States. There are many problems to be solved by the scientific method. I am sure that nurse-midwives will continue to provide leadership, support, and do much of the experimental work which is necessary.

The question of the unique contribution of nurse-midwifery in teaching in a basic collegiate course in maternity nursing has only been answered in part, by one person, in one situation. It will take many such presentations, written, analyzed, summarized, and pub- lished to clarify our thinking and mobilize us for action. Part of the question will remain unanswered until man has learned to evaluate the intangible, the things which make life good and work a joy.

HELPING BASIC STUDENTS LEARN HOW TO TEACH PARENTS

BY Mary 1. Crawford. R.N.. M.A., C.N.M.

Assistant Professor of Obstetric Nursing and Assitant Director of Nursing Service Colum bk-Presbyterian Medical Center

New York, N. Y.

By the time a student nurse reaches obstetrics, she has been given a fairly thorough grounding in histology, eugenics, and in anatomy and physiology of the human reproductive tract. Yet in most courses in obstetrics it is felt necessary to review all this background. By the time the student gets to obstetrics, a high percentage of the

.isolated facts which she has memorized during her many courses of science has been forgotten. Unfortunately, even with the time spent in obstetrics in reviewing all this material, all too often the same thing is going to happen again. As soon as the student leaves obstetrics, as soon as the last examination has been handed in, the facts again rapidly slip out of her mind. Why? Is it because the student fails to see any practical use for this material? Where does she have to fall back on this material in obstetrics? Certainly not in taking a pregnant mother’s blood pressure and weight in the clinic and following through with the perennial scolding about weight gain. -Nor is it going to help her support a mother in labor, scrub for delivery, give perineal care, or teach a mother how to bathe her baby before she goes home from the hospital. All too often we have merely repeated the pattern that has gone before, setting up isolated classes on such subjects as menstruation, sterility, fetal development, maternal changes during pregnancy, etc. But is the student helped to see how all this ties in with the health of the

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mother, not just physical health but mental and emotional health as well, not just health which means mere freedom from disease but health which is positive, dynamic, the very highest peak of health? Is she helped to see all the broad implications of health in obstetrics, not only for the mother and baby during this pregnancy, but for the mother and baby during the next pregnancy and the next generation of mothers and babies? Does she see this strongly enough that, regardless of what field of nursing she may choose, she is constantly striving to help parents and potential parents to see the importance of health? Is she stimulated to dig t h i s material out and gain a clear enough understanding of it for herself to enable her to explain it clearly in the simplest terms? If she can, she is ready to abandon the age old worthless admonitions of %e doctor knows best” or “because it is good for you’’ and to help the mother and father to see why their health and the health habits which they develop in their children are so important.

I t is becoming more and more apparent that, in order to solve many of the problems which still exist in obstetrics today, obstet- rics of tomorrow will have to broaden its horizons far beyond the nine months of pregnancy and the six weeks puerperium. True, we have no proof to substantiate these ideas as yet. Our knowledge of normal reproductive function is much too limited. However, if we study the chances of difficult or complicated labor or an abnormal baby for a mother having her first baby at the age of 35, in com- parison to the mbther having her first baby in her early twenties, we soon become suspicious that bodily reserves and physical condi- tion may play an important role. In a like manner, compare the labor of the mother in the upper economic level with the mother in the lower economic level, the mother who has always been interested in athletics to the mother who practically never had any such interest, the mother in the so called uncivilized regions of our world to the mother in the more civilized regions. Interest in sports and physical activity is lost at a fairly early age in our civilization, and by the time our female population has finished high school they have all too often settled into sedentary habits. Even worse, they are continually embarking on one dietary fad after another. If pregnancy is postponed until the age of 35, there has been just that much more time for the depletion of dietary reserves and the reduc- tion of muscle tone.

Helping Students Understand

Now let’s take a look at how a student can be helped to under- stand some of these facts through her review of reproductive physi- ology and how she can help parents to gain the same understanding. If the discussion with students is done in the simple terms which she would use in discussing this with parents, it should prove to some advantage. If this material can be made clear to parents through these simple terms, it should also be clear to basic students. If the student then desires more detail, there is no lack of textbooks into which she can delve for the more complicated details.

