THE PREPARATIONS FOR CONFINEMENT
Engaging the Nurse--Desirable Qualities in the Nurse--Preliminary
Visits of the Nurse--The Necessary Supplies for Confinement--The
Baby's Outfit--Sterilization--The Choice and Arrangement of a Room--
The Bed--The Preliminary Visit of the Doctor--When to Call the
Doctor--Personal Preparations--The Care of Obstetrical Patients at
the Hospital.
Prospective mothers are anxious to learn how they shall prepare for
the approaching confinement. They desire their preparations to be
thorough, reliable, and in accord with the most approved methods of
treatment, for they realize that preparations along these lines will
not only prevent haste and confusion at the time of birth, but will
also promote a satisfactory convalescence. Apparently trivial details
often safeguard confinement against serious accident. Indeed,
measures which aim at the prevention of illness form the chief asset
of modern obstetrics, and of these none takes higher rank than the
maintenance of strict cleanliness during and after childbirth. This
fact fortunately is widely appreciated at present, and not a few
women inquire voluntarily the means of observing the proper
precautions. It is true, of course, that even today many women are
delivered in filthy rooms and upon dirty beds, and that in spite of
such surroundings some of them make a good recovery. Yet grave
complications develop much more frequently among those who have not
paid attention to the preparations for confinement.
The surgical dressings and other supplies do not require attention in
the early months of pregnancy. A number of articles, invaluable when
delivery occurs at full term, are useless if the fetus is immature
and cannot live, and therefore it is unnecessary to provide them
until two or three months before the confinement is expected. In the
event of a miscarriage what is needed can be procured upon very short
notice. But, on the other hand, delivery subsequent to the twenty-
eighth week may require all the equipment useful at full term so that
everything should be in readiness by that time.
ENGAGING THE NURSE.--As soon as the existence of pregnancy is clearly
recognized the patient should select the doctor and the nurse who
will attend her. Prompt selection of a nurse will assure the widest
choice, for proficient nurses are in demand and book engagements far
in advance of the date they will be needed. Furthermore, it is a
relief to the patient to have her attendants selected. The
possibility of premature delivery never interferes with engaging the
nurse very early in pregnancy, for that accident releases both
patient and nurse from their contract.
Nurses demand that the date be specified upon which an engagement
shall begin, as, unless their calendar is definitely arranged, they
are unable to earn a livelihood. This leads to a question which is
difficult to answer, for the precise day of delivery is uncertain;
consequently to fix the beginning of the engagement may prove a
troublesome matter. On the one hand, there is risk of having to pay
the nurse for a time before her services are actually needed; on the
other, a false economy may result in the absence of the chosen nurse
at the critical moment. In finding a way out of this dilemma a
patient must be guided by her means and the location of her home.
Those who can afford it will not hesitate to employ a nurse from one
to two weeks in advance of the expected date of confinement; and for
those who live where nurses cannot be procured quickly, a similar
course is recommended. But persons of only moderate resources, living
in a city where, in an emergency, a substitute can be gotten from the
local "Nurses' Directory," will find it convenient to engage the
nurse from the calculated date. The substitute will remain with the
patient until the arrival of the nurse originally engaged.
Occasionally, it may happen that a patient will prefer to keep the
substitute. Such a course, however, would be unjust to the nurse who
was first selected, unless she could immediately secure other work.
She has reserved a definite period of her time for the patient, and
probably has declined work which seemed likely to conflict with the
engagement already made. She is fairly entitled, therefore, to assume
charge of the case, and the patient who refuses to make the change is
obligated to pay her according to the terms of the agreement.
How long will a nurse be needed after the child is born? The answer
to this question may be altered by so many circumstances that a hard
and fast rule cannot be given. Before the advent of "Trained Nurses,"
obstetrical patients were cared for by "Monthly Nurses," so called
because they remained one month with their patients. It is, likewise,
customary to keep the trained nurse four weeks after the birth; but
whenever possible it would be well to retain her six weeks, since
this period elapses before the mother has entirely regained her
normal physical condition. Those who can afford to keep a trained
nurse six months or a year are exceptional, but very fortunate.
Someone may feel that the suggestions I have made are not suitable to
her case. Very likely they may not be; to cover all the possibilities
could scarcely be expected, for every case has its problems and
peculiarities. After consultation with her physician each patient
will decide what is particularly advisable for her. Nevertheless, I
would emphasize the importance of securing a competent nurse and
retaining her for at least four weeks. Even with those who must guard
their expense account the truest economy will lie in such a course.
Whenever lack of resources seems likely to prevent this arrangement,
the patient who is looking to her best interests should enter a
hospital where excellent care can be provided at a cost within her
means.
DESIRABLE QUALITIES IN THE NURSE.--It is rarely advisable to select
as nurse a member of the family or an intimate friend. Some of the
motives governing such a course--sentiment, mutual devotion, and the
desire to be humored--are inconsistent with the best kind of nursing.
If the nurse knows the patient intimately, undue anxiety may
interfere with her judgment; thoroughness in routine duties may be
hindered by mistaken consideration for the patient; and in an
emergency sympathy rather than reason may guide her. A successful
nurse must satisfy at least two requirements; she must be capable
professionally and also personally agreeable to her patient. Some
regard advanced years as essential to the first of these
qualifications, but this does not necessarily hold good.
The personal qualities generally welcome in a nurse are neatness,
thoughtfulness, a sympathetic nature, an even disposition, and a
cheerful view of life. Since a short interview is insufficient for
taking the measure of a nurse, patients usually rely upon the opinion
of someone else in selecting her. The judgment of her former patients
is frequently prejudiced in one direction or the other, and such an
estimate must always be accepted with caution. Much the most
trustworthy method is to allow the physician to select her. He will
know nurses who possess the requisite qualities, and certainly he is
most competent to judge their professional attainments. If the choice
of a nurse be left to the doctor, the two are sure to work
harmoniously, and the patient will benefit by their cooperation.
