Popularly spoken of as the "lying-in period," and medically known as the puerperium, this time of convalescence immediately following childbirth is usually occupied by two important things: the restoration of the pelvic organs to their normal condition before pregnancy, and the starting of that wonderfully adaptative mechanism concerned with the production of the varying and daily changing food supply of the offspring.

The uterus, now more than fifteen times its normal size and weight, begins gradually to contract and assume its normal weight of about two ounces; and it requires anywhere from four to eight weeks to accomplish this involution. In view of all this it is obvious that there can be no fixed time to "get up." It may be at the end of two weeks, or it may not be until the close of four or five weeks, in the case of the mother who cannot nurse her child; for the nursing of the breast greatly facilitates the shrinking of the uterus. Extensive lacerations may hinder the involution as well as other accidents of childbirth, so it must be left with the physician to decide in each individual case when the mother may enter into the activities of life and assume the responsibilities of the care of the baby and the management of her home.

THE NURSE

During this period of the puerperium a member of the family, a neighbor, a visiting nurse, a practical nurse, or a trained nurse, looks after the mother and gives to the babe its first care; whoever it may be, certain laws of cleanliness must be carried out if infection is to be guarded against. If there are daily or semi-daily calls made by the physician, a member of the family may be trained to care for the mother with proper cleanliness and asepsis; but it is far better for the mother, if possible, to secure the services of a trained nurse, or the visiting nurse, in which instance she will call each day, wash and dress the baby, clean up the mother and care for the breasts. She is not supposed to clean the room, make the bed or prepare the food. If a trained nurse can be in charge, the convalescing time is usually shortened as the responsibilities are taken from the mother, her mind freed from care and it is her's to improve, rest, and wait for the restoration of the pelvic organs, when she may again go forth among her family.

The nurse may have to sleep in the same room; but, if it be possible, she should occupy an adjoining room, she should have a regular time each day for an hour's walk in the fresh air, she should be served regular meals, and be allowed some time out of the twenty-four hours for unbroken slumber. In return she will intelligently cooperate with the physician in bringing about the restoration of body and upbuilding of the mother's nerves.

REST AND EXERCISE

From a monetary standpoint there can be nothing so wasteful or extravagantly expensive in the home as to allow the mother to drag about from day to day and week to week with chronic weakness or invalidism because she did not have proper care during her already too short puerperium, or because she got up too soon.

Having a baby is a perfectly normal, physiological procedure. It is also, usually, downright hard work; and, beside the hard laborious work, there is not only a wearied and severely shocked nervous system to be restored, but there is also a certain amount of uterine shrinkage which must take place—and this requires from four to eight weeks; and so our mother must be allowed weeks or even a month or two to rest, to enjoy a certain amount of well-directed exercise, to have an abundance of fresh air, to be wheeled or lifted out of doors if possible into the sunshine, that she may be the better prepared for the additional duties and responsibilities the little new comer entails. Sunshine and fresh air are wonderful health restorers as is also a well-directed cold water friction bath administered near the close of the second week of a normal puerperium. During the second week a few carefully selected exercises such as the following are not only beneficial, but tend to increase circulation and thus to promote the secretion of milk and the shrinking of the uterus.

1. Head raising, body straight and stiffened.
2. Arm raising, well extended.
3. Leg stretching, with knees stretched and toe extended.
4. Massage, administered by the nurse.

A splendid tonic circulatory bath may be administered at the close of the second week (in normal puerperium), known as the "cold mitten friction," which is administered as follows: The patient is wrapped in a warm blanket, hot water bottle at feet, and each part of the body—first one arm then the other; the chest, the legs, one at a time—is briskly rubbed with a coarse mit dipped in ice water. As one part is dried it is warmly covered, while the next part is taken, and so on until the entire body has been treated. The body is now all aglow, the blood tingling through the veins, and the patient refreshed by this wide-a-wake bath. Properly given, the cold-mitten friction bath is one of the most enjoyable treatments known and under ordinary conditions, if intelligently administered, may be given as early as the eighth day.

