After all these years of self-sacrificing, pioneer work, of which

American nurses may justly be proud, Miss Holman has the enviable

satisfaction of knowing that she has lessened the perils of childbirth

for some 600 women and saved practically all of their babies. Much of

this in the simplest, most meagerly equipped mountain homes. She has

even managed to have some of the mothers taken to a nearby town for the

repair of lacerations which occurred during labor. And she has a little

hospital now up on the mountain top, with doctors and nurses, not only

caring for sick people, but, among other things, teaching women and

girls how to care for infants and children.

A complete maternity service for rural communities would evidently

include small hospitals for primiparæ and abnormal cases and to serve as

centres from which nurses and doctors would carry on prenatal

supervision and instruction, and give skilled attention at birth;

followed by visiting nursing of the young mother and her baby. The

prenatal supervision in sparsely settled districts might leave much to

be desired, because of the impossibility of seeing each patient as often

as is wise. But even a little care would be an improvement upon present

conditions. In some localities, it has been found possible to teach some

of the more intelligent of these rural mothers a good deal about their

own supervision. One nurse tells of a very isolated woman who could only

be visited at long intervals whom she taught to test her own urine for

albumen, explaining its possible significance and seriousness. One day

the report card that came by mail indicated that the last test showed

albumen. But the card also carried the remark, “Don’t worry about this.

I am drinking lots of water, taking nothing but milk for food and will

be in to see the doctor on Tuesday.”

This hints at some of the possible adjustments that must be made in

meeting the needs of the patient in unusual circumstances. For we are

constantly facing the unalterable fact, that no matter where she is, nor

what conditions surround her, the individual woman needs care and

supervision, and though conditions vary, the general needs of expectant

mothers are the same.

This survey of the situation in cities and rural communities gives us a

glimpse of what _can_ be done about it—this problem of mothers and

babies who need care—and also what _is_ being done, and we begin to

sense an answer to the question, “Is anything more possible?”

It is clear that a wide extension of provisions for prenatal care is

necessary if all mothers are to be reached; rich, middle-class and poor;

in cities, small towns and rural districts alike. We believe that it is

possible; and we are sure that wherever provision for prenatal care is

made, the achievement of its fine purpose will depend very largely upon

the spirit of the individual nurse.

What does it bring to the individual nurse—this survey of the problem as

a whole, with the suggestion for its possible solution? The appeal of

not a few mothers and babies, only, but of a legion, and of uncounted

homes and family circles in danger of being broken. And it brings a

suggestion of the immeasurable comfort and influence which the maternity

nurse may carry into each home that she enters. For she helps to save

lives and health, and through them, homes and family groups, and these

are the building blocks of the nation.

For the nurse whose imagination is touched by this appeal, it will exact

much—the best and most that she has to give—but in return she will find

a deep and enduring satisfaction in her work.

FORMS AND ROUTINES USED BY MATERNITY CENTRE ASSOCIATION, N. Y. C.

ROUTINE FOR PRENATAL VISITS:

_First Visit._—Get acquainted with the patient and get her

confidence. Learn if she has made any arrangements for her care at

time of delivery. If a doctor or midwife has been engaged

communicate with him or her. If the patient is registered with a

hospital, or is under other nursing care, note that on your record,

also on slip sent to Central Office. Always ask to see patient’s

hospital or clinic card, or any card which she may have been given

by any nurse or other visitor. Give patient pink card.

Explain simply the reason for an expectant mother seeing a doctor

and nurse early and regularly. Invite the patient to come to the

Center. Ask her in a general way about herself, when the baby is

expected, other pregnancies and deliveries, and illnesses; other

members of her family. Direct your conversation so as to get as much

data as possible without asking a direct question. Do not attempt a

full nursing visit unless the patient meets you more than half way.

Every patient is to be encouraged to come to the Center for as much

of the nursing care as is possible for that individual woman. In the

care of all patients it is the nurse’s responsibility to make every

effort to solve (by working with every existing agency) such home

problems as might effect the health of the mother or baby or disturb

the mother’s peace of mind.

_Complete Nursing Visit._—Ask the patient about any aches, pains,

troubles of any kind, directing your questions to cover all items on

record. Select a table, chair, machine top, or end of mantel, to use

as work table, and place on it:

Newspaper for protection

Paper napkin as cover

Nurse’s soap, hand scrub and towel

Watch

Fountain pen

Maternity Record

Thermometer

Tycos

Bottle for specimen or

{Test tube and holder

{Urinometer

{Litmus paper

{Acetic Acid—2%

{Sterno

{Matches

Take temperature, pulse, respirations and blood pressure (to take

blood pressure adjust sleeve, get radial pulse, pump until

obliterated, let out air and read dial at moment pulse returns. See

Tycos Manual, sample No. 2, for full detail.) Wash thermometer

thoroughly with soap and water, dry and return to case. Scrub hands.

Inspect or demonstrate the care of nipples; to be done daily after

the fifth month, not before. Use cotton ball (or soft toothbrush

previously scalded and kept for this purpose). Thoroughly scrub each

nipple with warm water and white soap and dry with a clean towel.

Apply albolene, pulling out the nipple. Do not handle breasts.

Listen to the fetal heart. If unable to hear make note on record

n.h. If fetal movements are felt by nurse put an “x”; if patient

says she feels the baby move, put “xx” in space on record for

recording fetal heart rate. Look for edema, varicose veins; do not

take the patient’s word for these symptoms. Apply bandage for

varicose veins (patient to pay 70 cents for bandage, or bandage to

be lent to patient as long as needed, to be washed and returned),

and teach patient right-angle position. Get specimen of urine,

either to take to the station for examination or to examine at once

for specific gravity, reaction and albumen, in accordance with

instruction given on page 30, Laboratory Technique—Wood, Vogel and

Famulener. Have the patient cleanse vulva before voiding, and void

in clean vessel. Teach patient proper disposal of urine, emphasizing

why kitchen sink is not to be used. If any abnormality in amount,

color, specific gravity, or trace of albumen, report to the doctor,

midwife or hospital in charge of the patient, if the patient has

engaged one; if not, use every effort to get the patient under care

of doctor.

Teach patient to measure amount of urine voided in 24 hours. Tell

her to void in toilet on getting up in A.M.; then for the rest of

that day and night and the following A.M. to void in a suitable

vessel and measure in a tomato can (if no suitable vessel, void in a

tomato can) and keep count of how many times she fills the can.

On an early visit examine teeth and show how to keep clean. Where

possible urge a visit to the dentist or dental clinic for

prophylactic treatment. Explain that it is not wise to have

extractions done during pregnancy without consulting a doctor, but

that cleansing and temporary fillings may be done with much saving

of teeth.

On one visit, as early as possible, ask to see the layette, and

advise about it, going over the list of baby supplies. Urge the

patient to visit the center to see the model layette, and get help

in the choice of materials and patterns. Note on the record if

layette is not complete by the eighth month. Demonstrate the

preparation of bed for the baby, made from clothes basket, soap box,

or in a baby carriage similar to the model at the center. If the

patient is to be delivered at home, some time after the seventh

month ask to see the mother’s supplies, going over the list. The

patient should be advised against the use of oilcloth from the

kitchen table as a bed protector, and especially urged to prepare

newspaper pads like the model at the center. Note on the report if

the mother’s supplies are not complete by the eighth month. Advise

about the arrangement of the room for delivery, and demonstrate the

preparation of the mother’s bed like the model at the center.

No treatment or medicine to be advised except in accordance with

standing orders, private physician’s orders, hospital orders and

Maternity Centre Association routine (note on record which).

Form letter signed by the head of the medical board sent to doctors who

have been engaged by patients for delivery:

My dear Dr. ......:

Mrs. ...... who has engaged you for her care at delivery, has been

referred to this association for nursing care.

In order to make the work of the nurses of this association of a

uniformly high standard, the Medical Board has adopted the enclosed

routine for the nurses to follow.

May we not have your cooperation in our effort to teach the women of

the community the need for, and value of, medical supervision

throughout their pregnancy?

May we have your permission to instruct our nurses to visit Mrs.

...... in accordance with our routine, and report each visit to you?

A prompt reply on the enclosed slip will be greatly appreciated.

Cordially yours,

Form for report sent after each nursing: visit to the patient’s doctor,

either privately engraved or the hospital resident.

PRENATAL VISITS

Name of patient, District, Date,

Address, Nurse, Agency,

T P R, Nipples: Erect, Flat or inverted, Edema: Face, Feet, Legs.

Varicose veins, Dyspnoea, Spots before eyes, Nausea or vomiting, A.M., All day.

Headache, Constipation, Diarrhea, Vaginal discharge: White, Yellow, or Bloody.

Vaginal Soreness. Fetal Heart Rate. Urinalysis: Sp. Gr., Reaction. Albumin.

Quantity in 24 hours. Blood pressure: Diastolic, Systolic.

Instructions followed. Patient, Husband, still working.

Occupation changed, Patient, Husband, Weekly income.

Remarks: (Treatment, advice, change in occupation, housing, etc.)

MATERNITY RECORD

The Maternity Record upon which a complete history of each case is

recorded is divided into four parts, the first section for the social

data about the patient, the second for other pregnancies and observation

of patient during this pregnancy, the third records delivery and

postpartum care, the fourth, post-natal care. (See insert for form.)

LEAFLET OF INSTRUCTIONS GIVEN TO PATIENTS

ADVICE FOR MOTHERS

Motherhood is natural and normal. If you do as the doctor and nurse ask

you to, you have no reason to worry about having your baby.

_DIET_

Eat the food you are used to. Do not eat what you know gives you

indigestion. Do not eat too much at any one meal.

Drink 8 glasses of water every day.

Drink all the milk you can.

Do not drink any beer, whiskey, wine or other alcohol. These hurt the

kidneys and thus may poison the baby.

