The avowed purpose of care given to the maternity patient to-day is to minimize the discomforts and perils of her pregnancy, labor, and the puerperium, and so safeguard her and her baby that both will emerge from the lying-in period in a satisfactory condition and with a bright prospect of having permanently good health.

The striking difference between obstetrics as practiced to-day, and that of former times, is that it now lays as much stress upon the future health of the mother and baby as it does upon their immediate safety.

Happily, the present-day obstetrician, who assumes the care of an expectant mother, does so with confidence and optimism because of the available knowledge upon which he may draw for her benefit. Progress in the various branches of medicine and nursing is steadily pointing the way toward greater and more effective safeguards for the maternity patient and her baby.

The value of these safeguards is attested to by the satisfactory results of the care which is given to the patients in well conducted hospitals or in their homes by careful physicians; by various out-patient departments and nursing organizations to patients within their reach. These results are in the form of a large proportion of mothers and babies who are well and continue to be well.

That is one view of the matter. Looking at it from another aspect, we discover that more than seven women still lose their lives for each 1,000 births that occur in this country, the actual number varying in different localities. Childbirth is still second to tuberculosis as a cause of death among women between fifteen and forty-five years of age, and in spite of the proved value of care in making maternity a safe adventure, the larger proportion of these women die from infection or toxÆmia which are almost entirely preventable.

The incredible fact in this connection is that, while there has been a decline in the deaths from such other controllable conditions as typhoid fever and some of the infectious diseases of childhood, there has been an actual increase in deaths from preventable causes associated with child-bearing.

Dr. Dublin estimates that throughout the United States as a whole, during 1920, the total number of deaths due to childbirth was about 20,000.

In addition to the high death rate among mothers the mortality among babies is even greater. Dr. Dublin estimates that out of every 1,000 babies born during 1920, about 85 died before they were a year old, or about 200,000 in the course of the year, and that the large majority of these died from congenital causes, from infection or nutritional disturbances. Another 100,000 babies perish, yearly, through still births. As all of these conditions are preventable to a greater or lesser degree, we have to acknowledge that many babies die whom we know how to save. There is sound reason, therefore, for the belief that proper care would save the lives of about two-thirds of the mothers and half of the babies who now die and half of the babies who are born dead.

And let it be remembered that conditions which destroy life, also destroy or greatly impair health and resistance to disease. Although we may count the number of mothers and babies who fail to survive the too severe test to which they are put during crucial periods in the lives of both, we cannot count, nor even approximately estimate, the number of those who escape death only to be imprisoned in frail, deformed, or diseased bodies. Therein lies much of the tragedy which follows in the wake of neglect—the lifelong handicaps, suffering, and inefficiency that need not have been.

This lack of care is not due to limitations in medical knowledge, for the efficacy of known methods is being constantly demonstrated. And our instant and generous response, the country over, to appeals for help in relieving various forms of need and disaster does not suggest a national cold-bloodedness, or even indifference, to needless suffering. But still a legion of mothers and babies die each year from lack of care, and almost at our very thresholds.

Perhaps the root of the difficulty lies in the fact that childbirth, as well as the attendant suffering and death, are so familiar that they are regarded as being normal incidents in the ordinary course of affairs.

One of the most dramatic of all human events, the birth of a new being, is accepted casually, almost without concern, because it is so frequent—so commonplace.

Moreover, we are all accustomed to hearing stressed the fact that child-bearing is not a disease, but is a normal physiological function.

Not so generally, however, do we hear emphasis made upon the equally important facts that there is extreme danger of infection while these physiological functions are in progress, and that they subject the entire organism to such a strain that there results a dangerously narrow margin between health and disease.

Accordingly, too much is expected, or taken for granted, from the provisions which Nature has made to promote these functions, and not enough assistance is given to protect the mother, while they are in course, or to help the immature baby in adjusting himself to the greatest change which he makes during the entire span of his existence.

When the time comes, and it seems to be approaching, that pregnancy, labor, the puerperium and infancy are regarded as crucial periods in the life history, demanding all the preventives and safeguards that all branches of medicine and nursing can offer, these periods will cease to be so enormously destructive of life and health.

We cannot build a strong race with sickly and maimed mothers and babies, and we can scarcely have other than sickly and maimed mothers and babies without care.

Apparently, then, our national health is in a large measure dependent upon good obstetrics and good obstetrics includes good nursing.