Otherwise she may suffer because of their dissensions, for, if the
doctor is accustomed to one procedure and the nurse to another,
misunderstandings may occur, although both methods yield equally good
results. Whenever he does not select her, she should be asked to
confer with him long before the case is due. Obviously, a physician
cannot be held responsible for a nurse's ability unless he is
acquainted with her training and methods of work.
In an effort to economize, many are inclined to employ "half-trained"
or "practical nurses." When the confinement is not the first and
there is no reason to anticipate any irregularity during labor or
thereafter, I can see no vital objection to such an arrangement. It
is of the first importance, however, to be assured that the
"practical nurse" is neat and appreciates the necessity of keeping
everything about the patient scrupulously clean. But competent nurses
who charge less than the customary fee will be hard to find. The
recommendations which these women receive are apt to be even more
misleading than in the case of trained nurses, because more is
expected of the latter. My experience has taught me that patients
form particularly unreliable opinions of practical nurses, and I have
frequently witnessed incompetence in such women which was overlooked
by the patient.
A low-priced nurse is seldom a cheap one, as her shortcomings may be
reflected in the health of the mother or the infant long after she
has left the case. Especially when the baby is the first, the mother
will depend upon the nurse for instruction which should be both sound
and thorough. The principles taught her will be put into practice and
utilized for many months, playing a vital part in the training of the
infant. It becomes essential, therefore, to secure a nurse who will
give the baby a good start, and instruct the mother along right
lines. Perhaps this is less needful if the mother has learned her
lesson from previous experiences. But even then a good nurse relieves
her of responsibility and materially assists her to a quick and
lasting convalescence. In the end the most proficient nurses are the
least expensive.
THE PRELIMINARY VISITS OF THE NURSE.--Many of the precautions which
safeguard a confinement should be considered by the patient and the
nurse together. The character and quantity of the supplies, the
choice of a room for delivery and subsequent convalescence, the
proper clothing for the infant--all these are problems which may be
solved most satisfactorily in the light of the nurse's experience and
the resources at hand. Two visits are usually sufficient to arrange
these details. An interview early in pregnancy, soon after the nurse
has been selected, provides an opportunity to lay plans and
especially to review the list of articles needed at delivery. Such
articles as are already in the house may be checked off; the others
may be procured at leisure. Eight to ten weeks before the expected
date of the confinement the nurse should pay a second visit and
should inspect the supplies to see that they are complete. Certain
articles which I shall indicate must be sterilized. As this procedure
is more reliable when carried out by an experienced person it will be
convenient to have all the dressings finished by the time of the
nurse's second visit, in order that she may sterilize them.
The question may arise as to whether the nurse shall come to the
patient upon the date for which she has been engaged or shall wait
until summoned. From the physician's standpoint it is often more
acceptable to have the nurse in the house a few days before the
confinement, though some patients strongly object to this. Provided
the nurse may be got quickly at any time of day or night, there can
be no objection to leaving the decision to the patient herself.
THE NECESSARY SUPPLIES FOR CONFINEMENT.--As to just what a
confinement outfit should contain physicians differ to some extent;
but this disagreement pertains rather to luxuries than essentials. In
the lists here suggested nothing essential has been omitted, although
economy, as far as is consistent with good judgment, has been kept in
mind. Any article not included in my list which the doctor or nurse
in attendance recommends may be noted in the space for memoranda.
Some patients prefer to take no part in preparing the supplies for
confinement. Indeed, the demand for a ready-made confinement outfit
has become large enough to lead several firms to put them upon the
market. These outfits differ in completeness and vary in price from a
few dollars up to fifty. The majority of patients, however, still
attend to such details themselves, and will find a list of the
needful supplies convenient.
_Make-up and Sterilize_:
7 Dozen Sanitary Pads.
2 Sanitary Belts.
2 Delivery Pads.
5 Dozen Gauze Sponges.
2 Dozen Gauze Squares.
4 Dozen Cotton Pledgets.
2 Sheets.
Bobbin for tying the Cord.
A Pair of Obstetrical Leggins.
A Dozen and a Half Towels (Diapers).
_Obtain from the Druggist_:
100 Bichlorid of Mercury Tablets.
100 grams Chloroform.
4 ounces Powdered Boric Acid.
4 ounces Tincture Green Soap.
1 pint Grain Alcohol.
A small jar of White Vaselin.
A cake of Castile Soap.
A two-ounce Medicine Glass.
A Medicine Dropper.
A bent glass Drinking Tube.
_The following articles should be in the house, ready for use._
An ample supply of Towels, Sheets, and Gowns.
A new Hand-Brush; the cheap variety with wooden back and stiff
bristles is preferable.
Two slop Jars or enamel Buckets with Covers.
A two-quart Fountain Syringe; an old one may be substituted provided
it has been thoroughly boiled.
Three Basins and a one-quart Pitcher of agate or enamel-ware.
A Douche-Pan; the "perfection Bed-Pan" is preferable.
Two pieces of Rubber-Sheeting are required, one large enough to cover
the mattress of a single bed (2 x 1-1/2 yds.), the other smaller (1 x
3/4 yd.). Should this be too expensive, the best substitute is white
table oil-cloth.
The nurse will explain how the various surgical dressings are made,
but, as the patient may forget some of the directions, all the
details will be given here. At least three to four pounds of
absorbent cotton will be used in the dressings. To make the pads
entirely of absorbent cotton is very expensive. The cheaper cotton-
batting is therefore employed to give them body, and they are faced
only upon one side with the absorbent material. Furthermore, the
rolls of absorbent cotton, as purchased, may be separated into three
or four layers, one of which is thick enough for the facing. About
six rolls of the batting should be purchased.