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Pregnancy

Pregnancy is primarily a process of tremendous growth - the growth of the baby from one tiny cell, which can not be seen by the naked eye, to a full term baby weighing 7-7% pounds, and, in the mother, the growth of the placenta, the growth of the uterus, the growth of the breasts, the changes in the cervix and birth canal, the formation of the fluid that surrounds the baby, and the formation of many new blood cells. If parents are going to have any real appreciation of how their baby grows, how the mother’s body develops during pregnancy so that she can effectively cany her baby, bring him into the world, and be prepared to care for him, they need to review the principles of growth. Parents also will be asking the nurse for help in how they can answer their children’s questions. They need the facts with some idea of how these facts can be explained in simple terms.

Everyone has learned some time during school days that the unit of growth in the body is the cell, and that growth takes place through cell division. One cell divides into two, and those two divide into four and so on. Someplace along the line in humans, certain cells begin to take on certain functions, and these cells group themselves together to form a tissue. So we have muscle tissue, bone tissue, blood tissue, hair tissue, skin tissue, etc., which continue to grow until they reach adulthood. Even when adulthood is reached, all growth does not stop. Hair continues to grow. New skin is formed. Fingernails and toenails continue to grow. Even those tissues which no longer increase in size are constantly adding new material to their structures and getting rid of the old worn out structures. Cells are therefore constantly in need of building materials, energy to build with, and the foreman to see that the work is carried out according to plan and in the correct order. In the body all these materials are obtained from the food we eat, or if not available in food, from the reserves which have been stored in the body. Proteins and minerals serve as the building materials, carbohydrates provide the energy, and vitamins in their close interrelationship with hor- mones and enzymes serve as the regulators for all this growth and activity which is taking place.

One question which might occur to us, if we spent much time thinking about this enormous growth which is going on in the body, is “how on earth do we keep looking like ourselves?” “Why don’t our looks change as new cells are added?” The answer to this, of course, is that the cell grows by division so perfect that each two daughter cells is an exact replica of the parent cell. Each cell con- tains the same identical genes which determine the qualities and tendencies passed on from one generation to another. Genes are contained in a tiny granular area called the nucleus. When a cell begins to divide, the division starts in the nucleus. The genes line up like beads on a string, each in its own allotted place, and then break up into a certain number of sections which are called chromo- somes. Every species of animal has its own number of chromosomes. In the human there are forty-eight chromosomes, really twenty-four

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pairs. These chromosomes line up .in the middle of the cell and each chromosome splits lengthwise to form two chromosomes exactly like the original. One of them moves to one side of the nucleus and the other to the opposite side so we have 48 chromosomes on one side and 48 on the other. As the cell then divides in half and each daughter cell receives the same chromosomes as the parent, it can easily be 7een why each cell always retains the same characteristics.

There is however one group of cells in the body that have a different method of dividing. These cells are called germ plasm and are the only cells that have a chance of living forever. They are very important because the very continuation of the race depends upon them. In the early weeks after conception these cells are segregated and put away for safe keeping. What happens to them depends on whether this is a girl baby or a boy baby.

It is not possible to go into detail in this article on what happens to the germ cells in the boy baby and the girl baby. And yet, as this is reviewed with student nurses in the simple terms which parents can understand, the opportunities for health teaching are unlimited. As we follow the development of the germ cells, we get a vivid pic- ture of the tremendous amount of energy which goes into quantity production in the male and quality production in the female. We begin to see that it is impossible for any sperm or ovum to contain more than half the mother’s or father’s characteristics. We find ways to help parents see that they cannot expect their children to be exactly like either of them. Their children are individuals unto themselves, individuals who desperately need their own potentialities encouraged, not those of their parents, and their own limitations accepted. I t is possible to illustrate how pure chance determines the sex of the baby, that neither parent is really responsible. Factors important in understanding seminal emissions and menstruation can be brought out. Parents can be helped to understand what a traumatic experience this can be for the young boy or girl with no understanding that this is a healthy body function and no one to turn for the answers to their questions except boys and girls of their own age. Here they may get an impression that this is anything but a healthy function. Student nurses can learn to explain this to parents in terms which children can also understand. As we discuss the development of the sperm and ovum and the preparation of the uterus for the baby, we have the opportunity to illustrate how important the general health of the mother and father may be in determining what kind of a start this baby gets on the road of life. We have an opportunity to show student nurses h,ow they can get this across to parents.