AFTER PAINS

After the birth of the first baby the uterus usually is in a state of constant contraction, hence there are no "after pains;" but after the birth of the second or third child, the uterine muscle has lost some of the tone of earlier days—there is a tendency toward relaxation—so that when the uterine muscle does make renewed efforts at contraction, these "after pains" are produced. They usually disappear by the third day. Nothing should be done for them, indeed they should be welcomed, for their presence means good involution (contraction) of the uterus.

THE TEMPERATURE

Careful notations of the temperature should be made during the first week. A temperature chart should be accurately kept and if the temperature should rise above 100° the physician should be notified at once. The third day temperature is watched with expectancy, for if an accidental infection occurred at the time of labor, it is usually announced by a chill and sudden rise of temperature on the third day. This may be as good a place as any to mention the commonly met night sweating. This is due to a marked accentuation of the function of the skin. It is not at all unusual for a sleeping mother in the early puerperium to wake up in a sweat with night gown very nearly drenched. The gown should be changed underneath the bedding, while alcohol is rubbed over the moistened skin surface.

These sweats will disappear as soon as the mother begins to regain her strength. A vinegar rub administered on going to bed may often prevent these sweats.

THE TOILET OF THE VULVA

Immediately after the birth of the baby and the expulsion of the afterbirth, the thighs and vulva are cleansed as follows: Into a basin of warm, boiled water are dropped four small antiseptic tablets of bichlorid of mercury; this gives a proper antiseptic wash. Into this solution are placed four pieces of sterile cotton Two of these are used, one at a time, without being returned to the solution to wash each inside of the thigh, the remaining two to cleanse the vulva. Without drying the vulva, two sterile pads are applied and pinned to the binder. These pads are changed every hour during the first day or two because of the profuse lochial flow.

After each urination and bowel movement, a lysol solution (prepared by putting one teaspoonful of lysol in a quart of sterile water) is poured from a clean pitcher over the vulva into the bed pan, and fresh pads applied. This toilet continues until the close of the second week or longer, if there is a lochial flow.

These sterile pads not only absorb the lochia but also, among ignorant or thoughtless mothers, prevent contamination by the patient's hands.

URINATION

The patient should be encouraged to urinate during the first few hours after labor; catheterization should not take place until every effort has been made to bring about normal urination; or, until there is a well marked tumor above the bony arch of the pelvis in the lower part of the abdomen. It is far less harmful to the patient for her to sit up on the jar placed on the edge of the bed, than to undergo the risk of inflammation of the bladder which so often follows catheterization.

THE LOCHIA

The first few days the lochia is very red because of the large amount of blood which it contains. After the third or fourth day it is paler and after the tenth it assumes a whitish or yellowish color. During the three changes it should always smell like fresh blood. Any foul, putrifying odor should be promptly reported to the physician.

If on getting up at the close of the second week the lochia should resume its red color, the patient should return to bed and notify her physician.

THE ABDOMINAL BINDER

After the tenth day, the abdominal binder may be pinned as tightly as the patient desires, but prior to the tenth day many physicians believe the exceedingly tight binder causes misplacements of the enlarged, softened, and boggy uterus. It should be pinned snugly; but not drawn as tight as possible with the idea of keeping the uterus from relaxing, for at best, it does not do it; while tight constriction may produce a serious turning or flexion of the uterus. The breast binder is applied during the first twenty-four hours to support the filling breasts, loosely at first, and as they increase in size, as the glands become engorged, the binder is drawn more tightly. A sterile piece of gauze is placed over the nipples.

THE BOWELS

On the morning of the second day a cathartic is usually given—say one ounce of castor oil or one-half bottle of citrate of magnesia. The bowels should move at least once during each twenty-four hours; if they are obstinate, a simple laxative may be nightly administered. Certain constipation biscuits, sterilized dry bran, or agar-agar may be eaten with the breakfast cereal. Prunes and figs should be used abundantly. Bran bread should be substituted for white bread. The enema habit is a bad one and should not be encouraged; however, the enema is probably less harmful than the laxative-drug habit. Mineral oil is useful as a mild laxative, and does not produce any bad after results.

