Books: The Prospective Mother
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J. Morris Slemons >> The Prospective Mother
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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.
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