Surgical gauze, which tradespeople sometimes call dairy-cloth, is the
most suitable material for covering the pads. Bleached cheese cloth
will answer the same purpose, but it is more expensive and rather
heavy. Approximately thirty-five yards of the gauze, which comes in a
thirty-six-inch width, will be needed. When the supplies are
finished, they are wrapped in separate bundles and sterilized. Old
muslin or some of the diapers are generally used for covers.
_The sanitary pads_, also called vulval or perineal pads, absorb
the discharge which always occurs after delivery. They are made of
absorbent cotton and cotton-batting covered with gauze; a convenient
size is ten inches long and three to four inches wide. Their
thickness is approximately an inch, one-third of which is composed of
absorbent cotton.
_The sanitary belt_ is used to hold these pads in place. Very
satisfactory ones are made of two strips of unbleached muslin, three
inches wide. The first of these must be long enough to reach around
the waist; the second, which passes over the pad, is somewhat shorter
and has two parallel slits in one end; through which the waist-band
passes at the back; the three free ends are pinned together in front.
_The delivery pads_ are made of the same materials as the
sanitary pads; preferably a yard square and four inches thick. A
rather heavy top-layer of absorbent cotton must be used in them, and
they should be quilted or tacked at several points to prevent
slipping. A rubber pad is ill adapted for use during delivery. Some
absorbent material made into proper shape proves much more
satisfactory since it can be thoroughly sterilized and can be thrown
away after it has been used.
I am told that cotton-waste is a good substitute for absorbent cotton
in the delivery pads. It is inexpensive, and will be rendered capable
of absorbing fluids after it has been boiled in washing soda and
dried in the sun. Each delivery pad should be separately wrapped and
sterilized.
_Gauze sponges_ will be needed by the doctor; about five dozen
should be prepared. The gauze is cut in eighteen-inch squares.
Opposite edges are folded toward one another, about two inches being
lapped each time; this finally yields a seven or eight-ply strip,
which is wrapped into appropriate shape about two fingers. The
ravelled ends are then tucked into the roll. It is most satisfactory
to divide the sponges and sterilize them in two bundles.
Small pieces of gauze about two inches square will also be needed in
caring for the baby's eyes and mouth. Several dozen should be cut,
and they may all be sterilized together.
_Cotton pledgets_ are simply bits of absorbent cotton the size
of a hen's egg, the rough edges of which have been twisted together.
A small pillow-case full of them ought to be made up and sterilized.
_Obstetrical leggins_ are preferably made of canton flannel;
they are cut to fit loosely and should reach the hip. If they are
prepared so as to extend to the waist at the sides, they may be held
in place by a waistband, and in this way will prevent unnecessary
exposure without interfering with the doctor. They should be
sterilized.
_Towels_, if used at all, should be without fringe. It is
economical not to employ them, but to use diapers in their place.
Three packages, each containing six diapers, should be sterilized.
_Sterilized sheets_ are often useful at the delivery; more than
two are never needed. They should be wrapped separately for the
sterilization.
_Sterilized bobbin_ is generally used for tying the cord.
Several pieces are cut in nine-inch lengths and sterilized in a
single package.
_A dressing for the cord_ will be required, but there is no
necessity for preparing a special one. It is generally satisfactory
to wrap the cord in one of the sterile gauze sponges which has been
previously soaked in alcohol.
Several methods of drying up the cord give equally good results, and
it is usually a good plan to allow the nurse to dress it as she
wishes, since the employment of a method with which she is familiar
will more likely insure a satisfactory result in her hands. A
dressing popular with many nurses is prepared as follows: In a piece
of muslin four inches square cut a small circular opening; double the
linen and dust boric acid between the folds. If this method is
preferred, several of the dressings should be prepared and sterilized
together.
THE BABY'S OUTFIT.--Preparations for the infant may be thorough
without being elaborate. Instinctively, the prospective mother leans
toward extravagance in fitting out her baby's wardrobe, and easily
slips into the error of providing too much. Time and energy are
frequently devoted to an extensive wardrobe which the infant quickly
outgrows; in consequence many articles must be made over before they
are used. Even with modest resources a prospective mother can acquire
everything the baby really needs.
A very sensible plan, in my judgment, is to prepare what will be
wanted during the first two months; subsequently, articles may be
made or bought as they are needed. Accordingly, the quantity of
wearing apparel and the nursery supplies I have suggested pertain
only to the early weeks of infant life. Although no essential has
been omitted, the outline is plain and economical.
At present, outfitters supply a variety of ready-made, garments for
the infant and conveniences for the nursery; in many of them notable
ingenuity is displayed which aims at the child's comfort or the
saving of labor to the mother. Catalogs of these articles, which are
often expensive, are furnished by dealers.
In preparing clothing for the new-born, several principles must be
kept in mind. The first is that the garments must be warm without
being unduly heavy; and another that they should be roomy, permitting
perfect freedom of motion. A third no less important principle is
simplicity. Adornment of the clothing gratifies the mother, but does
not serve a single useful purpose. The lists which follow include all
that is necessary for the young infant; they will also serve as a
basis for elaboration if a more lavish outfit is desired.
_Necessary Clothing_.
4 Abdominal Flannel Bands.
3 Undershirts.
4 flannel Skirts.
4 Night Gowns.
12 White Slips.
3 Knit Bands.
4 Dozen Diapers.
Cloak and Cap.
_Nursery Equipment_.
An old Blanket.
Assorted Safety Pins.
Soft Damask Towels.
Wash Cloths.
Hot-Water Bag with Canton Flannel Covers.
Talcum Powder.
Olive Oil.
Bassinet.
_Additional Articles; Convenient but Not Essential_.
Rubber Bathtub.
Rubber Bath-Apron.
Flannel Apron.
Bath Thermometer.
Bath Hamper.
Quilted Mattress Covering.
Baby Scales.
Screen.
Low Chair without Arms.
Drying Frames.