Good nursing implies more than the giving of bed baths and medicines, boiling instruments and serving meals. It is more than going on duty at a certain time, carrying out orders for a certain number of hours and going off duty again. It implies care and consideration of the patient as a human being and a determination to nurse her well and happily, no matter what this demands.

In carrying on her work, the maternity nurse may be called upon to aid in prenatal supervision and instruction; to prepare for and assist with a delivery, or to give either exclusive or visiting nursing care to a young mother and her baby. These patients may be in a hospital or at home and the home may be of any kind from a palace to a hut or a tenement. The patients may be in a city, a small town, or a rural community, and in the care of doctors whose methods vary widely.

But in spite of the diversity of conditions and the fact that no two will be quite alike, the general need of all of these patients will be the same.

Their need is care, which includes cleanliness in order to prevent infection; suitable food; fresh air and exercise; regular and sufficient rest and sleep; an equable body temperature; early treatment of complications and correction of physical defects. In short, each patient needs to be watched; needs clean care and to practice the approved principles of personal hygiene from the beginning of pregnancy. This without regard to race, color, creed, occupation, status, or location. It means all maternity patients and their babies the country over.

There was a time when the obstetrician first saw his patient in labor or shortly beforehand, and when the care of the baby began at birth or soon afterward.

We know what this tardy attention has cost in human lives and suffering.

We know, too, that among the mothers, abortion, miscarriages, toxÆmias, difficult or impossible labors may be largely prevented through prenatal care; while among babies, the enormously high death rate, during the first month of life from causes which begin to operate before birth, convinces us that we must begin to take care of the baby nine months before he is born, if he is to have the greatest benefits of present available knowledge. Such early care reduces still births and injury during labor; it reduces premature births, which is important, because the nearer the baby goes to term the better his chance of survival and of good health, and prenatal care also increases the prospects of satisfactory breast feeding.

Although we know that the ideal is to have all maternity patients supervised and instructed entirely by a physician from the beginning of pregnancy and then delivered in a well conducted hospital, it is scarcely probable that this ideal will ever be realized. There will always be patients who cannot afford to employ a doctor for so long a period; there will always be communities in which hospital provisions do not exist or are inadequate. There will always be expectant mothers whom it would be unwise to remove from home, excepting under pressing conditions, because of the influence exerted by their mere presence in keeping the family group intact. And so on, through a number of deterring conditions which will probably never cease to exist, and which will keep the patient at home.

Since patients who are supervised during pregnancy and delivered in hospitals usually recover, the high rate of death and injury, in this country, is to be found among women who are unsupervised before labor and subsequently delivered at home. Accordingly, if this widespread injury is to be reduced, the essentials of the care which is found to be efficacious must be made available for all patients throughout the length and breadth of the land.

Prenatal care, clean deliveries, and intelligent motherhood will go far toward solving the problem of a high maternal and infant death rate, and these require not widespread care, alone, but widespread teaching as well—impressing upon women and their families the importance of care and precautions in connection with childbirth. Important as it is for men to study and inform themselves in regard to the problems of finance and cattle raising, for example, it is still more important for both men and women to study and appreciate the problems of expectant and actual motherhood.

It is in this teaching that the nurse may be immeasurably helpful, in fact is indispensable, for the carrying of approved care into the home and the general teaching of personal hygiene are inextricably bound up with nursing.

The details of the care and teaching of patients are, of course, specified by a doctor or a medical board, but the effectiveness of the planning, whether for one or several patients, is very largely dependent upon the nurse’s intelligence, interest and conscientiousness, and her ability to teach.

This is borne out by the almost uniform recommendations, made by official bodies, for provisions looking toward the reduction of maternal and infant deaths including as they do the following:

1. The employment of public health nurses. (To give home care or instruction or both.)

2. The establishment of prenatal clinics and baby health centers. (In both of these the nurse aids in supervising and teaching the mother how to take care of herself and her baby.)

3. Trained attendance during labor. (The nurse aids greatly in preparing for and assisting with clean deliveries.)

4. Improved and increased hospital facilities. (There cannot be good hospital work without good nursing.)

5. Prompt and accurate registration of births. (Here, too, the nurse may be helpful by always making sure that the birth has been reported.)

Here is no light task nor mean privilege which is set before the nurse and in order to meet them fitly she must be prepared. The indispensable requisites for nursing and teaching the maternity patient, whether at home or in a hospital, are training, an exacting conscience, and genuine concern for her patient as an individual.