CARE OF THE NIPPLES

Fissures of the nipples should be reported to the physician at once. There are many good remedies which the physician may suggest; in his absence, Balsam Peru may be advantageously applied. Boracic acid solution should be applied before and after each nursing from the very first day; in this way much nipple trouble may be prevented through cleanliness and care. The nipples should be kept thoroughly dry between nursings Nipple shields should be used where fissures persist.

THE DIET

For the first three days a liquid and soft diet is followed such as hot or cold milk, gruels, soups, thin cereals, eggnog (without whiskey), eggs, cocoa, dry toast, dipped toast, or cream toast. There should be three meals with a glass of hot milk at five in the morning (if awake) and late at night; nothing between meals except plenty of good cold water. After the third day, if temperature is normal, a semi-solid diet may be taken, such as baked, mashed, or creamed potatoes, soups thickened with rice, barley or flour, vegetables (peas, corn, asparagus, celery, spinach, etc.); eggs, light meats, stale breads, toast, bland or subacid fruits (sweet apples, prunes, figs, dates, pears, etc.); macaroni, browned rice (parched before steaming), etc.; ice cream, custards, and rice puddings for desserts after the seventh day. Three good meals a day, at eight and one and six, with a couple of glasses of hot milk or cocoa or an eggnog at five a. m., to be repeated at 9 or 10 p. m., with plenty of cold water between the meals, will abundantly supply the necessary milk for the growing babe. Tea and coffee are not of any special value in encouraging a flow of milk.

The constant coaxing of the mother with "Do drink this," and "You must drink this, or you won't have any milk," not only saddens her but seriously upsets digestion and thus indirectly interferes with normal lactation.

GETTING UP

Everybody should stay at home and away from the mother and her new born child until after the seventh day, and then, if our patient is normal, visitors may call, but should not stay longer than five minutes. The convalescing mother will improve faster without the neighborhood gossip, or the tales of woe so often carried by well-meaning, but woefully ignorant acquaintances.

When the hard ball-like mass can no longer be felt in the lower abdomen, when the lochia has passed through the three changes already mentioned, and the flow is whitish or yellowish, scanty and odorless, the patient may sit up in a chair increasingly each day. Such conditions are usually found anywhere from the tenth to the fifteenth day. The patient first sits up a little in a chair—she has already been exercising some in bed—and this enables her to sit up with ease for a half-hour the first day, increasing one-half hour each day during the week following. At the end of three weeks, she may be taken down stairs providing there is ample help to carry her back up stairs. After another week (at the close of the fourth), if the lochia is entirely white or yellow, with no blood, she may begin carefully to go about the house. There should be no lifting, shoving, pulling, wringing, sweeping, washing, ironing, or other heavy exercise for at least another two weeks, better four weeks. Any variance from this program usually means backache, lassitude, diminished milk supply, and frequently a general invalidism for weeks or months—sometimes years.

COMPLICATIONS

Cystitis, or painful urination, is avoided by tardy "getting up;" quietly, slowly moving about; abundant water drinking; and the avoidance of catheterization.

Hemorrhage. Notify the physician if it occurs at any time. The treatment is heavy kneading of the abdomen until the uterus again becomes like a hard ball. Cold compresses over the lower abdomen may sometimes help.

Infection is manifested by chilly sensations or a distinct chill followed by fever, usually on the third day. Take a cathartic; notify the physician at once and follow his directions.

Mastitis, inflammation or caking of the breasts. Very hot fomentations wrung out of boiling water, alternating with ice-cold compress, should be applied to the breast for an hour or more, three or four times a day. Cathartics should be administered, and eliminative measures instituted such as the hot-blanket pack.

Pneumonia. Keeping the arms and chest well protected by a long-sleeved coat of warm texture, should help in preventing this serious complication. Pneumonia complicating labor is usually the result of carelessness and exposure.