Eat meat, meat-soup or eggs and drink tea or coffee only once a day.

_SLEEP_

At least 8 hours every night with windows open.

_EXERCISE_

Do your regular house work, but lie down several times a day, if only

for five minutes. If possible take a walk out of doors. Fresh air is

good for your baby. If you cannot get out, keep the windows open while

you work indoors. Do not do heavy work; it will hurt your baby.

_BATHING_

Wash all over every day with warm (not hot) water, but do not get into a

tub after the seventh month.

_GARTERS_

Do not wear round garters or any tight bands. The nurse will show you

how to make suspender garters.

_CONSTIPATION_

If you are constipated, drink a cup of coffee (no cream or sugar) before

breakfast, hot milk (not boiled) with breakfast, go to the toilet at the

same time every day (after breakfast best). During the day eat coarse

bread, green vegetables, stewed fruit, drink no tea, but all the water

you can, at least 8 glasses, hot or cold. Cook 2 tablespoonfuls of senna

leaves with a pound of prunes and eat four to six prunes every day. If

you have hemorrhoids (piles) hold a cold compress to anus for five

minutes after bowels move and do not let yourself get constipated. Never

take any cathartics unless your doctor, midwife, or nurse tells you to.

_IMPORTANT_

Do not have any sexual intercourse after the 8th month. If you have

severe headache, vomiting, spots before your eyes, if your face, hands

or feet swell, let your hospital, doctor or midwife and nurse know at

once.

Labor begins with pains in back or abdomen; with bleeding or watery

discharge. If you have any labor pains or bleeding before the time you

expect your baby, go to bed and send word to your hospital, doctor or

midwife and nurse at once.

If you are going to the hospital, have ready after the 8th month one set

of baby clothes, to take with you to put on the baby when you bring him

home. Do not take anything else with you, the hospital will supply all

you need. As soon as labor begins, go to the hospital.

If you are to be confined at home, as soon as labor begins send for the

doctor or midwife. If the doctor is one of the hospital doctors, follow

the directions on your card from the clinic.

While waiting for the doctor, boil a large quantity of water in a

covered vessel and set aside to cool. Prepare your bed as the nurse has

shown you, take a warm sponge bath, braid your hair in two braids, get

out a set of baby clothes ready for the nurse to dress the baby. Get out

supplies needed for yourself.

MOTHER’S SUPPLIES

2 gowns.

1 pair white stockings.

4 sheets.

6 bed pads.

Vulva pads or supply of freshly laundered old muslin.

Cotton (absorbent).

2 wash-cloths.

2 towels.

4 oz. lysol.

1 bedpan.

The bed pads are made from 6 thicknesses of newspaper open to full size

and covered with freshly laundered old muslin tacked in place. No other

protection for bed is necessary. As a precaution, when possible, the

entire mattress may be covered with oilcloth put on under the bottom

sheet. See model at center. All washable supplies for mother and baby

should be freshly laundered and put away in pillowcases or clean, ironed

paper until they are needed.

BABY’S SUPPLIES

The following is a list of the complete outfit of baby clothes and

toilet necessities. It may be modified as to material, quantity and

quality to suit the individual taste and pocketbook.

12 Diapers 18″ × 18″.

3 Bands 6″ × 27″.

3 Shirts, size 2, cotton and wool.

3 Petticoats.

3 Slips.

2 Squares 36″ × 36″.

Note: The squares are used instead of coat and bonnet until the

baby is more than 2 months old. See model at the center.

1 Oilcloth or rubber 12″ × 18″.

12 large safety pins.

12 small safety pins.

1 Basket or box for bed 15″ × 30″.

1 Felt pad or folded blanket for mattress.

1 Oilcloth case for mattress.

2 Muslin pillow-cases for mattress.

2 Crib blankets, small size.

2 Towels.

2 Wash-cloths, old pieces of linen.

1 piece Castile soap.

8 oz. boric acid powder.

1 package absorbent cotton.

1 quart oil—sweet or albolene.

1 package toothpicks.

Tray—fitted with:

Glass jar for boric acid solution.

Glass jar for nipple swabs.

Glass jar for oil.

Glass jar for small toothpick swabs.

Dish for soap.

Cake of soap to stick pins in instead of a pin cushion.

Hair receiver for absorbent cotton.

Newspaper cornucopias for waste.

Bottle and nipple for giving baby water.

Covered pail with borax water for soiled diapers.

Jars for tray may be empty cheese, candy or jelly jars.

CLINIC ROUTINE

The nurse is urged so to conduct her clinic as to assure privacy to each

patient examined, and the same treatment which the patient would receive

if she were the only patient in the office of one of our best

obstetricians.

Nurse is to wear her graduate uniform during clinic and during her

office hours.

=Nurse’s Duties=

=1—Preparation of Clinic Room=

Pads of doctor’s record, return visit to doctor, post-partum

examination; pencil; examining table; side tables; sterilizers; basins;

instruments; supply of clean dry gloves; Department of Health material

for taking Wassermanns, cultures and smears; cotton balls; tampons;

throat sticks; sheets; pillow cases; sounding towel; adequate supply of

clinic drugs; solutions; thermometer, in glass of 50 per cent alcohol;

glass of cotton; to be ready one-half hour before the time set for

clinic.

=2—Preparation of Patients’ Dressing Room=

Screens or curtains arranged to form individual dressing rooms; a

sufficient number of clean clinic gowns; separate chair provided for

each patient to leave clothes on, unless room is provided with racks or

hooks.

=3—Preparation for Urinalysis=

Unless the urinalysis is made so near the toilet that the waste urine

may be thrown directly into the toilet, a covered pail is to be provided

one-fourth full of 1 per cent lysol solution. All waste urine and

washings from the test tubes to be thrown into this pail, and under no

circumstances is waste urine to be thrown into any sink or wash basin,

even though the basin is not used as a wash basin.

Test tubes, sterno, litmus, acetic acid, funnel, filter paper, test tube

holder, vessel for collecting specimen, basin of 1 per cent lysol

solution and cotton balls for patient to cleanse vulva before voiding,

basin for used cotton balls, provision for patient to wash hands, to be

in readiness one-half hour before the time set for clinic.

=4—Preparation of the Patient for Examination=

Each patient to completely undress, except her shoes and stockings, and

to put on clean gown supplied by the clinic. Her shoes to be unfastened

so that the doctor can examine her ankles for edema, her temperature to

be taken and a urinalysis made _before_ the patient is seen by the

doctor.

=5—Assisting Doctor in Examining Room=

Make notes on record pad at the doctor’s dictation, reminding her

tactfully of any omissions made in her dictation. Conduct examination in

the following order: Head, chest, breasts, blood pressure, abdominal,

fetal heart, measurements, ankles, vaginal, Wassermanns or smears when

necessary.

_Note_: Preparation for vaginal examination. Sponge vulva with 1 per

cent lysol solution. Give doctor fresh gloves for each patient.

The nurse is responsible for the technique in the clinic room, not the

doctor.

If the doctor wishes to do a vaginal examination on a patient more than

eight months pregnant, or one who is bleeding, take same precaution as

though examining a patient in labor; clip; scrub with green soap and

water; then 1 per cent lysol; give doctor freshly boiled, sterile

gloves.

=6—Arrangement of Examining Room After Clinic=

Soiled linen in laundry bags; fresh linen on tables, tables covered; all

used instruments to be washed, scrubbed when necessary, boiled five

minutes, dried and put away; all gloves used to be washed in cool water

and green soap and thoroughly rinsed, wrapped in towel, dropped in

boiling water and boiled for five minutes, then dried, powdered and put

away in a clean towel ready for use at next clinic; solution basins to

be emptied, washed and dried; all waste to be securely rolled up in

newspaper and put in a house garbage can; supply of drugs to be checked

up and replenished when necessary.

=7—Records=

All “Doctor’s Record” cards to be written up and filed; reports mailed

to the central office; reports on the condition of patient sent to

nursing agencies caring for the patient and other agencies working on

the case; maternity records to be filed in date file before the nurse

goes off duty.

=Doctor’s Duties as Outlined on Doctor’s Record=

1. One complete physical examination including heart, lungs, breast,

blood pressure, abdominal examination, fetal heart, pelvic

measurements, vaginal examination and a Wassermann and G.C. smear

on all patients with a suspicious history. Notes on this

examination to be dictated to the nurse.

2. Blood pressure; abdominal; urinalysis; on return visits and

provides space for notes on such other observations as she may

wish to make.

3. One post-partum examination on every patient; including a statement

on general condition; examination of breasts; vaginal; uterus;

perineum; and note results of any intercurrent disease.

4. Recording advice given to patient.

5. Instructing patients when to return to see the doctor. _Note_: All

patients not registered with a hospital or private doctor, to be

seen by the clinic doctor once a month up to the seventh month,

and once in two weeks, or oftener as the case demands,

thereafter.

=8—Duties of Clinic Assistants=

At those clinics where a lay woman acts as assistant to the nurse, the

following duties (and no others without special permission) may be

assigned to the assistant:

1. Greeting patient; and from name on her pink card, getting her

maternity record from file and sending to nurse.

2. Taking temperature, a record of which is sent in to the nurse on a

scratch pad and copied by her on her clinic record.

3. Urinalysis.

4. Helping patient dress and undress.

5. Care of any children who may come with patient.

6. See that patient understands when to return and has her pink card

so marked before she leaves.