STERILIZATION.--Now and again, those who follow very rigid rules to
avoid infection during childbirth are criticized for their pains. The
general public has not yet grasped the true relation of bacteria to
this condition; a relation which, indeed, first became clear to
medical men within comparatively recent years. The development of our
knowledge of the nature of infection forms one of the most
entertaining chapters in obstetrics, and provides a simple way of
showing the genuine need of preventive measures. Several observant
physicians had previously suspected the character of "child-bed
fever" (as infection of the mother was once called), but convincing
proof of its contagious nature was not forthcoming until the middle
of the nineteenth century, when signal facts were pointed out by
three men, each working independently, though all came to similar
conclusions. The evidence they gathered should have left no one
doubtful that the disease is contagious, and largely preventable. On
the contrary, bitter opposition was encountered for the time, and
only within the last two decades has their teaching found wide
practical application.
In 1843 Oliver Wendell Holmes published the paper on "The
Contagiousness of Puerperal Fever," which is now preserved in his
volume of "Medical Essays." Physicians were startled to be frankly
told the responsibility they assumed if they neglected the truth
taught by epidemics of this disease. "The dark obituary calendar"
which marked the progress of these epidemics clearly indicated that
"the disease is so far contagious as to be frequently carried from
patient to patient by physicians and nurses." A violent controversy
followed this arraignment, and, consequently, the preventive measures
which Holmes so convincingly urged were not adopted as promptly as
they should have been. The full justice of his conclusions has since
been universally admitted, and medical men now find it difficult to
understand how anyone could have taken issue with the sentiment which
he expressed. "For my part," Holmes said, "I had rather rescue one
mother from being poisoned by her attendant than claim to have saved
forty out of fifty patients to whom I had carried the disease."
But the most important early observations upon child-bed fever were
made in 1847 by a young Hungarian, Semmelweiss, while he was an
assistant in the large Lying-in Hospital in Vienna. In thoroughness,
power of conviction, and practical value his work was masterful. It
is no exaggeration to regard his observations as the rock upon which
antiseptic surgery, the glory of the nineteenth century, was built.
Semmelweiss had been seeking an explanation of the dreadful scourge,
and his mind was ready for the reception of the truth when it was
revealed through the death of one of his colleagues. This physician
injured his finger accidentally in performing an autopsy upon a
patient who had died from child-bed fever. And the condition
disclosed by examination of his body after death was identical with
that found in cases of child-bed fever. Here then was the clew; the
disease was contagious. Semmelweiss was ignorant of Holmes' views;
what had happened before his eyes suggested to him that the disease
was due to a poison which could be conveyed from one person to
another. Moreover, his interest and his power of insight led to
further comparison. Clearly, the open wound on the physician's finger
had been the portal through which the poison entered; but where was
there a similar portal in obstetrical patients? The answer was plain.
The birth-canal at the time of delivery is always an open wound.
There the poison entered, and child-bed fever was a wound infection!
Several years later Tarnier, who was to become an eminent
obstetrician, but was then a student in Paris, chose the diseases of
the lying-in period as the subject for his graduating thesis. He was
unacquainted with the work either of Holmes or of Semmelweiss, and
approached the problem from still another standpoint, drawing
attention to the much higher deathrate among women delivered amid
unsanitary surroundings. Tarnier also considered that the disease was
a form of poisoning, that it was contagious, and that measures should
be instituted to protect patients against it.
Of these pioneers, by far the greatest credit is due Semmelweiss, who
devoted his life to the problem, although his opinions continually
met with scepticism and even ridicule. More convincing proof than he
could furnish was demanded before his contemporaries would believe
that child-bed fever was due to lack of precaution. Fortunately the
evidence was soon produced. In 1880, Pasteur obtained bacteria from
the organs which had been infected, and was able to grow the bacteria
in his laboratory; thus the ultimate cause of the disease became
firmly established. With the harmful agents in their hands, Pasteur
and his followers were enabled to study their characteristics and to
recommend means of destroying them.
Much as we must regret that the warnings of Holmes and of Tarnier
passed unheeded; lamentable as may be the blindness of the generation
of Semmelweiss to the truths revealed by his research, it is not
surprising that such radical teaching met with a hostile reception.
As we measure time in retrospect from the vantage ground of to-day,
the three to four decades required for full acceptance of their
revolutionary doctrines seem a brief span. Antiseptic methods would
not have prevailed so quickly as they did, had not the same epoch
which gave us a Pasteur also given a surgeon with a receptive mind,
ready to seize and apply the discoveries of the French genius. This
was the great service of Joseph Lister. Impressed with Pasteur's
studies on fermentation, Lister saw an analogy between this process
and the putrefaction of wounds, a condition which he was eager to
prevent. He had reason to believe that carbolic acid would check
decomposition, and he employed a weak solution of it in the treatment
of wounds; later he devised a "carbolic spray," by means of which
when his operations were performed the atmosphere round about might
be sterilized.
It is but a short step from antiseptic operations to our own era of
aseptic surgery, and that a step in the direction of simplicity. Now
we know that the sterilization of the air is rarely necessary and
have dispensed with Lister's elaborate apparatus. Furthermore, and of
far greater moment, experience has taught that the destruction of
bacteria before they have opportunity to come in contact with the
wound is more effective than efforts to kill them as they approach or
after they have invaded the tissues. Initial freedom from bacteria is
the ideal of asepsis; to secure it, the modern surgeon is ever
watchful of the cleanliness of his hands, his instruments, his
dressings, and of the site of operation or whatever may come near it.
The importance of the changes wrought by the adoption of aseptic
methods requires no emphasis, for the marvels of modern surgery are
even more impressive to laymen than to the medical profession.
Everybody now understands that strict cleanliness is indispensable to
the success of a surgical operation. But the general public has not
fully awakened to the same profound necessity in connection with
childbirth, although it was child-bed fever that called forth the
observations and experiments upon which modern surgical technique
rests.
