this substance has not the character of food. A more plausible supposition is that the fetus produces this material in the course of its natural living processes, and the substance would accordingly be a waste-product.

THE COURSE OF LABOR.—The current view that labor begins in the early evening and generally ends during the night is incorrect. This impression has grown out of the fact that the whole process frequently consumes twelve hours and must in such an event include some part of the night. Statistical evidence indicates that almost as many births occur at one hour of the twenty-four as another; to be precise, only five per cent. more children are born between 6 P. M. and 6 A. M. than between 6 A. M. and 6 P. M.

As already pointed out, labor commonly begins with transient discomfort in the lower part of the back. At first the uterine contractions are far apart; they last but a moment and cause only twinges of pain. Gradually, the preliminary contractions give place to others of more definite character, which appear at intervals of five to ten minutes. Estimates of the total length of labor will vary according as one counts from the first warning or from the advent of typical contractions which we hear called "pains of the right kind." These generally continue for about four hours, and this period represents the average length of time the physician remains constantly with his patient. Estimates which include the initial symptoms are longer, varying from ten to eighteen hours. Prolonged labors are rare; and extremely short labors are also infrequent, though now and again it will be only an hour or two from the very first pain until the child is born.

To predict absolutely the length of labor for any particular patient is impossible. The averages calculated from large groups of cases have no more than a broad scientific interest; when applied to any individual they are apt to be very misleading. Thus, from statistics we should expect the first labor to be longer than subsequent ones, but we are often surprised by an unusually rapid delivery.

To facilitate description, labor is divided into stages which are conveniently designated the first, the second, and the third. During the first stage the way is prepared for the expulsion of the child; at the end of the second stage the child is born; the third stage is occupied with the separation and the expulsion of the after-birth. The progress of labor may be ascertained from time to time by means of suitable examinations. Whereas formerly vaginal examination was the only method which served this purpose, we are now acquainted with several. For example much of the information necessary for the proper management of delivery may be gained from examination of the patient's abdomen; and this may be supplemented by observations too technical to consider here.

Occasionally I have heard doctors accused of negligence because they failed to make numerous vaginal examinations. Censure of this kind generally is unjust, for discretion in limiting the number of vaginal examinations provides against infection a guarantee which cannot be overestimated. In many cases, of course, they are still invaluable toward determining what treatment should be pursued, yet they are never employed to the extent once customary. Moreover, physicians have learned to take extraordinary precautions whenever vaginal examinations must be made.

Anyone who practices obstetrics in these days appreciates how careful he must be, especially of the cleanliness of his hands. Energetic scrubbing with soap and water and the free use of antiseptics, as physicians now employ both these measures, appear ridiculous to some women who have witnessed deliveries under a less stringent regime. They may be bold enough to express their disapproval. They may remind us that many women have been successfully delivered without such care. And in this they are correct; we know that nine of every ten mothers passed through childbirth uneventfully before modern precautions were dreamed of. Such precautions as are now taken, however, are necessary to secure the safety of the tenth patient. And it is because they are anxious that all their patients shall enjoy the greatest possible security that physicians dare not omit any precaution.

Disinfection of the physician's hands does not entirely exclude the danger of infection through vaginal examinations. Although he may have been most conscientious, there is some risk of carrying contaminating material into the birth-canal from the region about the opening of the vagina. Unless that region has been satisfactorily disinfected, sterilizing the dressings and cleansing the hands may become a waste of time. Sensible patients, therefore, will never object to the preparations which the nurse is instructed to make.

THE STAGE OF DILATATION.—For reasons which are sufficiently clear, the womb must remain closed while fetal development is in progress; but under normal conditions, when this development is complete, the mouth of the womb dilates and the infant is expelled. The infant never takes an active part in its birth, although physicians once thought it did and attributed tedious labors to stubbornness on its part. The error has been corrected in medical teaching, but many persons unacquainted with the facts cling to the idea that the infant forces its own way out of the womb.

At the end of pregnancy the mouth of the womb is small, too small, often, to admit an instrument as broad as a lead pencil. It is obvious, therefore, that very radical changes must be wrought before the infant can pass. The door, as it were, must be widely opened. This phenomenon, which we call dilatation of the womb, is brought about by involuntary contractions of the muscle fibers in its wall, every point of which they draw upward. Now, the top of the womb is directly opposite its mouth, consequently the contractions inevitably pull its lips wider and wider apart. Ordinarily another factor is concerned in this mechanism. To understand the whole process we must recall that a fluid surrounds the fetus, and that this fluid is contained within elastic membranes. The uterine contractions compress the fluid, drive the membranes, like a wedge, into the mouth of the womb and spread its lips apart. Thus, to the pulling effect just mentioned, a pushing force is added. After full dilatation has been accomplished and the membranes can serve no further purpose, they rupture; as the midwife puts it, "the bag of waters breaks." The quantity of fluid which escapes will vary.

Occasionally, a huge gush will drench the patient's clothing; but more often what is lost at first amounts to only a few teaspoonfuls, though small quantities of fluid often dribble away with subsequent contractions.