CLINIC EQUIPMENT STANDARD

=Requirements=:

Room for examining, and dressing room, screens, running water, gas, near

a toilet, urinalysis facilities, good light,

Chair 1

Desk 1

Blotting pad 1

Blotter 1

Ink-well 1

Penholder 2

Pens,

Erasers,

Ink 1

Pencil 1

Red Pencil 1

Rubber bands

=Office=:

Clips

Ruler 1

Waste basket 2

Hand blotters 12

Ink, Red and Black

Charities Directory 1

Map of Manhattan in Sanitary areas 1

Report on vital statistics 1

Babies’ Welfare directory 1

Guide Cards Baby Health Station 1

=Examining Room=:

Table 1

Pad 1

Pillow 1

Foot bench 1

Shelves or side table for supplies, etc. 1 set

Garbage pail 1

Pelvimeter 1

Tape measure 1

Stethoscope 1

Tenaculum 1

Scissors 1

Bivalve speculum 1

Uterine Dressing Forceps 1

Blood Pressure machine (Tycos) 1

Thermometers 3

Thermometer Glasses (1 for cotton) 2

Enamel jars for tampons and pledgets 2

Large basin 1

Small basin 1

Erlenmeyer flasks for green soap and Lysol 2

Medicine Glass 1

Hand Scrub 2

Rubber gloves, No. 7½ 6 pr.

Absorbent cotton 1 lb.

String 1 ball

Spatulæ 100

Hemoglobinometer (Tahlquist) 1

Needles (skin)

Wassermann Set from D. of H. 1

G. C. Smear Set from D. of H. 1

Culture tubes from D. of H.

Bandages (Ace) 6

Sterilizer 1

Sterilizer burner 1

Metal Shelf or table for Gas sterilizer

Scott Tissue Towels 6

Urinalysis outfit 1

Test tube rack 1

Test Tubes 12

Test Tube holder 1

Urinometer 1

Sterno

Matches

Enamel Measure 1

Dish (Chamber) 1

Litmus

Acetic Acid 2%

Toilet paper

Funnel 1

Filter paper

Covered pail

=Linen=:

Sounding towels (for use in listening to F. H.) 6

Sheets 6

Pillow cases 3

Doctor’s gowns 2

Dusters 6

Gown’s for patients 12

Covers for tables q.s.

Laundry bags 2

Towels 6

=Sewing Bag=:

Cotton 70

Cotton 30

Needles, assorted

Thimble

Tape measure

Tape

Safety Pins

Plain Pins

=Drugs=:

K Y

Lysol

Green soap

Boro Glycerin

Alcohol

Iodin

Albolene

=Breast Tray=:

Castile soap in dish

Small bowl

Bottle of albolene

Jar of cotton balls

Soft toothbrush

=Exhibit on Table=:

Patterns for baby clothes.

Complete layette. Slip and petticoat open in back.

Basket for baby bed.

Pad (of felt or hair mattress).

Rubber.

Pillow cases.

Blanket (crib).

Doll (baby) dressed.

Suspender garter for mother—abdominal support with garters.

Patient’s bed prepared for time of delivery, newspaper pads.

=Toilet Tray=:

Jar of boiled water (for washing mother’s nipples).

Jar of oil (mineral oil best).

Jar of boric acid—2% for baby’s eyes.

Jar of breast swabs.

Jar of small swabs.

Absorbent cotton in container (hair receiver).

Soap in dish.

Soap with safety pins, instead of pincushion.

Jar for clean nipples.

Bottle and nipple, or cup and spoon for giving baby water.

Bottle of boiled water (day’s supply boiled fresh each day) and

kept corked.

Newspaper cornucopia for waste.

=Contents of Nurse’s Bag=:

Any nurse may remove from her bag any article not necessary in her

district or for any one day’s work, provided she makes note of same on

card, which is left in bag pocket, stating where removed articles may be

found.

1 mouth thermometer

1 rectal thermometer

1 baby scale

Acetic acid—2%

1 test tube

1 test tube holder

1 test tube brush

1 blue litmus

1 urinometer

1 sterno

1 matches

2 specimen bottles

Paper napkins

Soap and hand scrub in bag

1 flashlight

1 fountain pen

1 Babies’ Welfare Directory

1 Board of Health Station card

1 Sounding towel in envelope

1 abs. cotton in envelope

1 scratch pad

Addressed postals

Advice to mothers

Letterhead memo pad and envelopes

Pink cards

Maternity Records for patients to

be visited

Blank Maternity Records

Prudential Ins. Co. Baby Primer

1 Tycos Blood Pressure apparatus

3 Ace Bandages

1 Street directory

MATERNITY CENTRE STANDING ORDERS FOR NURSES

These standing orders may be used at the discretion of the nurses when a

patient is under no other medical supervision. When patients are

registered with a midwife, may be used with her consent.

=Ante-Partum Orders=

Cathartic: After hygiene, diet, prunes and senna have ailed,

use either

Cascara, grains 5, or,

Licorice Powder, beginning with drams 2 and

reducing dose gradually.

For neglected constipation use one-half pint warm

oil (sweet oil, albolene or olive oil) enema,

followed in one-half hour by soap suds enema

(this treatment to be given by the nurse).

Heart Burn: After advice as to diet, water, habits,

constipation, use Soda Bicarbonate tablet,

grains 10 (do not advise or allow Baking Soda).

Binder: Abdominal binder like pattern P.R.N. for heavy

abdomen, backache.

Brassiere: Brassiere for breast support P.R.N. (Debevoise

tape best if patient can afford; if cannot

afford have patient make one like sample

support at Center).

Toxemia: Until medical attention can be secured advise:

1. Mild—as much rest as possible; force water 8

to 10 glasses a day.

Diet—milk, cereals, vegetables, stewed fruits and

oranges (no peas or beans).

Eliminate all salt and condiments.

2. Severe—patient in bed. No vegetables; diet of

milk and cereals only.

3. With edema. Reduce water to 3 or 4 glasses for

three days, after that force water and follow

2.

=Post-Partum Orders=:

Breasts: For all cases instruct mothers to leave breasts

alone, no pumping, no massage. Supporting

binder P.R.N. (brassiere best).

For engorgement, follow preceding, and restrict

so-called milk-making foods, but not water. To

dry up milk, follow preceding and advise sodium

phosphate daily in frequent small doses (about

drams 1).

For cracked nipples, apply paste of Bismuth

Subnitrate and Castor Oil, equal parts each.

Use nipple shield. If not healed report to

Central Office.

Cathartic, Cascara grains 5, or mineral oil ½

dram, or licorice powder drams 2. For neglected

constipation, use enema as described for

ante-partum patients.

=Post-Natal Orders=:

Thrush: Solution of Soda Bicarbonate (1 tablespoonful to

1 glass of water); apply to spots with swab

before and after nursing. If not effective send

baby to dispensary or doctor.

Constipation: Olive Oil and Glycerin, equal parts of each,

minims 5–15 to dose.

Circumcision: If penis is not thoroughly healed, dress with

Aristol powder.

Excoriated Buttocks: Castor Oil and Bismuth Paste, equal parts of

each.

Oozing Umbilicus: Cleanse with alcohol on swab, dust with Aristol

powder, apply dry sterile dressing.

Protruding Umbilicus: If dry, strap with well covered button or coin,

using wide adhesive tape.

ROUTINE FOR POST-NATAL FOLLOW UP

=Hospital Cases=

See patient as soon after she is dismissed as possible, to make sure she

understands how to care for baby. Urge her to take baby to nearest baby

health station (see Blue Card) when baby is three weeks old. Telephone

health station to see if she does register. Urge her to bring baby to

your own station when one month old. At that time arrange for

post-partum examination: if it is the practice of the hospital, at which

the patient was delivered, to instruct patient to return for post-partum

examination, urge her to go at time set by hospital; if not, urge her to

come to your station for such examination. If she fails to come, visit

her to learn condition of baby, and to urge post-partum examination. If

during the post-natal follow-up work, any abnormality is discovered in

baby or mother, report that at once to the resident of the hospital,

where patient was delivered, and carry out his orders as to whether

patient is to return to him or be referred to gynecological or baby

clinic.

=Patient Delivered at Home=

Urge all pre-natal cases to send you post card when baby is born. When

postal is received, visit as soon as possible to see that everything is

all right; arrangements made for care of home and children so as to keep

mother in bed proper time, etc. If a Henry Street nurse is doing

post-partum bedside nursing, make no other visit but urge mother to

bring baby to see you at station when the baby is one month old. If a

practical nurse or a midwife case, visit every day or so, but do not

interfere with her conduct of the case. If you find it necessary to

report any irregularity to the Department of Health communicate with the

midwife before doing so. After she has dismissed the case follow the

routine outlined above. Make special effort to get all midwives’ cases

to come for post-partum examination, and also private physicians’ cases

if they dismiss case before baby is six weeks old.

CHAPTER XX

CARE OF THE MOTHER AND BABY BY VISITING NURSES

The preventive value of post-partum care is now so generally recognized

that maternity care by visiting nurses is given not only in the larger

cities, but is being extended even to rural communities. The routine of

the Visiting Nurse Society of Philadelphia, under the direction of Miss

Katharine Tucker, may be taken as an example of effective post-partum

care, in which daily visits by a nurse bring to large numbers of

patients the minimum of necessary attention. As the same kind of work is

effective and possible in smaller communities, the routines and

instructions used by the Philadelphia Society are reproduced on pp. 439

to 445. These include

1. The equipment of the nurse’s bags.

2. Delivery routine.

3. Routine technique in caring for mother and baby.

In normal maternity cases, a visit is made once a day for eight days.

After that time, if the mother is up and about and the baby is in good

condition, the nurse visits at least once a week for supervision until

the fifth week, when the case is transferred automatically to the Child

Welfare Nurses under the City. If, however, there is any complication

with either the mother or baby, the nurse continues daily visits or

twice daily as indicated by the condition, until both mother and baby

are normal. Instruction to the mother in the care of the baby is one of

the important phases of the maternity nurse’s program.

The points observed and recorded on the bedside cards are: condition of

breasts, urination, condition of bowels, character of lochia, position

of uterus, T.P.R. or any abnormality. If there is any rise in

temperature or other abnormality noted, the physician is called by

telephone and the situation reported.