Although most obstetrical patients appreciate the fact that there is
an advantage in sterilized dressings and sanitary surroundings, few
realize the risk they run without them. One must know the mournful
history of the past to be adequately impressed with that danger, for
we no longer see the epidemics of childbed fever which formerly swept
over communities, sacrificing ten of every hundred women as they
became mothers. Precaution is no less necessary on that account; the
scourge would be rampant again if the reins were loosened.
Most instances of puerperal infection are, it is true, referable to
lack of care. Nevertheless, the complication develops now and then
where all precautions have been conscientiously observed. Under such
conditions the infection will in all likelihood be a mild one, and a
tedious convalescence usually proves its most disagreeable feature.
Such stringent preventive measures as are now practiced in many
hospitals have reduced the frequency of infections to the point where
only one fatal case, or even less, occurs in a thousand deliveries.
These rare cases remind us that vigilance must never be relaxed, and
that patients who are confined at home require just as much care as
those in hospitals, where conditions are the best to prevent
infection and the complications, which follow.
The first essential toward the avoidance of infection in obstetrical
cases is clean dressings. Naturally, these should be clean to the
sight, but it is in invisible dirt that serious danger lurks;
bacteria are the causative agents of this disease. Experiments have
taught the bacteriologist that disease-producing organisms are killed
in half an hour when subjected to a high atmospheric pressure and the
temperature of steam. Special apparatus has been constructed for
carrying out the procedure. It is unnecessary for our purposes,
however, since the essential conditions may be secured, though with
less convenience, in any kitchen. If a prospective mother finds it
awkward to do the sterilizing at home, and her nurse is unable to
take charge of the matter, she may arrange with a local hospital or
the nearest nurses' directory to sterilize her dressings. Yet a very
little ingenuity suffices to do the work at home with perfect
satisfaction. Installments of the smaller bundles may be sterilized
in a galvanized bucket. To do this place an inverted bowl, with a
depth of three to four inches, at the bottom, and pour in water until
the bowl is almost covered. A breakfast plate rests on the bowl, and
upon this the dressings are stacked; a second larger plate which fits
the top of the bucket is utilized as a lid to close in the
sterilizing chamber. This will not accommodate the larger packages; a
more satisfactory method for all of them is to use a wash-boiler in
which has been swung a muslin hammock.
To arrange the latter form of home sterilizer, cut an oblong piece of
unbleached muslin large enough to sink far down into the boiler and
run a drawing-string of stout cord about the edge. Cover the bottom
of the boiler with several inches of water; tie the hammock in place,
passing the cord beneath the handles of the boiler to hold the muslin
securely. Pack in the dressings, which have been wrapped in
appropriate bundles; put the lid in place, thus closing the
sterilizing chamber, and leave the dressings exposed to the steam for
at least half an hour. After the operation has been completed, the
bundles are taken out of the boiler and allowed to dry in the air.
They must not be opened until the occasion for which the supplies
were prepared arrives; awaiting this event, they are laid away in a
convenient closet or drawer.
A word of caution may be added concerning a method of sterilization
employed at home more frequently, perhaps, than any other. According
to this procedure, the supplies are wrapped in paper, thrust into a
hot oven, and left there until the paper is scorched. From the
standpoint of economy as well as of thoroughness, this method is
likely to prove unsatisfactory. Frequently, the dressings themselves
are scorched; I have known patients to ruin several installments of
their supplies in this way. Moreover, dry heat is not so trustworthy
as steam for sterilizing purposes.
Judicious management means the preparation of the supplies necessary
for confinement before turning to the selection of the infant's
outfit. Ordinarily, both these tasks should be finished by the end of
the eighth month, and final arrangements for the approaching delivery
will then claim attention. If the patient expects to remain at home,
she must decide which is the best room to occupy; she will wonder how
it ought to be equipped, and she will be anxious to learn what
personal preparations are advisable at the beginning of labor.
Intelligent answers to these questions are important. A patient
should request the physician to criticize her plans when he pays the
preliminary visit four to five weeks prior to the expected date of
confinement. If she has acted unwisely in any respect, he will point
it out, and may suggest changes which will enable her to employ to
the best advantage the resources at hand.
THE CHOICE AND ARRANGEMENT OF A ROOM.--An old-fashioned custom, which
relegated obstetrical patients to the most secluded part of the
house, with little regard for comfort and still less for hygiene, has
now few, if any, adherents. There is an advantage, to be sure, in
having a quiet room; but this qualification may be secured in a room
well located with regard to other essentials. Selection of a suitable
room is not a trivial point. In most cases, since patients ordinarily
remain for convalescence in the same room in which the infant is
born, the chamber must serve a two-fold purpose. A number of
requirements, therefore, must be met, and they must all be kept in
mind when the room is chosen.
We have seen that the act of birth, natural as it is, may have a very
unnatural sequel if precautions against infection are treated
lightly. It is proper, therefore, that the delivery-room should be as
clean as care can make it. Such radical measures as may be employed
in sterilizing the dressings are here out of the question; if
possible, they would be absurd. Infection usually develops because
harmful bacteria come in contact with the patient. For that reason,
an infection is more likely to be communicated by the dressings than
by articles about the room, which only become a source of danger when
the dirt upon them is transferred by an attendant.
An acceptable delivery-room may be arranged in any home; it is by no
means necessary to duplicate the equipment of a modern hospital. To
choose a room convenient to the bathroom will be found advantageous
not only at the time of birth but throughout the lying-in period. The
furnishing should be simple and scrupulously clean; indeed, it is
improbable that one of these good points can be secured without the
other. Furthermore, the preparation of the room should be completed
well in advance of the date of confinement.