A certain amount of scientific knowledge is necessary, in this as in any other field, to give the nurse an intelligent background and a kind of definiteness and stability to her work. She should be trained in the essentials of general nursing, of surgical nursing and operating room technique, and in the care of babies. She must of necessity know something of the anatomy and physiology of the female generative organs; the physiological adjustments during pregnancy; the development of the baby within the uterus; the normal process, or mechanism, of labor, and the changes which ordinarily take place during the puerperium. Such information will make clear to her the reasons for the care which she gives to her patient, and accordingly her care will be more intelligent. And she will be better able to recognize the difference between evidences of normal physiological changes and the symptoms of complications.

Two of the newer branches of medicine—nutrition and mental hygiene or psychiatry—have a more and more apparent relation to the safety and welfare of the maternity patient, and accordingly are of moment to the maternity nurse. For, it must be remembered, it is the purpose of obstetricians to-day to establish future health for their patients as well as immediate safety. The nurse should endeavor to help with all that the doctor attempts to do toward these ends, and in order to help she must understand.

The maternity nurse can scarcely be expected to specialize in nutrition or in psychiatry, but she may give to her patients the practical benefits of many valuable discoveries in these fields. She may not be able to remember, for example, all of the sources and purposes of lime in the diet, nor of each of the protective substances, often referred to as vitamines, but any nurse can remember and be guided by the fact that her patient will not be satisfactorily nourished either before or after the birth of the baby unless she has a varied diet containing milk, eggs, and green vegetables. She also can explain to her patients that faulty dietaries are responsible for the tradition that each child costs the mother a tooth, as well as the fact there may be undernourishment even among babies who are fed at the breast, if the mother’s diet is inadequate.

And though the mass of nurses cannot be expected to grasp all of the intricacies of psychiatry, they may without exception apply one of its most important principles by adopting a warm and sympathetic attitude toward their patients and by this means win their trust and confidence. The restfulness of this; the relaxation and general state of mind that this will engender in a large proportion of patients will exert a definitely beneficial effect upon the physical well-being of the expectant mother, the woman in labor and the nursing mother.

These simple applications of important scientific discoveries that relate to the everyday life of her patient—these are things for the maternity nurse to bear in mind. She is nursing a human being who is passing through crucial periods and anything that affects her as a human being affects her as a patient.

Apparently, then, the work of the obstetrical nurse necessitates a training in general nursing and its various branches, in addition to obstetrics, for there seems to be no aspect of nursing which may not, under some condition, have its place in the care of the mother or her baby. All of this training, however, will prepare her for effective work only if she herself has a spirit of eagerness and enthusiasm. But if she has these and even a little training, she may do much.

Accordingly, let the nurse who has been prepared by a general and special training, and who wants to be of the greatest possible service to the maternity patient start by appreciating a few general principles which will be absolutely indispensable to the success of her work. They may be expressed somewhat as follows:

1. Cleanliness—under all conditions, to protect both mother and baby from infection.

2. Watchfulness—for early symptoms of complications in either mother or baby.

3. Adaptability—to the patient, the doctor, and the surroundings.

4. Sympathy—for every mental and physical stress which the patient may suffer.

If the nurse convinces herself of the import of these requirements and is exacting of herself in giving them broad interpretation, she cannot but nurse her patients well.

She will appreciate the invariable need for cleanliness and watchfulness if she will hark back to the fact that our mothers and babies die in distressingly large numbers from infections, toxÆmias, and nutritional disturbances, all of which are usually amenable to preventive or early treatment.

In order to be always clean, always watchful, and always ready to execute, both in letter and spirit, the orders of doctors whose methods of treatment will differ, the nurse will need to be very adaptable. She will need to keep a clear head and an open mind and to remember always the ends that are being striven for: the immediate safety and the future wellbeing of the mother and the baby. And she may rest assured that, no matter how they vary as to details, all doctors want all of their patients to be given clean care; watched for symptoms of complications; and given good general nursing.

Considering the need for cleanliness in a very broad and practical sense, the nurse will realize that the test of her ability to protect her maternity patients from infection is not what she is able to do in a hospital where there is every facility for clean work. It is not the ability to maintain asepsis in a tiled operating room that counts, where she is aided by sterilizers, basins, and solutions of various kinds and colors, a wealth of ingenious appliances and a corps of co-workers. It is the understanding and imagination which will enable her, perhaps single-handed, to carry the principles of such work into a patient’s home; to do clean work, from the standpoint of avoiding infection, in a mountain hut or a city tenement where everything is dirty.

