When to Notify the Doctor
Most doctors want to be called as soon as rhythmic, infrequent pains begin or the membranes rupture, no matter what the hour. A considerate patient who hesitates to call at two in the morning may be solaced by the knowledge that disturbing an obstetrician is not the same as disturbing any other of mortal breed; for he is a rare species of night prowler who through years of specialized training is able to turn sleep off and on at will, has indeed learned to be almost independent of the god Morpheus, thus acquiring the worn look that distinguishes him from such diurnal healers as psychiatrists and dermatologists.
Do Not Eat if in Labor
At the request of one of my medical colleagues, an anesthesiologist, I insert a timely note of warning. Whenever there is any likelihood of labor, the patient should eat nothing until she consults her doctor; it is safe to drink clear liquids. Many anesthetic accidents have occurred when the patient entered the delivery room with a full stomach, then vomits and aspirates stomach contents into the lungs while going under or coming out of a general anesthetic. Recently one of our patients delivered a few hours after a dinner of corn. She vomited and sucked some of the kernels into her lungs. Prompt bronchoscopy (inserting a periscopelike instrument down the windpipe) and the removal of several kernels averted serious consequences.
Why the Hospital?
Until the second decade of the twentieth century it was mainly streetwalkers and the very destitute who sought hospital deliveries; available accommodations were in keeping with the standards of such clientele. Since 1910 there has been a complete revolution. Magnificent obstetrical institutions have been built for poor and rich alike, who use them in increasing numbers—regardless of class or financial station. By 1942, two out of three births in the United States were conducted by doctors in hospitals and by 1959, 96 out of every 100. More than 99 per cent of the 160,000 children born each year in New York City are delivered by physicians in hospitals.
Why have hospitals become the vogue? There are two reasons: the patient and the doctor. The patient prefers them because they are more comfortable when she is in labor and they assure her days of rest after delivery, entirely isolated from domestic cares. Delivery at home, moreover, requires complicated preparations. Most important of all, the patient has faith in hospitals. She is confident that the modern hospital is equipped to meet any sudden complication, and she knows that when her own doctor is out of the building a competent junior staff member is in attendance.
The doctor prefers the hospital for several reasons. In case of emergency—in obstetrics emergencies occur with lightning suddenness—the hospital can save the patient’s life with a transfusion, a Cesarean section, the use of an oxygen tent, etc. Any complication of pregnancy, labor, and the puerperium (the six-weeks period following childbirth) can be better diagnosed and treated there because of laboratory facilities and consultation staffs. Obstetrical analgesia—pain-relieving drugs in large doses—can be given with safety only in a hospital. To have his cases centralized rather than scattered over a large metropolis is essential to the busy obstetrician.
Much has been written about the relative safety of the home and the hospital for childbirth. I know of no evidence to prove that the home is safer. Of course there are all sorts of hospitals, and, as the Commonwealth Fund Report so clearly demonstrated more than 2 decades ago, an inadequate private-sanatorium type of proprietary, obstetrical hospital is often a worse menace than a filthy home. The ideal hospital is one considered Class A according to the standards of the American College of Surgeons, and one with a separate maternity unit directed by a qualified staff of obstetricians. Such a hospital is superior to any home, unless the home is so elaborate that a complete private hospital can be set up. Hospitals are constantly improving in this country, and by now almost every community has some local or neighboring nonprofit institution which is safe for obstetric care.
When the Patient Is Sent to the Hospital
The labor of a multipara (a woman who has borne a child before) may be so sudden and unpredictable in its termination that she is usually sent to the hospital as soon as the doctor is reasonably certain the call is no false alarm. In his management of the primiparous woman he takes advantage of the psychological fact that most patients calculate the length of labor from the time they enter the hospital and not from the actual onset of pains. Labor is shortened in the mind of the primipara by keeping her at home during the first several hours and sending her to the hospital only when pains become regular and five or six minutes apart.
Going to the Hospital
Departure for the hospital to have a baby is an event surcharged with drama, some inherent, some engrafted. You can lessen the latter by accepting two pieces of advice. Above all, be calm. Then the next most important admonition is, be prepared! Either pack your suitcase in advance or prepare a list of things to bring along; otherwise, in the excitement of the moment, necessities may be left at home. Do not take baby clothes, since most hospitals will not allow you to use your own articles in the nurseries. Clothes for the child to leave the hospital can be brought the last day of your stay. As far as your own things are concerned, bring the minimum; most patients bring too much. Toilet articles and accessories, a robe, bed jacket, slippers, and several pajama tops are the primary requisites; the latter are more easily managed than nightgowns. You also need two nursing brassieres and two sanitary belts to hold napkins in place. The hospital furnishes sterile sanitary pads. Entertaining literature, stationery for thank-you notes, your address book, and perhaps a small portable radio complete the cargo.