Any one can call the nurse—children, husband, neighbor, doctor, social

worker,—and a nurse is sent out on every call. A doctor must be in

charge of every case, and if one has not been engaged when the nurse

gets there, she sees to it that one is procured. The only exception is

in cases delivered by midwives, in which instances the nurse gives any

necessary care and supervision, having it clearly understood that if any

abnormality occurs, she will first notify the midwife and then the

midwife or the nurse will immediately call a doctor.

The doctor ordinarily brings his own equipment for delivery. The

contents of the nurse’s bag is the same for delivery as for post-partum

care, except for the addition of the nurse’s gown, extra towels and

silver nitrate. Perineal pads, cotton, boric solution, etc., are

supplied at cost, or free of charge if the patient is unable to pay. Bed

linen, nightgowns, layettes, etc., are provided for patients who cannot

procure them.

The cost per visit to maternity patients averages one dollar and the

cost for services at the time of confinement averages five dollars. Miss

Tucker says of the maternity work:

“A complete maternity service which includes prenatal work, service

at time of confinement, post-partum care and subsequent supervision

of mother and baby is essential if adequate results are to be

accomplished. Anything less than this complete service does not give

full protection to the life of the mother and the baby. The

Philadelphia Visiting Nurse Society has found that the inclusion of

service at time of confinement has given a tremendous stimulation to

both their prenatal and postnatal service. In the branches where a

delivery service has been added, the prenatal service has increased

fourfold. Both doctors and patients are enthusiastic and see far

more reason for instruction and supervision from a nurse who is

going to see the case through than from one who drops out at the

crucial moment. It certainly has strengthened our whole maternity

service, both as to results accomplished and in our relationship to

the doctor and to the community.”

FORMS AND ROUTINES FOR MATERNITY WORK, VISITING NURSE SOCIETY

PHILADELPHIA

EQUIPMENT FOR BAGS

Bottles containing:

1. Alcohol.

2. Licreolisis.

3. Green soap.

4. Mouth wash.

Jar with boric acid crystals.

Jar with cord powder.

Jar containing vaseline.

1. Hypodermic syringe.

2. Tongue depressors.

3. Two thermometers: rectal and mouth.

4. Toothpicks.

5. Adhesive plaster.

6. Fountain syringe or funnel and tube in linen bag.

7. Gauze and bandages in linen bag, cord dressing and cord tape.

8. Cotton and p.p. pads in linen bag.

9. Paper napkins on which to lay articles.

10. Granite pan.

11. Two towels.

12. One apron.

13. Hand-brush.

Instrument case containing:

Scissors, forceps, 2 artery clamps, glass catheter, rubber

catheter, colon tube, connecting tube, glass nozzle, medicine

dropper.

Folder containing:

Records.

Fee slips.

Literature.

ROUTINE TECHNIQUE

=1. Uniforms.=

Except in the case of substitutes during their first six months and

staff nurses during their probation period, all the nurses are required

to wear the uniform of the Society.

Prescribed hat and coat.

Sensible black shoes.

Plain dress of prescribed material.

=2. Bags.=

Lining to be changed once in two weeks.

Bottles to be kept neatly labelled.

Lost articles to be replaced at the expense of the nurse.

New equipment may be obtained only in exchange for the worn-out one.

Notebooks, charts, other papers, and pencils to be kept in the long

pocket.

Instruments to be boiled before and after dressings.

Brush to be boiled twice a week and after all infectious cases.

=3. Thermometer Disinfection.=

To be washed before and after using in running water if possible.

After using wrap in cotton soaked in alcohol and leave until the work is

finished. Then wash with green soap under running water.

=4. Routine in the Home.=

=General Care=:

A. Remove hat and coat, folding coat right side out and placing on

chair away from wall. Place bag on chair or on table with

newspaper underneath.

B. Ask nature of illness, doctor’s orders, etc.

Ask family for a kettle of boiling water; pitcher of cold water;

basin, soap and soap dish; pail for the waste; tumbler; towels

and wash cloth; bath blanket or sheet; clean gown and necessary

bed linen; newspapers; comb and brush.

C. Open the bag; put on apron; roll up sleeves; take from bag

necessary articles, placing on clean newspaper or napkin. Wash

hands and thermometer. Take everything needed from the bag at

once to prevent unnecessary handling. Take and record T.P.R. of

all cases except chronics of long standing.

D. Place newspapers-one on chair, one under edge of bed for soiled

linen, one for utensils (kettle, pitcher, etc.)

Make cornucopia of newspaper for waste and pin to the side of bed.

E. Bath. Cover patient with blanket or sheet.

Remove upper bed clothes, fold and place on chair.

Soiled linen should be placed on paper with the stains turned in.

Avoid unnecessary exposure of the patient at all times.

Give thorough bath, using plenty of soap and rinsing carefully.

Change water at least once.

Bathe upper half of body, give local bath, change water and bathe

lower half.

Put on nightdress before completing bath.

Clean teeth and nails.

Comb hair, protecting pillow with towel.

In making the bed be sure that there are no wrinkles under the

patient and that the bed clothes are neatly tucked in.

F. Clear room of articles used. Empty basin. Wrap soiled linen in

paper.

Burn cornucopia before leaving the house.

Wash hands.

Complete bedside record, sign receipt for fees, and place in an

envelope.

Instruct the family to give it to the doctor.

G. Instruct the Family

1. To have hot water and necessary articles ready for the next

visit.

2. To keep room clean and well ventilated and emphasize the

importance of damp dusting and sweeping.

3. To have table cleared for patient’s use.

4. About the care to be given between visits.

Choose most suitable member of the family and instruct carefully.

H. Observe general health of other members of family and the hygienic

conditions of the home.

=Partial Care=:

Prepare as for general care.

Bathe the patient’s hands, face, neck, axilla, and breasts, and

give local bath. With maternity cases do post-partum dressing.

Cleanse the mouth.

Make bed as in general care.

DELIVERY ROUTINE

Extra articles to be carried in bags: gown, 2 towels, clamps, 2% silver

nitrate solution.

The doctor should be called at the same time as the nurse. This should

be ascertained when call is taken over telephone.

If the nurse arrives first, she should judge from the progress of labor

whether an urgent call should be sent for the doctor and how much time

she will have to spend in preparation for the delivery. Unless directed

otherwise by doctor, the nurse should proceed as follows:

Have a supply of boiled water and pour some in covered vessel to cool.

Take necessary articles from bag, wash hands, put on gown.

Prepare patient by giving enema, sponge bath, braiding the hair, putting

on clean white stockings and a gown which can be rolled up around waist.

Make bed with tight sheet, oilcloth and draw sheet, protect with pads

made of many thicknesses of newspaper, covered with old muslin.

Protect floor with newspapers, and place basin for placenta. On bedside

table, place alcohol, green soap, glass of boric acid solution, silver

nitrate, basin containing scissors, clamps, catheter, medicine dropper,

cotton gauze, cord tape and dressing, perineal pads, hypodermic,

thermometer. Basin of lysol within reach. Prepare a place for baby by

covering pillow with blanket and placing hot water bottle. Have olive

oil (warmed). Get baby clothes, also gown and binder for mother.

Scrub hands and cleanse patient locally with green soap and water and

put on sterile pad.

Assist doctor in any way possible during delivery.

Ask doctor whether he wishes to instill silver nitrate into baby’s eyes.

This should be followed by normal salt solution and boric acid.

After delivery, cleanse vulva with warm lysol, put on fresh pad and

binder, and make patient as comfortable as possible, giving her

something hot to drink.

Weigh, oil, cleanse, dress baby. Unless doctor orders otherwise,

instruct mother to nurse every three hours and to cleanse nipples with

boric acid solution before and after nursing. The following additional

information is to be written on the medical history card of patient

attended at delivery:

1. Time nurse arrived.

2. Time baby was born and sex and weight.

3. Presentation.

4. Instrumental—high or low.

5. Laceration.

6. Repair, kind and number of sutures.

7. Hemorrhage.

8. Prophylactic used for the eyes.

9. Number of hours in labor.

10. Condition on discharge—fundus and lochia.

This technique is given as a general standard but the nurse is expected

to use her own discretion in adapting it to the condition of patient,

the home surroundings and the wishes of the doctor.

ROUTINE AFTER DELIVERY

=Care of the Baby=:

=A.= Make preparations as for general care.

Have everything ready before the baby’s bath.

Have separate basin for the baby whenever possible.

Test temperature of water with the elbow.

If the room is cold bathe in the kitchen.

Use table whenever possible for the baby’s bath.

If not possible sponge on lap beside the mother’s bed so that she can

observe technique.

When cord is off, tub.

Place on paper napkin on third chair, table, or corner of dresser, glass

of boracic acid sol., olive oil, warmed, cord powder, and dressings,

safety pins, band, absorbent cotton, rectal thermometer, vaseline and

alcohol. Have baby’s clothes within easy reach. Protect lap with blanket

or bath towel.

Remove clothing.

To protect cord dressing, unpin but do not remove band.

Take temperature first and last visit, and when indicated.

Weigh baby on first and last visit.

Examine carefully for any abnormalities and note when found.

=B. Eyes.=

Unless there is a secretion, let the eyes alone.

When secretion or redness, wash eyes gently with 2% Boric acid sol.

using separate pledget for each eye.

=C. Mouth.=

Examine mouth.

No treatment unless required.

If necessary to cleanse use cotton wrapped around little finger and

dipped in boracic acid.

=D. Nose.=

No treatment unless required.

If necessary use piece of twisted cotton and boracic acid sol.

Never use toothpicks.

=E.= Wash face and ears gently with wash cloth or absorbent cotton and

dry.

Soap head with hands, rinse with cloth and dry carefully. Soap body with

hands, rinse with cloth and pat dry with soft towel. Fold binder across

abdomen, protect with hand and turn baby on stomach. Bathe the back.

