The time of confinement can never be accurately determined, because the onset of labor is purely an accident, dependent on many factors. Furthermore, conception does not take place necessarily at the time of intercourse, and we have no means of knowing whether conception occurred just after the last period present or just before the first period missed. So there is always a possible error of three weeks.

Pregnancy in the human family normally lasts from 275 to 280 days, and the approximate date of confinement can be obtained by the following convenient rules:

1. Take the first day of the last menstruation, count back three months and add seven days.

2. Or, assuming that quickening occurs at the seventeenth week, count ahead twenty-two weeks from the day on which quickening was observed.

3. Or, count two weeks from the day of lightening.

4. Or, with a pelvimeter, get the length of the foetus by Ahlfeld’s rule (measure from symphysis to breech of child, subtract two cm. for thickness of abdominal wall and multiply by two. The result is the length of the child in centimeters) and compare with fifty centimeters, which is the average length of a mature child. After the seventh month, the child in utero grows at the rate of about 1 cm. a week (0.9 cm.).

5. Or, by the tape, according to Spiegelberg’s standard of growth, as previously mentioned.

The hygienic rules to be observed during pregnancy are founded on three basic principles: (1) To watch attentively the different organs and see that they functionate normally; (2) To eliminate all those conditions that favor the premature expulsion of the egg; and (3) To provide, so far as possible, for the normal gestation and the physiological delivery of the child. These factors will be taken up in detail.

The Diet.—The appetite is usually somewhat increased, but it is unnecessary to indulge the stomach on the ground that the mother “must eat for two.” Longings, however, should be gratified so far as the demand is not for unwholesome things. Food should be simple and plainly cooked. Meat is permitted in moderation unless some organic change exists to contraindicate it. Rich pastries and gravies should be avoided, but cereals, fruits and vegetables should be used in abundance. It may be better to eat four times a day instead of three. Fluids should be taken freely, from one to two quarts daily. Milk is especially valuable, and alkaline, natural and charged waters, such as Vichy and seltzer, are useful. Wine, beer and other alcohols should not be taken, or if the patient is habituated to their use, the amount should be restricted on account of danger to the pregnancy and danger to the child.

In contracted pelves it is sometimes desired to furnish a special diet, with the idea of controlling the size of the child (see Prochownick’s Diet, p. 332) but this is an emergency. Certain books on maternity, designed for popular reading, advocate diets that are supposed, by depriving the child of lime salts, to keep its bones soft and make the labor easy. If it succeeds, the child will be injuriously affected. If it does not succeed, the claim is false.

Exercise.—Exercise should be taken, but it should not be violent, nor attended by risk. Golf, swimming, tennis, dancing, horseback or bicycle riding and fast driving in automobiles should be forbidden, lest abortion follow. General exhaustion must be avoided and all conditions that even approximate traumatism. Walking and slow driving are best, and housework is excellent up to a mild degree of fatigue. Travel should be restricted. If exercise is not feasible, massage will furnish the required stimulation to the circulation. The menstrual epochs are peculiarly favorable to abortive influences.

The Bowels.—Most women have a tendency to constipation during pregnancy. Many times this can be corrected by increasing the “roughening” in the food; more vegetables and fruits, bran bread and muffins, whole wheat bread, spinach, beans, carrots, turnips, peas and especially potatoes, baked and eaten, skin and all. Prunes, figs, and dates are valuable aids. Agar may be eaten three or four times daily. Russian oil (liquid petrolatum), taken in tablespoon doses three times daily, is an adjuvant, and finally, some form of cascara or aperient pill may be taken, if necessary.

Violent cathartics should not be used at all, and enemas as little as possible; only when quick results are necessary.

Heartburn.—Heartburn is a frequent complication, especially in the later months. It is due to an inordinate secretion of acid in the stomach. Soda mint tablets, bicarbonate of soda, and magnesia, in cake or as milk of magnesia, will relieve. The magnesia is also a laxative.

The kidneys require particular care during pregnancy, and in every case the urine should be examined monthly, up to the fifth month, and every two weeks thereafter, until the last six weeks, when a weekly test should be made.

The amount passed in twenty-four hours should be measured. Three pints is an average quantity. Albumin, sugar, and casts must be looked for and reported. Albumin may or may not be a serious symptom. Casts are significant of nephritis and indicate danger. Sugar may be lactose and be derived from the milk secreted in the breast. Edema of feet, hands and eyelids must always be investigated, with the possibility in mind, of heart and kidney lesions. Blindness, dizzy spells, headaches and spots before the eyes are always alarming symptoms until their innocence is established.

Through constant watchfulness of the urine, many cases of eclampsia may be averted.

Bathing is more important in pregnancy than at other times. The more the skin secretes, the less the burden on the kidneys. The skin must be kept warm, clean, and active. Then again, during pregnancy the skin is often unusually sensitive and only the mildest soaps and blandest applications can be used. The water must be neither hot nor cold, but just a comfortable temperature. Cold bathing, whether shower, plunge, or sitz, must be denied. Sea bathing is also unwise. The warm tub bath of plain water or with bran answers all conditions until the expected labor is near, then the warm shower or sponge bath should be substituted, lest germs from the bath water enter the vagina.