Fertility

Fertility is another area in which parents have little understand- ing. In summarizing the development of the sperm and ovum, they can see that germ cells vary considerably in the male and female. In the female one ovum is produced per month which is non-motile, does have food available for growth, and if not fertilized, is capable

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of living approximately twelve hours. In the male many sperm are developed. They are very motile, have practically no food available for growth, and, if not fertilized, are capable of living approximately forty-eight hours. This means that concepqon is possible approxi- mately thirteen times per year for a maximum period of forty-eight hours. I t can easily be seen that a couple desiring children, may easily m i s s these few short periods in a year when conception is possible. Yet all too often young couples have very little understand- ing of this side of the picture. Any counseling they may receive prior to marriage may emphasize the importance of a physical examina- tion and advice on contraception. Yet how often are couples helped to understand the possibilities of not being able to conceive? In their ignorance they may blithely put off starting a family until conditions are ideal for raising children. They are completely unaware that fertility decreases with age; that the health of each ovum, of each sperm, depends on how well their own bodies are functioning.

Time and time again, couples who desperately want children, find much to their discouragement, that, in spite of all efforts, they have had no success. The doctor finds no physical reason for sterility. If the nurse took time to sit down and talk to these couples, these are some of the things she might discover. Usually both husband and wife are working. They may be spending two or three hours a day traveling to and from work. They probably get up at the last minute in the morning and gulp down a cup of coffee on the way out the door. Lunch is shoved down over some crowded lunch counter. Rather than brave the crowded transportation systems at rush hours, they may meet downtown for dinner. They’re probably trying to save money so they eat in a cheap restaurant. Housework, recrea- tion, and sleep is then sandwiched into the few spare hours left in the day. If this is the picture, are these couples really giving their bodies a chance to build healthy cells? In the meantime they’re working themselves into a state of anxiety trying to have a baby. If couples are trying too hard, what happens to the sperm being developed? Remember it takes ten days for these sperm to mature. With too frequent intercourse, all the mature sperm are used up. Nothing but green sperm remain. The couple gets more and more worried. Often the wife shoulders the blame. Her increasing ten- sion and anxiety tends to effect the muscles of the tube just as it does all the other muscles of the body. Doctors have found that it is actually possible for muscle tension to close off the tubes. Often couples who are helped to understand this, succeed in solving their own problem even where other methods have failed. Too often this kind of help never comes. Sometimes after they have adopted a baby and stop trying to have a child of their own, they unknowingly correct their mistakes.

Good General Health

Something which every couple should understand is that their chances of having a baby, as well as the kind of start that their baby

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gets, depends on how well they plan to provide for their own body needs. No parents are satisfied with anything but the best for their baby after it is born. Why should they be satisfied with anything but the best before it is born, right down to those two tiny cells from which the baby begins? Parents who already have children or are pregnant may say, “Why talk to us? We’re fertile. We can prove it.” What we need to get across to them is that this information is something they need to impress upon their children. Cell function, body function, is not dependent on what we did yesterday or even during the last month. It is dependent on the habits we develop as children and the sum total of life’s years.

In the discussion of fetal development, student nurses can again be helped to understand how important health habits are and how to get this across to parents in terms which they can understand. At the very moment that those two tiny cells come together in the mother’s tube, the baby’s hereditary endowment is all decided. Nothing more can be done about it. From now on environment will play the dominant role and for a long time the baby’s environment is going to depend on the parents. This is the time when the founda- tions for physical and mental health are laid. For the next nine months this environment will be the mother’s body which is so beautifully designed to carry on this function. How well it functions, however, wiIl depend on how well the parents plan together to pro- vide for it+ needs.

The body is complex with many interdependent parts. I t is affected by the mind and the emotions just as much as the mind and the emotions are affected by it. Providing the building materials, the rest, the activity whichlthe body needs, is not enough. I t must also be allowed to function in an atmosphere of satisfying relation- ships, in an atmosphere of inner contentment. This includes the opportunity to love and be loved. Then only can the body function at its peak capacity.

Even after the baby is born, the environment continues to be the dominating influence on his or her life. If the child grows up with an understanding of the importance of these things, if he under- stands that they do not just happen, but that all this requires plan- ning, then parents are laying the foundations for the mental and physical health of their own grandchildren. Children learn by example, and their principle example will be their parents.

Long before the first baby is born, the parents should be taking a good look at themselves and at the way they are living together. Are they helping each other, not making each other over, but help ing each other to approach his or her idea of what they should be? No one is perfect. Each must be able to see the other’s strengths. Each must learn to supplement and compliment the other. Again this takes planning. I t means talking over together what they really do want for this new life for which they have shared creation and how they are going to obtain the very best for this baby.