Fold diaper and place under buttocks.

=F.= Genitals should be carefully cleansed.

In the case of boys, the foreskin should be gently pushed back once in

every two or three days, and the parts underneath bathed carefully with

absorbent cotton and boracic acid sol., removing the white pasty

material which causes irritation.

In the case of girl babies, carefully bathe genitalia. If deposit is

difficult to remove, soften with olive oil.

=G.= On first visit wash umbilicus with 70% alcohol and apply dry

sterile dressing. Do not remove this dressing except when soiled. After

the first time dress with cord powder. Put on clean binder, pinning on

side with safety pins. Oil under arms, buttocks and all creases.

Put on shirt.

Pin diaper.

Petticoat and dress should be drawn on over the feet.

Use hot water bottle filled with warm, not hot, water.

If necessary beer bottle, tightly corked, is a good substitute.

Clear away articles used for the baby.

=H.= Points to be observed, recorded and reported to the physician if

urgent:

1. Condition of cord.

2. Eyes; discharge, swelling or redness.

3. Urination and stools.

4. When foreskin is very tight and in every case when it cannot be

easily pushed back.

=I. Instruct the Mother=:

1. To nurse every three hours unless otherwise ordered.

2. To cleanse nipples with boracic acid sol. before and after nursing,

and to keep the breasts covered with clean cloth.

3. To give cooled, boiled water at least twice a day between feedings.

4. If fluid appears in the baby’s breasts, caution the family not to

touch.

=J.= Do not discharge the baby until cord is off, umbilicus is in good

condition and no further nursing care required. Premature babies should

be oiled and wrapped in cotton. Premature jackets can be secured from

the V.N.S. for 35 cents.

=Care of Mother=:

Make preparations as for general care.

Extra articles needed:

1. Pitcher for solution.

2. Glass for boracic acid.

3. Absorbent cotton.

4. Dressings.

5. Binder.

Take T.P.R.

Give complete bath.

Post-partum dressing:

1. Make sol. of lysol in pitcher (or glass jar) which has been washed

and scalded.

Directions for lysol Sol.: Use ½ teaspoon lysol to 1 quart hot

water.

2. Place paper napkin on table or chair at side of bed and on it

pledgets of cotton, and clean pads.

3. Arrange sheet or bath blanket to avoid exposure.

4. Place soiled pad in cornucopia.

5. Place clean douche pan or basin under patient.

6. Scrub hands with green soap and brush under running water.

7. Pour sol. over vulva. Use pledgets for cleaning vulva, wiping

always towards rectum.

Dry thoroughly with pledgets.

8. Remove pan.

Turn patient on side and wipe from perineum back over rectum with

pledget. Dry.

Dry back and put on pad.

While in this position place binder and draw sheet.

9. Wash hands.

10. Binder.

Locate fundus.

Draw edges of binder together and begin pinning from fundus down.

Then pin from fundus up, taking dart in either side.

Fasten pad to binder, front and back.

Unless especially ordered the binder may usually be replaced by a

T-binder on the fourth day.

11. Complete as in general care.

Points to be observed and recorded on bedside notes if necessary:

1. Condition of the breasts.

2. Urination.

3. Condition of bowels.

4. Lochia.

5. Position of uterus.

Record any abnormal conditions.

Do not massage breasts unless ordered.

Full post-partum care to be given on first visit if possible.

Give general care every other day.

=Douche.=

When douche is ordered boil nozzle before and after using.

Boil douche bag before using and wash afterwards—use boiled water.

When sutures, instruct the family how to irrigate after urination and

movement of the bowels.

Normal maternity cases should be visited daily until after the 8th day

of puerperium and at least once a week for supervision until the 5th

week. The case is then transferred to Child Welfare nurse.

Additional visits should be made if the patient is still in bed and

there is no intelligent adult to give care, or if the baby’s condition

is not satisfactory.

A SUGGESTION FROM MONTREAL

Ingenuity, resourcefulness, and quick wit on the part of an intelligent

nurse can almost always apply hospital ideals to circumstances which

would at first seem hopeless. It is the nurse’s knowledge of obstetrical

nursing and principles, rather than her equipment, that counts in saving

lives. The following directions given to visiting nurses, by Cecil A. K.

Dawkins, R.N., Supervisor of the Outdoor Department of the Montreal

Maternity Hospital, indicate the possibility of clean, efficient care in

conditions far from ideal:

“MATERNITY CASE CONDUCTED IN A HOUSE WHERE THERE IS VERY LITTLE TO WORK

WITH

“=Appliances You Are Likely to Find in Any House=:

“Bed, table, chair, two boxes, basin, pail, kettle, saucepan, plate, two

cups, spoon, several fair sized bottles, sheet, two towels, pillow,

pillow case, handkerchief, newspapers, old clean rags, small package

boracic powder, small bottle vaseline, soap, baby clothes.

“Doctor’s bag will usually contain towel, clamps, scissors, ergot,

chloroform, creolin, rubber apron, hypodermic syringe, nail brush.

“1. I would take a look at the fire. Put on the kettle to boil, also

saucepan containing scissors, clamps, hypo (cord ligatures),

clean rags to use as sponges, if absorbent is not available. I

would put several pieces of clean rag (some small for cord

dressings, others large for vulva pads) on a plate in the oven to

bake. This will only take a minute.

“2. Attack the bed. Strip it, place a good pad of newspapers where the

patient is to lie. Then the sheet. Cover this all over with

newspapers, particularly where the patient lies. Here I would

form a Kelly pad, rolling the paper up at the top and bottom and

left side, the right side falling over the edge of the bed into

the pail. Cover with clean rag. Paper under the pail.

“3. Place basin, towel, soap and nail brush on table. Wash up and

prepare patient. Braid her hair. Put on a clean nightdress.

“4. Clip away the pubic hair with scissors, if razor not available to

shave. Give S.S. enema, provided you have the time to do it in,

and the syringe to do it with. Wash the vulva well with soap and

water. Put on pad, rag wet with disinfectant.

“5. The instruments, swabs, etc., should be boiled by this time. Place

scissors and clamps on plate, and swabs in basin. Get hypo ready.

Water for ergot. Boracic for baby’s eyes. Baby’s clothes

together,—also warm cloth to wrap baby in. Fold handkerchief

crosswise, and make funnel for chloroform mask.

“6. When baby comes, wrap him up warmly, and place on the right side in

a safe place. If no other place available, pull bureau drawer

half open and put him in, but be careful not to close it again.

The plate that has held the scissors and clamps may be used for the

placenta.

“7. To clean up the bed and make the patient comfortable, roll her on

her right side, rolling the paper up to her back. Wash her and

turn her on her left side, removing paper. Put on a clean pad and

“T” binder.

“8. A jug of boiled water left to cool would be useful in emergency,—as

also several glass bottles filled with hot water for case of

shock. The boxes may be used for raising the foot of the bed.”

Yet it is but a little human babe,

Given at last into his reaching arms

And carried to the hollow of her breast!

MARGUERITE WILKINSON.

PART VII

THE CARE OF THE BABY

CHAPTER XXI. CHARACTERISTICS AND DEVELOPMENT OF THE AVERAGE NEW-BORN

BABY. New Functions. Description. Growth and Development. Weight.

Height. Head and Chest. Fontanelles. Teeth. Stools and Urine. Skin.

Tears. General Behavior.

CHAPTER XXII. NURSING CARE OF THE NEW-BORN BABY. Mortality of First

Months and Year of Life. Preventable Causes. Dangers of Babyhood.

Essential Features of Early Care. Daily Schedule. Bath. Clothes.

Fresh Air. Exercise. Training the Baby. Bowels. Thumb-sucking.

Ear-pulling. Crying. Ruminating. Feeding: Breast Feeding. Artificial

Feeding. Necessary Characteristics of Artificial Food. Requirements

for Milk Used. Articles Needed in Preparing Food. Preparation of

Milk. Pasteurization. Boiling. Giving the Bottle. Ingredients of

Food. Percentage Feeding. Average Formulae. Mixed Feeding.

Commercial Baby Foods. Proprietary Foods, Canned Milks, Milk

Powders. Other Articles of Food Sometimes Included in Baby Diet.

Travelling. The Premature Baby. Summer Care of the Baby.

CHAPTER XXIII. COMMON DISORDERS AND ABNORMALITIES OF EARLY INFANCY.

Malnutrition, Marasmus and Inanition. Diarrheal Diseases: Acute

Gastro-enteritis. Symptoms. Treatment and Nursing Care. Acidosis.

Colic, Constipation, Convulsions, and Vomiting. Infections:

Ophthalmia Neonatorum. Symptoms, Treatment, and Nursing Care.

Syphilis. Thrush, or Sprue. Impetigo. Pemphigus. Vaginitis.

Abnormalities: Icterus or Jaundice. Cephalhematoma. Club Foot.

Engorgement of Breasts. Hare Lip. Cleft Palate. Hernia.

CHAPTER XXI

CHARACTERISTICS AND DEVELOPMENT OF THE AVERAGE NEW-BORN BABY

Before undertaking the care of the new-born baby the nurse should stop

and consider him for a moment and review in her mind just what he

represents; what he has been through; what struggles and dangers are

ahead of him; what are the weaknesses of his equipment to meet these

perils and what must be the character of her service to him if she is to

do all in her power to help him safely over that most hazardous period

in the entire span of his existence: the first month of his life.

That little new-born baby is quite as helpless and appealing as he

looks, for his chances for present and future health lie very largely in

the hands of those who care for him during these early weeks, and any

injury which is done at this time, either through acts of omission or

commission, can never be entirely repaired.

At the time of birth, the baby makes the most complete and abrupt change

in his surroundings and condition that he will make during his entire

lifetime.