If the kidneys need aid, a hot pack may be used; but in all cases, frequent rubbing of the skin with a coarse towel should follow the bath.

The dress must be warm, loose, simple and suspended from the shoulders. To prevent chilling, wool or silk, or a mixture of both, should be worn next to the skin,—light in summer and heavy in winter.

The patient must be sensibly clad in broad, loose, low-heeled shoes. There should be no constriction about chest or abdomen. Circular garters must not be worn. If a corset is insisted upon, it must support the abdomen from below and lift it up. No corset is admissible that pushes down on the abdomen. This is especially true if the woman has borne one or more children and has a pendulous abdomen. The breasts may get heavy and require the rest and ease supplied by a properly fitting bust supporter.

Fainting is an annoying symptom in some women. It may come when quickening is first perceived, or from the excitement of crowds, or from hysteria. It usually passes quickly. The pallor is not deep, the pulse is not affected, and consciousness is not lost. It does not affect the ovum. Heart trouble should be excluded, and the daily habits of dress, diet, and bowels investigated. Smelling salts will usually suffice for the attack.

The abdominal walls may be strengthened by appropriate exercise before and after gestation, so that the muscles will preserve their tone. After delivery nursing the child will help greatly in the preservation of the waist line and figure, by aiding involution.

About the seventh month in primiparas, the abdomen gets very tense and in places the skin is stretched until it gives way and forms striÆ. This tightness can be relieved to a considerable degree by inunctions of cocoanut oil or albolene.

Pain in the abdomen at this time may be due to mechanical distention, to strain on the muscles, to stretching of operative adhesions, to gas, constipation, or appendicitis. The physician should be informed of it. In every case, constipation, swelling of feet, hands or eyelids, blurring of vision, ringing in the ears, vomiting, persistent backache, or the passage of blood, no matter how slight, should be reported to the doctor.

The Breasts.—There should be no pressure on the glands and they should be warmly covered. The nipples must be kept clean and soft by soap and water, and about a month before the labor is expected, the nipple should be anointed with albolene or cocoanut oil and rubbed and pulled for a few minutes every night. This removes the crusts and dried secretions that collect on the nipple and prepare it for the macerating action of the baby’s mouth. No alcohol or strongly astringent washes should be used. Injuries must be avoided. If the nipples become tender they may be protected from external irritation by the lead nipple shield or by a wooden shield with a hollow center, such as Williams recommends.

Leucorrhoea.—This is one of the commonest discomforts of pregnancy, and the sense of uncleanliness, if the discharge is excessive, as well as the resulting irritation, may demand attention. It must be kept in mind, however, that the normal vaginal discharge of a healthy pregnant woman is strongly germicidal and should not be douched away without definite indications.

Vaginal douches of warm boric acid solution will do for cleanliness, but the douche bag must not be higher than the waist. Stronger and more antiseptic solutions are potassium permanganate 1:5000, or chinosol 1:1000. A suppository may be used, consisting of extract belladonna, gr. ss; tannic acid, gr. v, and boroglyceride dr. ss.

Sexual intercourse is distasteful to most pregnant women, but sometimes the inclination is intensified.

Coitus often causes much pelvic discomfort and may be an influential factor in producing abortion. It should be forbidden during the early months, at all menstrual epochs, and for at least two weeks before labor. The uterus may be infected by germs beneath the foreskin and hÆmorrhage may follow the act if the placenta is low. In healthy persons, at the instance of the female, intercourse in moderation is permissible.

The mental condition should be placid without either excitement or fatigue. Anxiety should be dissipated by cheerful company and surroundings. Judicious amusement is desirable and a congenial occupation, but neighbors who tell frightful tales of disaster in labor, or nurses who relate the details of their critical cases, are equally to be avoided.

Many women of neurotic temperament dread the labor desperately. They are sure that death impends and they dwell with tragic interest on the stories of complicated cases related by thoughtless or malicious neighbors. The nurse can do much to allay these apprehensions by cheerfulness, optimism, and gentleness. Her buoyant temperament will drive away the patient’s fears just as effectively as the assurances of the physician.

Great allowances must be made for attacks of irritability, for the changes going on in the woman’s pelvis keep her in a capricious and whimsical condition. A good book to read at this time is, the “Prospective Mother,” by Slemons.

The subject of maternal impressions is the cause of much anxiety during pregnancy. It is safe to assure the mother that it is nearly impossible to mark her child by emotional stress. There is no demonstrable nervous communication between mother and child, and most of the deformities that occur and are attributable to shock, etc., can be explained by our knowledge of intrauterine changes. Furthermore, the same deformities occur in lower animals, to which it is difficult to ascribe such high nervous organization.

Many of the birthmarks, supposedly due to shock, occur too late in the pregnancy to affect the child, even if it were possible, for the child is completely formed before the fourteenth week.

The Determination of Sex.—It is not possible to know in advance of delivery whether the child will be a male or a female. It is equally impossible to determine or even to influence the sex of the coming child. Many theories have been advanced, and much talent has been wasted in trying to solve this problem.

Reasoning by analogy from the facts obtained from lower animals, the sex of the child is unalterably decided the moment conception occurs. The responsibility for the decisions seems to lie with the male cell. All we really know is that the sexes appear in the ratio of 100 girls to 106 boys.