If you already have children at home, make arrangements with a neighbor or relative for emergency baby-sitting coverage. See to it that the sitter can get there under her own chaperonage; fetching her first may use up strategic time at the last minute.
If you have no car, make preliminary arrangements about transportation in advance. If you are at term and live a distance from town, and paralyzing sleet or snow threatens, it might be safer to spend the night in the environs of the hospital. If you are snowbound, the State Police are magnificent in such an emergency.
It is well to rehearse with your doctor which door to use in entering the hospital at any hour. Ringing the wrong bell at two in the morning and getting no response is, to say the least, frustrating.
Arriving at the Hospital
After the patient arrives at the hospital the routine varies from institution to institution, in some measure depending on its size. In many, the pregnant woman is met at the front door by an attendant with a wheel chair who trundles her to the admitting office. There her registration card is removed from the file of undelivered cases, and notations are made on it, including the number of the room assigned. The patient, with the husband bringing up the rear, bag in hand, is then either wheeled to the delivery floor, where the labor rooms are situated, or taken directly to her own room.
Admission to Delivery Floor
At the Mount Sinai Hospital the patient goes directly to the delivery floor, where the nurse in charge greets her with a cheerful, ‘How are you, Mrs. Jones? It’s nice to see you here; we have been expecting you. We hope you will have a pleasant stay. Do not hesitate to call upon me or my staff for anything which will add to your comfort.’ If these are not her exact words, at least the content is similar. The husband is relieved of the bag and told to go to the waiting room and return in half an hour.
Patient and nurse enter one of several labor rooms, which are light and cheerful with pastel-colored walls, curtains at the windows, and modern French prints on the walls. The regular adjustable hospital bed has a comfortable foam-rubber mattress; in addition there are attractive chairs, a bedside table-cabinet combination, and an Executone two-way conversation connection with the nursing station. Each labor room has its own lavatory.
Process of Admission
The head nurse is relieved by a student nurse or an aide, who divests the patient of her clothes, which are listed on a form to be signed by the patient. The clothes are put into a paper bag, properly tagged, and sent to a locker area. The laboring woman has been given a plain, abbreviated heavy cotton gown, which partially fastens in back; when she is standing, it comes about halfway down the thigh. Temperature, pulse, respiration, and, in some institutions, weight are taken. A specimen of urine is obtained. If labor is not far advanced, pertinent historical data are recorded.
The patient’s doctor, or, in one of the large teaching institutions, the resident on duty, performs the admission examination. Heart and lungs are examined, blood pressure taken, and abdomen palpated to determine accurately how the baby lies. The fetal heart is located and its rate counted. As the final act of this first examination, either a vaginal or rectal examination is performed to discover how far labor has progressed. In most hospitals a rectal examination is preferred because it possibly exposes the patient to less risk of bacterial infection and does not require preliminary sterile preparations. The progress of labor is gauged by two criteria: the extent to which the cervix has dilated, and the depth to which the presenting part has descended in the birth canal. The opening in the cervix is round, and the amount of dilatation is expressed in terms of the diameter of this circular opening. When labor begins, the opening is less than 2 centimeters (4/5 of an inch, or a single finger-breadth); a completely dilated cervix is 10 centimeters (4 inches, or five finger-breadths) in diameter. The depth of descent is measured by the relation of the presenting head or breech to a little bony prominence on either side of the pelvis, the ischial spine, situated midway down the birth corridor. The corridor is six finger-breadths in length from the inlet where the baby enters to the outlet from which it emerges, and progress is expressed in the number of finger-breadths that the presenting part of the baby is above or below the midpoint milestones, the ischial spines. The presenting part advances from a minus-three station through zero to plus three, when it becomes visible as the doctor spreads apart the lips of the vagina.
If the admission examination proves that labor has begun, the genital area is washed and shaved by a nurse, who uses a safety razor and soap and water or a detergent. Unless labor is too far advanced, an enema of warm soapy water is given.
Conduct of First Stage
During early labor, if facilities permit, the husband is welcomed as a visitor in the labor room. The patient is encouraged to walk about or to occupy herself with reading, knitting, etc. When tired, she should rest. One of the unique occupations of labor is for the husband and wife to time and record the occurrence and length of the contractions. During labor no solid food is allowed, but clear fluids such as water, broths, and tea are permitted in the beginning phase.