He has existed and evolved as a parasite for nine months, during which

time he has been protected from injury; kept at the temperature which

was best for him, and above all has been furnished with exactly the

proper amount and character of nourishment necessary for his growth and

development.

Suddenly he emerges from this completely protecting environment into a

more or less hostile world, where he must begin life as a separate

entity with a frail little body that in many respects is only

imperfectly developed. And yet the baby must not only continue the

bodily functions and activities that were begun during his uterine life,

but must also elaborate and establish others which were imperfect or

were performed for him. Otherwise he will not live.

The nurse will recall that the fetus received its nourishment and

oxygen, and gave up waste material, through the placental circulation;

that the lungs were not inflated and that most of the blood flowed

through the foramen ovale instead of through the pulmonary vessels, as

it does after birth. The digestive tract, excretory organs and nervous

system were not needed during fetal life and therefore are imperfectly

developed at birth and are capable of functioning only within very

narrow limits.

The pulmonary circulation usually is established immediately after

birth, and when the baby cries vigorously the lungs are expanded and

filled with air and the respiratory function is inaugurated. The ductus

arteriosus, ductus venosus and two hypogastric arteries are gradually

obliterated, as the normal circulation of the blood becomes established

and the foramen ovale is closed. See Figs. 28 and 29.

The other functions are established more slowly and the care of the baby

must be such that the immature, unused organs will not be overtaxed, and

yet that their development will be promoted through activity.

The new-born baby weighs 3250 grams, or 7¼ pounds, and is about 50

centimetres, or 20 inches long. The body is well rounded and the flesh

firm. The skin is a deep pink, or even red, and is covered with a white,

cheesy substance, the vernix caseosa, which is likely to be thickly

deposited in the folds of the skin, in the creases of the thighs and

axillæ and over the back. Some babies still have the fine, downy lanugo

hair over parts or all of the body.

The head and abdomen are relatively large, the chest narrow and the

limbs short. The legs are so markedly bowed that the soles of the feet

may nearly or quite face each other, but they finally assume a normal

position. The bones are largely cartilage and the entire body is

therefore very flexible. Some of the bones, which are separate at birth

unite later in life and the adult skeleton finally becomes firm and

rigid.

Most babies have faded blue eyes at birth, the permanent color appearing

gradually, while the amount and color of the hair varies greatly, some

babies being bald and others having abundant hair from the beginning.

The shape of the baby’s head is sometimes distorted at birth, being so

elongated from chin to occiput as to give the parents deep concern. But

they may be confidently assured that in the course of a few days the

head will assume the lovely rounded contour, so characteristic of

babyhood. The temporary deformity is caused by a moulding and

overlapping of the bones of the skull as it is forced through the birth

canal, and sometimes also to a collection of fluid under the scalp,

called the _caput succedaneum_, and which, too, is due to pressure

during birth. Both the anterior and posterior fontanelles may be felt at

birth.

GROWTH AND DEVELOPMENT. The progress during the first year, of average,

normal babies who are satisfactorily nourished and cared for, is fairly

uniform and the accepted average is suggested by the following schedules

which are based upon observations made upon a large number of normal,

healthy infants.

=Weight.= The average baby boy weighs at birth, 7¼ to 7½ pounds and

girls a little less, as a rule. There is an initial loss of from six to

ten ounces during the first week, through body waste and the passage of

meconium and urine, before the full amount of nourishment is taken and

assimilated, large babies losing more than small ones. (Chart 5.) From

this time the gain is usually from four to eight ounces, each week,

during the first five months, after which it is only about half as

rapid, or at the rate of from two to four ounces weekly. At six months,

therefore, the average baby weighs from fifteen to sixteen pounds, or

double the normal birth weight of 7½ pounds, and at twelve months, from

twenty to twenty-two pounds, or three times the average birth weight.

The weight is perhaps the most valuable single index to the baby’s

condition, that we have, but at the same time, it must be remembered

that a baby whose food is rich in carbohydrates may be of normal weight,

or over, but be incompletely nourished and very susceptible to

infection. Other babies who are small and seem to gain unsatisfactorily

are sometimes very well and vigorous. And very commonly there are

periods in the lives of entirely normal babies when there is little or

no gain in weight. This may occur during the period from the seventh to

the tenth month, for example, or during very warm weather. But the

baby’s weight should be watched carefully, for a loss or prolonged

failure to gain may be an evidence of faulty nutrition or disease.

[Illustration:

CHART 5.—Weight chart showing average weekly gain during first year of

life.

]

=Height.= The average height at birth is 20 inches, though boys may

measure a little more and girls a little less; at six months, 25 to 25½

inches and at one year, 28 to 29 inches.

=Head and Chest.= The circumference of the head and chest are about the

same at birth, the chest being possibly a little smaller. Both measure

about 13½ inches, increasing gradually to about 16½ inches at six months

and 18 inches at the end of the first year.

=Fontanelles.= The posterior fontanelle usually closes in six or eight

weeks but the larger, anterior fontanelle is not entirely obliterated

until the baby is eighteen or twenty months old. Closure of the

fontanelles is usually late in rickets, cretinism and hydrocephalus and

early in cases of malnutrition and microcephalus.

=Teeth.= Although it occasionally happens that a baby has one or two

teeth at birth, the average infant has none until the sixth or seventh

month, when the two lower, central incisors appear. After a pause of a

few weeks the two, upper, central incisors appear, followed by the two

lateral incisors in the upper jaw. At the end of the first year,

therefore, the average baby has six teeth, or eight, if the lower,

lateral incisors have come through by the first birthday, as they

sometimes do. (Fig. 148.) This is the usual course of dentition during

the first year, but there are wide variations among entirely well and

normal babies, the first tooth sometimes not appearing before the tenth,

eleventh or even twelfth month. But as a rule if no teeth are cut by the

time the baby is a year old, it is regarded as an evidence of faulty

nutrition, perhaps bordering on rickets.

The baby who is properly fed and cared for cuts his teeth with little or

no trouble, in spite of the widely current belief that a teething baby

is a sick baby. We have no way of estimating the number of babies who

die needlessly from infections and digestive disturbances because of

this fallacious conviction. For if the baby is sick while teething, the

disturbance is all too frequently accepted as a normal occurrence and

nothing is done until too late.

Frail, delicate babies may have convulsions each time that a tooth is

cut and if a baby is having digestive trouble it is likely to grow worse

while he is teething. But dentition is a normal physiological process

and the healthy, properly fed baby suffers little or no inconvenience at

this time.

[Illustration:

FIG. 148.—Diagram of first or deciduous teeth and ages at which they

usually appear.

]

The care of the baby’s teeth should begin when the first tooth appears.

It should be wiped, front and back, with a piece of gauze or cotton

dipped in a solution of boracic acid, or sodium bicarbonate or some

other weak alkaline wash, to neutralize the acid secretions of the mouth

which start decay. After the baby has five or six teeth, the use of a

very soft brush, with tooth paste, is often advised, the teeth being

brushed with a circular motion or from the gums toward their edges. The

teeth should be wiped, or brushed, morning and evening and after

feedings. The reason for such close care of the temporary teeth is that

they serve as a mould or brace to hold the jaws in proper shape for the

permanent teeth which appear later. If the “milk” or deciduous teeth

decay or crumble away before the jaws are developed to the point when

the permanent teeth appear, these second teeth are likely to be crooked

and uneven.

=Stools and Urine.= During the first two or three days, the stools are

of dark green, tarry material called meconium. Meconium consists of

cast-off cells from the skin and intestines, fat, mucus, hairs and bile

pigment. In the course of two or three days, the stools begin to grow

lighter and shortly the normal, milk-feces appear, being bright yellow,

of a smooth pasty consistency and having a characteristic odor. During

the first month or six weeks the baby’s bowels may move three or four

times daily, but after this they usually move but once or twice in the

course of twenty-four hours. As the diet is increased, the stools grow

somewhat darker and firmer and finally become formed.

[Illustration:

FIG. 149.—Appearance of umbilical cord immediately after birth.

]

The new-born baby’s bladder usually contains urine which may be voided

immediately after birth or not until several hours later. After the

first voiding the bladder may be emptied five or six times a day, or

oftener. The nurse should watch for the first evacuation of the bowels

and bladder, and if they do not occur during the first few hours, the

fact should be reported to the doctor, as the omission may be due to an

imperforate anus or meatus.

[Illustration:

FIG. 150.—Appearance of umbilical cord, four days after birth.

]

[Illustration:

FIG. 151.—Appearance of umbilicus immediately after separation of

cord.

]

[Illustration:

FIG. 152.—Appearance of a well healed umbilicus.

]

=Cord.= Within a few days after birth the stump of the umbilical cord

begins to shrivel and turn black, and a red line of demarcation appears

at the junction of the cord with the abdomen. By the eighth or tenth

day, as a rule, the cord has atrophied to a dry black string, when it

drops off and leaves an ulcer, or small granulating area which heals

entirely in a few days. (Figs. 149, 150, 151, 152.) Before the days of

sepsis, infections of the cord were not uncommon and babies frequently

died of tetanus, streptococcus and other infections. But at the present

time an infected cord is a rare, and, it may be added, an almost

inexcusable occurrence.

=Skin.= By the end of the first week any lanugo remaining usually

disappears and there is frequently a scaling of the superficial layers

of the skin which lasts for two or three weeks, while a delicate pink

tint replaces the deeper color of the skin in the course of ten days or

two weeks. The baby does not perspire until after the first month, as a

rule, when insensible perspiration begins, gradually increasing until

perspiration is free by the time the baby is a few months old.

=Tears.= There are no tears at birth and opinions differ as to whether

they appear in the course of two or three weeks, or three or four

months. The absence of the lachrymal secretion is one explanation for

the necessity of bathing the baby’s eyes during the early days and

weeks, for if dust or other foreign material gains entrance it is not

washed out by the tears as it is later.