The nurse will do well to begin to develop her powers of adaptability while she is still in training. She may greatly increase the value of her hospital experience by trying always to understand the purpose of the care which she is giving and trying at the same time to imagine how, in an average home, she would accomplish the results of this or that procedure which is made easy of execution in the hospital by special equipment. She should never lose sight of the fact that she is not being trained solely to conform to any one hospital routine or to become expert in only one method of nursing care. She is being prepared to go out and give nursing care to any young woman and her baby who need it, no matter where or how they are situated or by what methods they are treated.

If conditions are such that the doctor’s orders and the patient’s requirements seem impossible of fulfillment, then the nurse must attempt the impossible and attempt it with confidence of success.

It is clear that the nurse must cultivate adaptability and resourcefulness if she is to give good care to all her patients under all conditions. But even the most efficient and intelligent work will not be wholly satisfactory unless it is infused with a spirit of sympathy for the woman as an individual.

The thing that counts in this connection is what the nurse, herself, means to the woman who is facing a very important and mysterious event, who, after every known aid has been given, must still go through a great deal alone, both mentally and physically. It is not helpful to a woman in such a situation to be told that women have borne children since the dawn of Creation and that they all have had pain; that she will have to go through with it, as they have, and that the less fuss she makes about it the better. But it does help her to have the nurse say that she has been with so many women in labor that she knows they suffer intensely, and because she knows it so well she wants to do all that lies in her power to give even a little relief. The nurse may never know just how she has helped and reassured; how a pain was made a little easier to bear, not only by the hand slipped under an aching back, but also by the sympathy that the act conveyed. But she may be sure that she has helped.

In such a connection, the nurse must guard against the mistake of dividing her patients into well defined groups: those who are poor and those who are more favored. If she unfailingly looks for the human being beyond the patient she will find some of the most sensitive and appreciative of women among the simplest and poorest and they will be warmly responsive to a thoughtful, considerate attitude. And at the same time, the patient in comfortable circumstances who seems to be surrounded by all that one could desire, is often pathetically lonely and isolated. She, too, will be appreciative of encouragement and an attitude of concern for her comfort.

Suffering and anxiety make no class distinctions and have a very leveling effect, for prince and pauper, alike, need sympathy when afflicted.

From the standpoint of the nurse herself, there might be discouragement in this description of what is expected of her, and what are her opportunities in this work of caring for mothers and babies, if she did not go straight to the heart of the matter and see that all that is needed, after all, is good nursing. She must realize, of course, that good nursing necessitates training and a spirit of such eager service that she will do for her patient all that lies in her perhaps limited power, and then try to learn of still more that she may offer. And she may rest assured that the value of her work will be quite as dependent upon such a spirit as upon her training.

Obstetrical nursing may be defined, with accuracy, as the nursing care of an obstetrical patient, but its true significance is limited only by the nurse’s ability, resourcefulness, and vision. And the more spirituality which pervades this work the more effective will be the nurse’s skilled ministrations and the more satisfying will it all be to her.

This aspect of maternity nursing—what it means to the nurse herself—should be given full recognition, for although the demands which are made upon her are exacting, she will find more than compensating interest and gratification in her work.

It provides a channel of expression for some of her most elemental and deeply rooted impulses. The desire to create exists within most of us, and surely the nurse tastes of the joys of creation when she watches the beautiful baby body grow and develop under her care. And she has a consciousness of patriotic service, too, for while helping to secure the immediate safety and future health of the baby citizen she is helping to build a strong race.

But this work goes still further and offers even more than these.

The average nurse has a deep maternal instinct. She may not be conscious of it as such, but it is this instinct which prompts her to select nursing from the wide range of occupations and professions which are open to her. And it is entirely natural that she should derive great satisfaction from this vicarious motherhood—this giving of her knowledge and skill in service to the woman with a baby in her arms.

The opportunities for self-expression which are open to the nurse who gives this form of service make us wonder if she should not be included in the enviable group of those others whose life work is an expression of themselves—the poets and painters; the architects, musicians, and sculptors—those who create and build because of an urge within them. Surely, the spirit and the results of the work of the nurse who thus gives of herself may be ranged with the efforts of those others whose work is an expression of themselves.

“The body is the crowning marvel in the world of miracles in which we live. Fearfully and wonderfully made, it claims our respect not only because God fashioned it, but because He fashioned it so well—because it is a thing of beauty, a perfection of mechanism.”