A large collection of furniture interferes with the nursing, and also
increases the difficulty of keeping the room free of dust. It is
sound advice, therefore, to remove everything which will not serve
some good purpose during the delivery. Should any article be wanted
later, it can be brought back to its accustomed place. The furniture
may be conveniently limited to a bed, a bureau, a washstand, a table,
and several chairs, one of them a large, comfortable rocker, which
will prove invaluable during the early part of labor.
To approach perfect conditions, bric-a-brac, needless hangings, and
everything that might collect dust should be temporarily removed. A
profusion of pictures does not accord with the best sanitation of a
room devoted to the treatment of obstetrical patients; those which
are to be left upon the wall ought to be taken down and wiped
carefully with a damp cloth. Other desirable preparations would be
instinctively undertaken by the modern housekeeper, and it may seem
presumption to mention that the room itself ought to be subjected to
most thorough cleaning. It is well to leave the floor bare or merely
covered with freshly cleaned rugs. Carpeting is difficult to protect
against soiling and is not sanitary. If left down, the carpet should
be covered with some suitable material, firmly stretched and tacked
in place.
We know that the air in most households does not contain disease-
producing bacteria; but the presence of any contagious disease
materially alters the situation, and may imperil the convalescence of
an obstetrical patient. Preferably, one should never select a room in
which there has lately been sickness, and under no circumstances may
such a room be used until carefully fumigated. The more conspicuous
diseases which for at least several months absolutely disqualify an
apartment for obstetrical purposes are diphtheria, pneumonia,
pleurisy, erysipelas, scarlet fever, typhoid fever, tuberculosis of
all varieties, and every sort of discharging sore.
When possible, two adjoining rooms should be given over to the mother
and the infant; if this is impracticable, the single room should be
large, easily ventilated, well lighted, and heated in such a way as
to permit a change of temperature without difficulty. All these
features help to make convalescence comfortable and free from petty
annoyances. A room which has a southern or eastern exposure proves
grateful for those who must remain indoors; frequently, this will be
beyond reach, but a room getting the sun's rays directly during part
of the day will always be available, and the selection should be made
with that requirement in mind. At the time of birth and for the first
few days which follow, a patient may not appreciate this feature;
ultimately she will understand the need of sunlight better than the
need for the more technical, and therefore the more impressive,
preparations.
THE BED.--Now that housekeepers recognize how easily such furniture
can be kept clean, few homes are without a brass or an iron bedstead;
they are equally sanitary. Undoubtedly, this kind of bedstead
fulfills the needs of an obstetrical patient much better than any
other; and, if at hand, it should be used. The single bedstead is the
most acceptable, and the mattress ought to be at least twenty inches
above the floor. A low, wide bed interferes with proper management of
the delivery and later handicaps the nurse in taking care of the
patient. Wooden blocks may be used to raise a bed which otherwise
would be too low. It is well worth while to provide them if one
desires good nursing, for no attendant can do her best when she must
continuously bend over a very low bed.
The location of the bed at the time of delivery is not an unimportant
matter; it must always be placed so that the brightest possible light
will shine over the foot. Since birth often occurs at night, one
should make certain that the artificial lighting of the room is good,
and place the bed most advantageously in reference to it; at the same
time the necessity of a good light from the windows, when delivery
occurs during the day, should not be forgotten. The head of the bed
may be placed against the wall, but both sides must remain freely
accessible not only at the time of delivery but also throughout the
lying-in period.
A smooth, firm mattress, made in one piece, should be provided. One
which has been used several years and possibly worn in a hollow will
require renovation to be made comfortable. A feather bed should not
be used under any circumstances. The mattress must be protected; and
protection is best secured by means of a large piece of rubber
sheeting. The regulation household sheet covering the rubber should
be tucked well under the mattress at the ends and sides; in that way
the rubber sheeting will be held firmly. Since the part of the bed
where the hips rest will be most exposed to soiling, the protection
of this area is usually reinforced by a "draw sheet." To arrange
this, a cotton sheet is doubled so as to make a strip about one yard
wide and two yards long; the smaller piece of rubber sheeting is laid
between the folds. The draw sheet will reach from the middle of the
back to the knees; its ends should be tucked under the sides of the
mattress, to which it is fastened by means of large safety pins.
After delivery, the draw sheet may be removed without disturbing the
mother, who will thus be assured a clean, dry, and comfortable bed.
The bed-clothes covering the patient during labor will vary with the
season of the year, but should always be light; in summer a single
sheet will suffice, and in winter a blanket will likely be needed.
For sanitary reasons, a freshly laundered sheet should also be placed
outside the blanket until the delivery has been completed; later, it
may be replaced with a light spread. Two pillows will be needed, and
it is very convenient to have one of hair, the other of feathers.
While there is no necessity for sterilizing the bed-clothes, it is
advisable to use linen which has been recently laundered and kept
well protected from dust. Among the poor, infection from soiled bed-
linen is not uncommon.
THE PRELIMINARY VISIT OF THE DOCTOR.--No teaching of medical science
has been given greater prominence of late than the principle of
prevention. In obstetrics it finds a particularly wide field of
application, and its practice is responsible for removing many of the
former terrors of childbirth. We have just learned that preventive
measures effectually reduce the frequency of puerperal infection, and
in an earlier chapter we saw the value of routine examination of the
urine as a means of anticipating other complications. Moreover, the
benefit of promptly reporting to the physician anything that does not
seem to be as it should has been urged constantly, for in this way is
afforded the earliest opportunity to treat complications. Similarly a
visit from the doctor about four weeks before the expected date of
confinement is indispensable to skillful management of the delivery;
neglect of this precaution is sometimes responsible for bad results.
At this visit the physician not only becomes familiar with the
general health of his patient, but he also notes certain facts which
will have a direct bearing upon the course of labor. By means of a
few simple measurements he may accurately determine the character of
the pelvis, the bony structure through which the fetus passes. When
they are compared with what we know as the normal measurements, a
very good idea is gained as to whether the birth-canal will present
any obstacle to the passage of the child; and, if it will, there is
opportunity to deliberate what treatment may be necessary. Since
another factor in the problem, namely, the size of the child, cannot
be accurately predicted, occasionally the physician may hesitate to
express as definite an opinion as the patient may wish. Nevertheless,
though it may be impossible to learn every detail, the available
information well repays the time and trouble expended. In nine out of
ten cases nothing whatever is found out of the way; the result is an
assurance which always justifies the examination.