=General Behavior.= During the first few weeks the average baby sleeps

most of the time: that is from nineteen to twenty-one hours daily. He

gradually sleeps less, as the special senses develop and will sometimes

lie quietly for an hour or more with his eyes open, sleeping only

sixteen or eighteen hours daily at six months and fourteen to sixteen

hours at the end of a year.

The baby begins to make noises and “coo” at about two months and to

utter various vowel sounds when about six months old. By the end of a

year these indefinite noises and sounds become distinct words. At about

the fourth month, he grasps at objects and smiles and very soon even

laughs. He holds up his head at about the third or fourth month; sits up

and also begins to creep at six or seven months; while sometime between

the ninth and twelfth months he will stand by holding to some one’s hand

or the furniture, and will begin to walk with assistance.

These degrees of development at different ages are not to be taken as

the only measure of normal progress, for many well babies mature more

rapidly and others more slowly than at the rate which is found to be the

average.

In addition to these fairly specific evidences of the baby’s condition

and progress, such as weight, height and muscular development, there are

other and less definite indications of his well-being which the nurse

must watch for and accord a very high value.

The baby who is well and is being properly fed in all respects, will

have good color; his flesh will be firm; he will take his nourishment

with a certain amount of eagerness and seem satisfied afterward. He will

sleep for two or three hours after each feeding; will sleep quietly at

night, and while awake, unless he is wet or uncomfortable for some other

good reason, he will seem contented, good-natured and happy.

CHAPTER XXII

NURSING CARE OF THE AVERAGE NEW-BORN BABY

It is estimated that out of every thousand babies born alive, in this

country, forty die during the first month of life, and that more than as

many again, or about eighty-five all told, perish before reaching the

first birthday.

So hazardous is this period of early infancy, in the United States, that

our annual loss of baby life is between seven and eight times as great

as was the yearly toll of our young men during the war, for upwards of

200,000 babies less than a year old die each year. That the first month

of life is fraught with greater danger than any which follow is shown by

the fact that about 100,000 of these deaths occur during the first four

weeks.

The tragedy of these figures is made darker by the knowledge that at

least half of the babies who are lost die from preventable causes. In

other words, they die from lack of proper care.

That is the significant fact for the obstetrical nurse, since more and

more frequently she has the young baby in her care during the crucial

first month and inevitably plays an important part in increasing his

chances to live. She does this by helping to keep the well baby well,

rather than by nursing a sick baby.

The dangers which make babyhood such a precarious period may be grouped

very largely under the general headings of unfavorable ante-natal

conditions, nutritional disturbances and infections. The care and

supervision of the expectant mother will remove many of the unfavorable

ante-natal causes. Nutritional disturbances and infections must be dealt

with after birth.

Faulty nutrition may result in rickets, scurvy, malnutrition, marasmus,

acute inanition or the less serious colic, constipation or diarrhea. The

most frequent results of infection among young babies are the

respiratory diseases in winter, such as bronchitis and pneumonia, and

the intestinal disorders in summer, commonly referred to as “summer

complaint.” Since undernourished babies are very susceptible to

infection, the two conditions are frequently coincident.

With the baby’s frailty and imperfect development in mind, as well as

the needs of his growing body and the evils that beset his way, we can

understand the reasons for the painstaking, protecting care which he is

given during the early weeks of his life.

The essential features of this care are as follows:

1. Proper feeding.

2. Fresh air.

3. Regularity in his daily routine.

4. Cleanliness of food, clothing and surroundings.

5. Maintenance of an equable body temperature.

6. Conservation of his forces.

These requirements seem so rational that one might expect them to be met

as a matter of course; but the annual sickness and death rate among

babies are a constant reminder that they are not.

The nurse should begin by arranging a daily schedule for the baby’s

feedings, fresh air, bath, sleep and exercise, and follow it with

unfailing regularity. The hours for the nursings, which vary with

different doctors, will constitute the greater part of the daily

schedule, and for a baby on four hour feedings, for example, some such

program as the following may be arranged:

6 a.m. Feeding.

8 a.m. Orange juice (when ordered).

9 a.m. Bath.

10 a.m. Feeding.

10.30 to 2 p.m. Out of doors.

2 p.m. Feeding.

2.30 to 4 p.m. Out of doors.

4 p.m. Orange juice (when ordered).

4 to 5.30 p.m. In-door airing and exercise (when ordered).

5.30 p.m. Preparation for the night.

6 p.m. Feeding.

10 p.m. Feeding.

2 a.m. Feeding (when ordered).

The importance of punctuality in the daily routine cannot be stressed

too often and it is one aspect of the baby’s care for which the nurse is

absolutely responsible. No matter how well the baby is nursed, in other

respects, nor how skillfully the doctor directs his care, the baby

cannot be expected to progress satisfactorily if his life is irregular.

=The Bath.= The first office which the nurse usually performs for the

new-born baby, and which she repeats daily, is to bathe and dress him.

The bath may be given in a tub, under a spray or in the nurse’s lap,

according to the wishes of different doctors, while sponge baths are

sometimes given with soap and water and sometimes with oil.

The first bath, particularly, is likely to be an olive oil sponge, given

immediately after birth, before the baby is taken from the mother’s

bedside, and many doctors have the sterile cord dressing and abdominal

binder applied at this time. This oil bath is given, not alone for the

purpose of removing the vernix caseosa, but also, to lessen the

radiation of body heat, which the baby can ill afford to lose. When such

a practice is followed it only remains for the nurse to dress the baby

and place him in his crib to sleep undisturbed for several hours.

Some doctors have the baby sponged every morning with albolene or olive

oil, instead of with soap and water, until the cord separates, when tub

bathing is adopted. When the daily bath is given with oil, the baby’s

thighs and buttocks are wiped clean with an oil sponge each time that

the diaper is changed. Other doctors have the baby’s first bath given in

a tub, with soap and water, while still others who fear that the cord

may be infected by immersing the baby, have him sponged with soap and

water, after the vernix caseosa has been softened with oil.

Sponge bathing is commonly employed for all babies until the cord

separates and for frail delicate babies or those suffering from skin

trouble. The sponge bath may be given in the nurse’s lap or on a table

covered with a pad, either method being satisfactory if the baby is kept

warm and comfortable. But one inclines to the idea of having the baby

bathed in the nurse’s lap for he seems happier there; more comfortable

and less frightened and we cannot be sure that these factors are

unimportant.

The best time for the daily bath, during the first three or four months,

is about an hour before the second feeding in the morning. After this

age the full bath is sometimes given before the six o’clock feeding, in

the evening, for a bath at this hour is soothing and restful and often

helps toward giving the baby a good night.

Preparation for the bath should made with its possible effects, both

good and bad, in mind, for the baby may be helped or harmed according to

the skill with which he is bathed. He must not be chilled during his

bath, and fatigue and irritation must be avoided by giving it quickly

and with the least possible handling and turning. These ends may be

served by conveniently arranging all of the articles which will be

needed, on a low table at the right hand side of the nurse’s chair,

before the baby is undressed.

There should be a pitcher of hot and one of cold water; a bath

thermometer; two soft wash-cloths; soft towels; bath blankets; Castile,

or some other mild soap; boracic acid solution; sterile cotton pledgets;

large and small safety pins, or large ones and a needle and thread if

the band is to be sewed on; unscented talcum powder; sterile albolene or

olive oil; soft hair brush and a complete outfit of clothing. The little

garments should be arranged in the order in which they will be put on,

the petticoat slipped inside the dress, and all hung before the fire or

heater, to warm.

The temperature of the room should be about 72° F. and if it is possible

to bathe the baby before an open fire or a heater, so much the better.

In any case he must be protected from drafts. A sheet hung over the

backs of two straight chairs will serve very well as a screen if no

other is available.

The tub or basin should be about three-quarters full of water at 100° F.

for the new baby; about 95° after the third month and gradually lowered

to 85° F. or 90° F. for the baby a year old. The temperature of the

water should not be guessed at, but tested with a thermometer, though in

an emergency the nurse may safely use water that feels comfortably warm

to her elbow.

It is a good plan to lay a folded towel in the bottom of the tub, before

beginning, as babies are often frightened by coming in contact with the

hard surface.

[Illustration:

FIG. 153.—Nursery at Manhattan Maternity Hospital. Note beam scales,

low table with articles for bath, and method of protecting babies’

heads from drafts.

]

The nurse should wear a waterproof apron, covered with one of flannel

over which is laid a soft towel until the bath is finished, when it is

slipped out, leaving the dry flannel apron to wrap about the baby. She

should wash her hands thoroughly with hot water and soap; sit squarely,

with her knees together, in a chair without arms; take the baby in her

lap and undress him under a blanket.

In order that the bath may be given deftly and quickly, it is a good

plan to give the different parts in the same order every day, for

practice makes perfect.

It is usually a routine to weigh the baby every morning, during the

first two or three weeks and once or twice a week afterwards. Premature

babies and those who are very frail are weighed at longer intervals

because of the inadvisability of disturbing them so often. The baby is

undressed for his bath, wrapped in a blanket, and laid in the scoop or

basket of a beam scale (Fig. 153) and a note made of the entire weight,

for if he is placed in the scales without protection he is likely to be

chilled and frightened. The weight of the blanket is ascertained

separately and deducted from the total thus giving the baby’s exact

weight.

The eyes should be bathed first, with pledgets of sterile cotton dipped

in warm boracic acid solution, each pledget being used but once. To

prevent the solution from running from one eye into the other, the

baby’s head is turned slightly to one side and the lower eye wiped

gently from the nose outward. The lids may then be separated by placing

one thumb below the brow and lifting it slightly, and the eye flushed

with a gentle stream by squeezing a freshly soaked pledget just above

it. The head is turned to the other side and the eye on that side bathed

in like manner.