The baby begins at the very moment those two tiny cells join together in the mother’s tube. Immediately it begins its long journey of growth which will continue for the rest of its life. One cell divides

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into two, those two cells divide into four, and so on, until it forms a cluster of cells which look like a tiny raspberry. At the same time it is slowly moving down the tube toward the uterus. After about three days it reaches the uterus, and here the cells begin to rearrange themselves into a thin walled sac. The baby settles over on one side of this sac and continues to develop. It gets food from the supply which was stored in the ovum. The cells now begin to take on individual functions. The baby also begins to show its first charac- teristics of a human being. It wanders around in the uterus for two or three days looking for a good spot to settle down. In the mother whose body is functioning at peak capacity, a fine healthy lining has been prepared. The baby has little difficulty in choosing a spot where it can snuggle down into the soft thick velvety lining, much like we would sink into a feather bed and pull a thick downy comforter up over us. Food can now be absorbed from the fluid surrounding the cells in the lining of the uterus. Mother and baby begin to work together to build the placenta. The baby sends little finger-like projections down deep into the lining, while the blood vessels in - the lining of the uterus weave in and out around these projections. In time they will be completely surrounded by blood vessels.

Fetal Development

By the time the mother misses her first menstrual period, the baby is approximately fourteen days old. The complex process of cell multiplication and differentiation has been going on; the baby has settled into the lining of the uterus; and the groundwork has been laid for the placenta, the membranes, and all the organs and systems of this new individual; all before the mother has the first inkling of what is happening. By the twenty-fifth day, the foundations for the heart, the circulation, and all the essential organs and systems have been laid down. The mother still cannot be sure she is pregnant. What better opportunity do we have to point out to parents how important their health is before pergnancy ? What better incentive is there for developing good health habits in our children?

During the next month all of the baby’s systems, as well as the placenta, are developing. By the time the mother misses her second menstrual period, the baby is about one inch long and weighs one gram. At eight weeks of age, he has eyes, nose, mouth, fingers and toes. Bones are beginning to harden, muscles are forming and the baby can move. The placenta, which will nourish and protect the baby, is not completely formed until the end of the third month. How well it is built will depend on how well the mother’s body is functioning during these first three months. Up to this time the baby continues to absorb nutrients from the surrounding cells in the uterus. Once complete, however, the placenta will serve as a reservoir. Nutrients, including oxygen, will be brought to the pla- centa through the mother’s blood stream. The baby takes what it needs, to carry on the tremendous amount of growth and activity going on in its body and brings waste products back to the placenta. Once the placenta is completely formed, it also protects the baby by

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serving as a barrier to disease. During these first three months nature works hard to provide protection for the baby. The mother finds herself feeling unusually sleepy. She may notice that she seems unusually concerned about herself. Here nature is trying to help her provide the best kind of environment for her baby during these early months until the placenta is completely formed.

As we trace the development of the baby and the physiological changes through the remainder of the nine months of pregnancy, we have an opportunity to show parents the cause of minor discom- forts of pregnancy and how they can be alleviated. We can illustrate why the doctors give certain instructions and the importance of following these instructions. In discussing what happens during the last two months of pregnancy, and the needs of the baby if born prematurely, we can help parents understand that there is every indication that parents, who are themselves in the best possible health and under the best possible medical care, need not have a premature baby. Yet this will be one of the most difficult points to get across. Parents whose babies are born prematurely will be the first to insist that they have always been healthy. They have never been sick a day in their life. They have always had plenty to eat. There has never been any sign that their bodies are not functioning properly.

We continue to base health or lack of health on the presence or absence of disease. We look at the person who exudes energy, who starts the day feeling alive and full of anticipation, who really enjoys life, and we think, “Isn’t he lucky to be endowed with such a fine constitution?” But do we ever inquire carefully into his daily habits of rest, recreation, eating, etc.? Do we notice that somehow he has taught himself how to relax in spite of the turmoil of life going on around him? Do we observe his relationships with other people, and the degree of inner contentment which he has been able to work out for himself?

Horizons Must Be Broadened

We in obstetrics have an opportunity to teach at a time which is ripe from the standpoint of parents’ interests. But we need to broaden our horizons. Children must be helped to gain a fullaware- ness of how their bodies function. They must fully understand the importance of rest, nutrition, muscle tone, and peace of mind to efficient functioning of the body, and its effect on something as important to them as having babies. They must be fully aware that this takes planning. The best way to do this is through their parents. In order to teach parents, however, nurses must know more than scientific facts. They must know how to explain these facts in terms which parents can understand. The challenge in preparation for parenthood is real, not only for maternity nurses. In order to accept this challenge, we need the help of all nurses -pediatrics nurses, school nurses, industrial nurses, public health nurses, medical and surgical nurses-all nurses, whether they are practicing in the profession or raising families of their own.

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