During this examination the position of the child is also
ascertained. By means of a series of painless manipulations through
the abdominal wall of the mother, the head, the body, and the
extremities of the child may be mapped out, and the conclusions
verified by locating the fetal heart-sounds. In this regard, also,
the physician usually finds normal conditions. The most favorable
presentation, that in which the head is the part to be born first,
occurs in ninety-seven of every hundred cases. When less favorable
conditions are recognized, they may frequently be corrected at once;
but should that prove impossible, with foreknowledge of the
presentation, the physician will be more competent to conduct the
delivery.
With a clear understanding of the character and value of the
information gathered at the preliminary examination, patients are not
likely to refuse it. If they do, the risks should be fully explained
to them. Some physicians decline to assume the responsibility of a
patient who will not permit these observations. Such a decision is
rarely necessary, for in my experience the patient's consent has
never been difficult to obtain. Many women now regard the visit as
part of the routine attention, and inquire when it will be made.
The appropriate time for this examination, as I have indicated, is
approximately one month prior to the calculated date of confinement.
Before this period, we have no assurance that the presentation which
is found will continue until the time of birth. The fetus frequently
alters its position as long as it is not large enough to fill out the
cavity of the womb, consequently it is only during the last month of
pregnancy that the final presentation can be determined. But to defer
the examination after the period I have specified is unsafe since we
lack an exact method of fixing the day of confinement, and too long a
delay might render a preliminary examination impossible.
Aside from its relation to the observations just outlined, the
preliminary visit provides an opportunity for the physician to
criticize the preparations which have been made, and for the patient
to inquire about the personal preparation advisable at the beginning
of labor. She will also learn the signs which indicate that labor has
begun and will be told what to do when they appear. Although
physicians may not agree in all these directions, there can be no
difference of opinion relative to the essential points. At least, the
rules given here will serve to bring the patient and the doctor to a
definite understanding as to the course he desires her to follow.
WHEN TO CALL THE DOCTOR.--During the last two or three weeks of
pregnancy not a few patients are more comfortable than they have been
for several months. About this time the womb usually drops somewhat
and relieves the pressure which has interfered with breathing. These
changes, however, do not promote comfort in every direction; more
freedom for the organs of the chest means compression of the
structures below the womb; consequently, the inclination to empty the
bladder and for the bowels to move becomes more frequent. Patients
complain also of cramps in the legs and experience difficulty on
walking. This order of events enables some women to recognize the
approach of delivery. Of course there is other evidence when labor
actually begins. Its onset may be indicated in one of three ways,
namely, by periodic pains, by a gush of water from the vagina, or by
a discharge of blood as though the patient were taken unwell. Each of
these unmistakable signs is a sufficient reason for notifying the
doctor.
At the onset of labor, dragging pains are usually felt at the back,
but sometimes in the lower part of the abdomen. The rhythm with which
they come and go identifies them more certainly than any other
feature, though this indication is not entirely reliable, for
intestinal colic also causes rhythmical pain. At first the uterine
contractions which occasion the discomfort are weak and appear at
long intervals. Gradually they become stronger and closer together.
When the interval between them has been shortened to half an hour or
less their significance is fairly certain, provided the abdomen
becomes tense and hard with each pain, remaining comparatively soft
between them.
When contractions begin during the day or early evening, the
physician will be glad to have immediate notification in order that
he may arrange his appointments and thus be free to attend the
patient when she needs his services. On the other hand, if they begin
between 11 P.M. and 7 A.M. the nurse, who will always be summoned
with the very first warning, should be allowed to decide when the
doctor is to be called. Unless other instructions have been given,
she will usually wait until the interval between the contractions is
five to ten minutes.
Usually the symptoms make it clear that labor has begun, but
occasionally the greatest difficulty will be experienced in deciding
whether the discomfort has not some other origin. Uncertainty may
prevail not only because of the similar effects of colic, but also
from the fact that uterine contractions do not always have the same
value. Preliminary pains may appear several days, or even weeks,
before the actual onset of labor. Now and then the "false" pains
cease, and after a period of comfort efficient contractions are
established. There is never difficulty in recognizing the latter;
doubt always relates to the preliminary pains, which may subside or
may pass into the efficient type. We lack a method of foretelling
which turn they will take; developments may be calmly awaited, with
the assurance that ample warning will precede the birth.
A slight mucous discharge from the vagina is frequently seen toward
the end of pregnancy and may be disregarded, but a gush of watery
fluid always means that the sac which contains the fetus has
ruptured. Uterine contractions generally follow within a few hours,
though in a few instances they will not appear for a number of days.
Under any circumstances the event ought to be promptly reported to
the doctor. Similarly, he should be notified whenever bleeding from
the vagina occurs, since it is important to have him determine its
significance.
Anyone who supposes that patients are more likely to be infected when
delivery occurs so quickly that there is not time for the doctor to
arrive overlooks the leading factor in the production of this
complication. Unless harmful bacteria are introduced into the birth-
canal and lodge there, infection is impossible. Bacteria never enter
of their own accord; they are usually carried into the vagina by
means of an examining finger or some other foreign body. Accordingly,
with the exception of those instances in which local inflammation
already exists, there is no reason to fear infection when delivery
proceeds so rapidly that internal examinations are not required.
PERSONAL PREPARATIONS.--Ordinarily, if the nurse is not already in
the house, she will arrive in time to assist the patient in making
the final arrangements for delivery. Should the nurse be delayed, the
patient herself may make certain preparations to insure personal
cleanliness, another very important factor in the prevention of
infection.