The mouth is swabbed out _very gently_ with boric-soaked cotton wrapped

about the tip of the little finger, care being taken not to abrade the

delicate mucous lining. The nostrils are cleaned with little spirals of

cotton dipped in liquid petrolatum or olive oil.

The face is then washed with warm water, no soap, and patted dry. The

scalp, neck and ears are washed with soap and water and thoroughly dried

by patting and wiping gently in the creases. The body should then be

well soaped, with the nurse’s hand, only one part being exposed at a

time, to avoid chilling. To place the baby in the tub the nurse may slip

her left hand under his head in such a way that his head will rest upon

her wrist, her fingers support his shoulders and her thumb curve over

and hold the upper part of his arm. She may then grasp his ankles with

her right hand and lower the little body into the water, feet first. If

his arm and shoulder are firmly held and supported by the left hand it

is an easy matter to steady the entire body and keep the baby’s head out

of the water while giving the bath with the right hand. (Fig. 154.) The

new baby is not usually kept in the tub for more than two or three

minutes, but when he is three or four months old he may stay in for five

minutes and still longer as he grows older.

[Illustration:

FIG. 154.—Method of supporting baby’s head above water while giving

tub bath.

]

Hot water should not be poured into the bath after the baby has been

placed in it but cold water is often added, for a three or four months

old baby, or the warm bath followed by a quick sponge with cold water.

The little body is quickly patted dry and rubbed briskly with the palm

of the nurse’s hand; the legs and arms stroked toward the body; the back

from the neck downward and the chest and abdomen with a circular motion.

Babies who react well to cold baths are benefited by them but such

“toughening” methods have to be tempered to the resistance of the

individual baby and are employed only under the supervision of the

doctor.

[Illustration:

FIG. 155.—Preparation for circumcision. (From photograph taken at The

Cleveland Maternity Hospital, with description, by courtesy of Miss

MacDonald.)

]

_On Table at Left_:

Basin of sterile water.

3 sterile towels.

12 small sponges.

6 cotton pledgets.

1 inch gauze bandage.

Tube of 00 plain catgut with small needle.

Needle holder.

2 small hemostats.

Curved Kelly clamp.

Sharp pointed curved scissors.

Blunt dissector.

Mouth tooth forceps.

_Stand at Right_:

Large basin of sterile water.

_For Baby_:

Brandy, 1 dram. } In sterile medicine glass with

Sterile water, 6 drams. } dropper.

Sugar, ½ dram. } Used for anesthetic.

One nurse holds the baby by his knees with his hands under her arms.

The second nurse begins the anesthetic, three minutes before doctor

begins to operate, by dropping brandy and water on small piece of

sterile cotton in gauze in baby’s mouth.

The genitals should be bathed and dried with care; inspected daily

and any abnormality reported to the doctor. It is not uncommon for

girl babies to have a slight bloody discharge from the vagina. This

is unimportant and soon disappears, but a purulent discharge is

likely to be an evidence of gonorrheal vaginitis. It is routine in

many hospitals to retract the foreskin of male babies every morning

at the time of the bath by rubbing it back with gauze or cotton,

taking pains that it is again pulled forward into the original

position after the part underneath has been bathed with boracic acid

solution. If retraction is impossible after several successive daily

attempts, the baby is not infrequently circumcised. (Figs. 155,

156.)

[Illustration:

FIG. 156.—Baby in Fig. 155 draped with sterile sheet.

]

When the entire body, including creases and folds, has been patted

quite dry, it may be dusted with an unscented talcum powder, but

this powdering must not be resorted to as an aid in drying the skin.

In order to prevent chafing, the buttocks and thighs should be wiped

clean with oil or bathed with warm water, no soap, patted dry and

powdered or oiled each time that the diaper is changed.

[Illustration:

FIG. 157.—Cord stump dressed with dry sterile gauze. (From photograph

taken at Johns Hopkins Hospital.)

]

If the first bath is a tub bath the cord is dressed after the baby

is dried and powdered. The form and method of cord dressings vary

somewhat with different doctors but in practically all instances the

dressings are sterile, to prevent infection, and porous in order

that air may gain access to the cord and promote the drying,

separating process. The dressing itself may consist of dry, sterile

gauze or gauze wet with alcohol, applied to the cord in the manner

of a finger bandage (Fig. 157); or it may consist of squares of

sterile gauze or muslin with holes in the centres to fit around the

cord, and dusted with some such powder as boric acid, bismuth or

salicylic acid and starch. These squares are folded about the cord

stump which is laid over on the abdomen, being directed upward to

prevent its being wet with urine. A gauze sponge is placed over the

dressing and the binder applied with firm, even pressure, but not

tightly, and sewed on or held in place with safety pins. (Fig. 158.)

The cord dressing is not removed until the cord separates, unless it

is wet or soiled, but as a rule the band is removed every morning at

the time of the bath, or whenever it is soiled.

[Illustration:

FIG. 158.—Flannel band applied over cord dressing.

]

After the band has been applied the warmed shirt, diaper, petticoat

and dress are put on, with the fewest possible motions, and the

baby’s hair brushed upward from the neck and back from his forehead.

He should be wrapped in a small blanket, fed and laid quietly in his

crib to sleep. If his hands and feet are cold a hot-water bottle at

125° F. with a flannel cover, may be placed beside him.

When the baby is made ready for the night he may have either a

sponge bath or simply have his face and hands sponged with warm

water, according to the wishes of the doctor. The clothing which the

baby has worn during the day should be replaced by an entirely fresh

outfit. The day and night clothing may be worn more than once, if

clean and if aired between times, but it is better not to have the

baby wear the same clothes day and night.

=Clothes.= The baby’s clothes may play an important part in

promoting his well-being, and to accomplish this they must be warm,

light-weight, soft and porous. They should be simple; fit smoothly

and be loose enough and short enough to permit the baby to move

unhampered. In order that his body may be kept at an even

temperature their weight must always be adjusted to the needs of the

moment. The general tendency is to dress the baby too warmly, as a

result of which he perspires; is listless, pale, fretful; sleeps

badly; is susceptible to colds and other infections and has poor

recuperative powers. His digestion is likely to be deranged and he

may have prickly heat. On the other hand, if the baby is not dressed

warmly enough his hands and feet will be cold and his lips blue; he

will cry from discomfort and the general result may be lowered

vitality and disturbed digestion. If the baby’s clothes are not

comfortable, if they pull and drag or have tight bands, he will be

fretful and restless, with disturbed sleep and digestion in

consequence.

The little wardrobe will be entirely adequate, under ordinary

conditions, if it consists of shirts, bands, diapers, flannel

petticoats, dresses, flannel wrappers and sacques with a cap and

cloak for extra warmth during in- or out-door airing. (Fig. 159.)

The =shirts= should have long sleeves and high necks; they should

open all the way down the front and come well down over the hips.

During the cold months they should be of silk, silk and wool or

cotton and wool, as all wool shirts are usually too warm, and during

the summer months they should be of all cotton and very thin. Size

No. 2 is the best size to start with as the smaller size is soon

outgrown.

[Illustration:

FIG. 159.—An outfit of practical baby clothes:

A. Thin cotton dress, open down the back.

B. Flannel night-gown with set-in-sleeves.

C. “Gertrude” petticoat, open down the back.

D. Shirt, opened all the way down the front.

E. Flannel night-gown with kimono sleeves.

F. Knitted band with shoulder straps.

G. Flannel square with tapes run through casings to form hood of one

corner.

H. Bag, with hood, suitable for premature baby or for outdoor

sleeping.

]

The first =bands= usually consist of strips of all wool or cotton

and wool flannel about six inches wide and eighteen or twenty inches

long, torn across the width of the material and not hemmed. This

straight binder is worn until the cord dressing is discontinued,

when it is replaced by a knitted band with shoulder straps. If the

cord dressing is held in place by a gauze binder, the knitted band

with straps is used from the beginning. Whether the binder be

flannel or gauze, it must be applied firmly and with even pressure,

but not tight. It is a mistake to think that a tight band

strengthens the baby’s abdominal muscles for it has the opposite

tendency. A tight band may give pain or discomfort and even cause

colic or vomiting.

[Illustration:

FIG. 160.—Appearance of properly adjusted diaper which has been folded

diagonally.

]

[Illustration:

FIG. 161.—Appearance of properly adjusted diaper which has been folded

longitudinally.

]

The knitted band is usually worn for three or four months,

particularly in cold weather, to provide a little extra warmth over

the abdomen. Thin, delicate babies sometimes need this band for a

year or more.

The =diapers= should be of soft, absorbent material, of a loose

weave, such as cheese cloth, bird’s-eye, stockinette, thin Turkish

towelling or outing flannel; should be 18 or 20 inches square and

hemmed. There are two methods of putting on the diaper. One is to

fold the square diagonally and bring the diagonal fold around the

baby’s waist. One of the lower corners is drawn up between the

thighs, the two corners from the sides brought over this and the

fourth corner brought up over these and all pinned securely with a

safety pin. (Fig. 160.) Small safety pins hold the margins together

above the knees. The other method is to fold the diaper straight

through the centre, forming a rectangle, twice as long as it is

wide; lay the baby on it lengthwise, draw it up between his thighs

and pin it on each side at the waist line and above the knees. (Fig.

161.)

In either case the diaper must be put on smoothly and care taken to

avoid forming a thick pad between the thighs as this will tend to

curve the bones of the legs. Squares of soft, absorbent material,

which may be burned, placed inside the diapers, will greatly

facilitate the laundry work. In some hospitals a very soft absorbent

paper is used for this purpose, sometimes being covered with gauze.

The baby’s diaper should be changed whenever it is wet or soiled,

for in addition to making him restless and fretful for the time

being, the skin about the thighs and buttocks will grow red and

chafed if he is allowed to wear wet diapers. Wet diapers should not

be dried and used again but washed with a mild soap, boiled and

whenever possible, dried in the open-air and sunshine.