The term ‘natural childbirth’ was introduced into modern obstetrics by the English obstetrician, the late Grantly Dick-Read. Many authorities dislike the term because it connotes that any other way of conducting delivery is unnatural, and by implication wrong. We prefer the terms ‘educated’ or ‘non-medicated childbirth,’ but despite our preference it appears that the English term is here to stay.
Two of Read’s key concepts are that fear and a muscularly unrelaxed, tense state are the chief sources of pain and difficulty during labor. Read advocates the elimination of fear through knowledge, which dispels terrorizing mystery from the birth process. This is done by professional instruction through discussions and the use of visual aids such as pictures and diagrams. He would also prevent the patient from being left alone during labor. Solitude at such a time breeds fright. In addition, patients are taught relaxation exercises during the prenatal period so that they may apply them during labor and delivery. They are taught how to pant during a labor pain and how to relax skeletal as well as vaginal and perineal muscles. Read prescribes that the term ‘labor pain’ be expunged and ‘contraction’ substituted. He forcefully insists that the contractions of the first stage are not minded at all by those who learn and employ his teachings, and that the expulsive phase of the actual birth is easily tolerated because of the physical satisfaction which results from giving in to the instinctive urge to expel the baby. Read finds that anesthesia, even the deadening of sensation by local anesthesia, is unnecessary for most properly prepared subjects.
Read attests that the gratification which the mother feels in being awake and an active participant in the process of birth gives rise to a feeling of exultation and a sense of accomplishment which no other experience in life bestows. He states explicitly that any patient employing natural childbirth who needs help from pain-relieving drugs or anesthesia should never be denied them.
Hypnosis for obstetrical pain relief has been employed experimentally since the middle of the nineteenth century, at first in France and later in Germany and England. In the last ten years several scientific studies and some popular books concerning hypnosis for labor and delivery have emanated from the United States. There is no doubt that in some instances hypnosis is spectacularly successful; the patient delivers in a trance, experiencing no pain. In fact I have witnessed a Cesarean section performed on a highly receptive subject with no other anesthetic than hypnosis. The drawbacks to this technique are its unpredictability—not all pregnant women are equally successful candidates for hypnosis— and the extravagant amount of time the physician-hypnotist must invest in the prenatal conditioning of his patient. Because of these deterrents, hypnosis is still viewed as a trick in its application to birth.
Many scientists feel that Read’s technique works through self-hypnosis—that the highly successful patient enters a modified hypnotic state. Read vehemently denies this. He feels that his success is due to suggestion in a patient marvel-ously relaxed, so relaxed that the soft tissues do not hold back the baby. The relaxed state stems from a confident fearlessness which owes its origin to knowledge and preparation.
Pain relief by conditioned reflex, called the psycho-prophylactic method, the latest development in this field, has come to America from Russia via France. This form of pain relief is based on the conditioned-reflex response of Pavlov, the eminent Russian physiologist who first described it. A simple illustration is the day-after-day repetition of burning a hungry dog with a brand as he is fed. At first the dog howls in pain, but if the ritual is repeated again and again the dog shows no response to the pain stimulus and merely salivates in anticipation of its meal. By repeated verbal instruction, the same type of conditioned-reflex response can be developed toward the pains of birth. Contractions of the uterus during birth are never referred to as labor pains; the patient’s mind is repeatedly divested of the idea that pain is an inseparable part of the birth process. She is taught to feel her own uterine contractions of late pregnancy (Braxton-Hicks), and it is pointed out that these are painless. Therefore, why should contractions of labor be different? Rehearsed relaxation of certain voluntary muscle groups is also an important component of the conditioned-reflex technique.
Which of the Three ‘Natural’ Methods?
If the pregnant woman wishes to try ‘natural childbirth,’ she should read Grantly Dick-Read’s Childbirth without Fear, or his Natural Childbirth Primer, and Marjorie Kar-mel’s Thank you, Dr. Lamaze, which gives an author’s happy experiences in being delivered with the psycho-prophylactic technique. The case for hypnosis is well stated by William Kroger in his book, Childbirth with Hypnosis. Perhaps literary acquaintance with the three methods will allow the woman to develop her own preference. Then she must choose an obstetrician who is not only familiar with the technique of the method she has chosen, but who uses it frequently in his work. The doctor will either instruct her himself or arrange classes where she can be taught. It is not improper for a patient to telephone an obstetrician’s office to determine whether he uses the one of the three methods she wishes before making her first appointment. If he does not, he is likely to refer her to a colleague who does.