The presence of hair and the folding of the skin about the outlet to
the birth-canal render the disinfection of this area somewhat
difficult. It is advisable, therefore, to clip the hair as short as
possible and, while bathing the whole body, to scrub the region in
question with especial thoroughness. Before the bath an enema of
soap-suds should be taken to clear the rectum of material which
otherwise might be expelled during the birth and contaminate the
field of delivery. The bath-towels and the gown which are used should
have been freshly laundered.
Other especial preparation of the delivery-field will be made later
by the nurse. But whenever labor progresses so rapidly that neither
the nurse nor the doctor arrives before the child is born, such
preparations as I have indicated will be sufficient, for more minute
precautions are unnecessary unless an internal examination must be
made.
THE CARE OF OBSTETRICAL PATIENTS AT THE HOSPITAL.--The majority of
obstetrical patients are attended at home, and there is no reason why
this should not be. Generally it is unfair to urge a woman to go to a
hospital if she has already passed through a normal confinement and
there is no reason to anticipate trouble in the approaching one; on
the other hand, if any complication whatever is anticipated, the
patient should certainly enter a hospital. Furthermore, it frequently
proves advantageous to do so where the pregnancy is the first, though
no complication is expected and none develops. The average labor with
the first child lasts somewhat longer than with subsequent ones, and
in consequence there is greater opportunity for the patient's family
or friends to interfere with the management of the case, which never
benefits a patient, and is sometimes a serious handicap. Then again,
the cramped apartments, so common in these days, are poorly adapted
to the treatment of sickness of any sort and should induce many
obstetrical patients to choose the hospital. There are, besides,
other features which favor this course, such as economy, convenience,
and safety. From my own experience, which includes the care of
patients both at home and at the hospital, I am convinced that, as a
rule, the latter is much more satisfactory.
Most cities now have institutions which provide a room and all the
essential care, exclusive of the doctor's services, at approximately
the cost of a trained nurse at home; luxuries will naturally add to
the expense in hospitals as quickly as elsewhere. If one considers
the various items connected with attention at home, such as the
maintenance of the nurse and of the patient, the cost of the
equipment necessary for confinement, the additional household
laundry, and the sundry other details, it is clear that hospital
treatment becomes distinctly economical. Moreover, the uncertainty of
the date of confinement may necessitate paying a nurse for a longer
or shorter period before the birth. Expense at the hospital, on the
contrary, usually begins when the patient enters; and if she lives in
the city it is rarely advisable for her to leave home until the
beginning of labor. Even aside from the matter of expense some women
prefer the hospital, since in this way they avoid the technical
preparations for the birth.
Much more vital, however, is the care patients receive in the
hospital, for rigid adherence to surgical cleanliness is exemplified
in the hospital as it can be nowhere else. Infections rarely develop
there. Formerly these accidents were more common in the hospital than
in the home, but conditions are now reversed and fatalities
predominate among those delivered in private houses. The modern
theory of asepsis has, to be sure, been widely accepted and is
practiced so far as possible wherever obstetrical patients are
attended, but only in the hospital can the underlying principles be
applied with complete thoroughness and persistence. The hospital is
constantly alert, whereas in private houses carelessness or
ignorance, or both, often lead to lax technique. As a result,
statistical evidence indicates that two to three infections occur
among those delivered at home for one at the hospital.
In the event of an emergency during labor, the hospital affords
another distinct advantage in its staff of trained attendants. Of
course they may be brought to one's home, yet not without some delay
and extra expense; whereas in the hospital their assistance is
instantly available. In institutions charity patients are often
delivered under more favorable auspices than are the wealthy at their
homes. Convalescence likewise is favored at the hospital, since the
rules which control the admission of visitors guard the mother from
exhaustion and annoyance. Moreover, isolation such as can only be
secured in a hospital is conducive to a well-trained baby.
Patients debating what course to follow often ask when they must
leave home, what they should take with them, and how long they ought
to remain at the hospital. The attending circumstances will alter the
answers to these questions, but in a general way the following
directions will serve as a guide.
Ordinarily, the patient may remain at home until the first warning of
labor. Departure from this rule is justified if the patient becomes
unduly anxious about reaching the hospital in time, especially when
she lives some distance from the institution, or if there is any
doubt of securing accommodations. In either event, she should go to
the hospital at least one week before the confinement is expected.
There is no danger in riding to the hospital after labor has begun;
frequently, the ride exerts a helpful influence and shortens the
labor.
Whatever is to be taken to the hospital should be packed in a bag
several weeks before the predicted date of confinement and put in a
convenient place so that one may be spared the trouble of gathering
it at the last minute. Beside her usual toilet articles, the mother
will require several gowns, a dressing-robe, and bedroom slippers.
Clothing for the child will also be needed since most institutions
stipulate that the infant use its own wearing apparel. If
impracticable to transport the entire wardrobe when the mother enters
the hospital, so much may be taken as will be needed during the first
few days, and other articles may be brought as the need of them
arises. The personal laundry of both mother and infant is usually
done outside the institution.
Surgical dressings of every description are provided by the hospital.
Those who intend to enter a hospital, therefore, may disregard the
list of articles necessary for confinement. Similarly, the
sterilization, the preparations of the room and of the bed, and
personal preparations will be of interest only to the patient who
intends to stay at home.
It is not always possible for the physician to say how long a patient
should remain at the hospital; the rapidity of the mother's
convalescence and the progress of the child, both important factors,
cannot be accurately foretold. Frequently, it is a good plan to
remain until the infant is four weeks old, but the majority of
patients are dismissed at a somewhat earlier date. In no instance,
however, should the mother be allowed to leave before the infant is
two weeks old. Even when given the privilege of leaving so early she
will always understand that competent assistance must be provided at
home, for the mother should not resume her routine duties until six
weeks after the birth.