The foregoing discussions of prenatal care and the principal complications of pregnancy, and the dangers to which expectant mothers, young mothers and their babies are exposed, bring us sharply face to face with the questions, “What can be done about it?” “What is being done about it?” and, “Is anything more possible?”

We have considered the problem, and the remedy, at very close range; that is, from the standpoint of the individual patient. We are now concerned to know whether or not the remedy, in the shape of care and supervision during pregnancy, may be extended in proportion to the enormous multiplication of the problem, when instead of one patient we must think of millions. In other words, is country-wide prenatal care, with all that it implies, practicable? And if so, by what means or method?

Let us review the problem for a moment, and acknowledge the pathos and tragedy of it.

Child-bearing is so dangerous, under present conditions in this country, that it stands second only to tuberculosis as a cause of death among women between the ages of 15 and 44. The discharge of woman’s supreme function is apparently very hazardous.

Dr. Dublin summarizes as follows the rate at which mothers die throughout the country at large:

1.

“More than seven women die from disorders of pregnancy or childbirth out of each 1,000 confinements. This is equivalent to one maternal death out of every 140 confinements. (About 20,000 in 1920.)

2.

“Forty-five babies out of every 1,000 births, or one out of every 22, are born dead. (About 112,000 annually.)

3.

“Forty babies out of every 1,000 born alive, die before they are one month old. (About 100,000 annually.)

“Such are the dangers to mother and infant at the present time.”

And then, as though in answer to our question, “What can be done about it?” he states that, “among women who receive prenatal and maternal care under skilled direction:

1.

Only two women instead of seven die out of every 1,000 confinements.

2.

Only twelve babies, instead of 45, are still-born in every 1,000 births.

3.

Only ten babies, instead of 40 per 1,000 born alive, die before they are one month old.”

Obviously, then, only a few—too few—American women are receiving the minimum of care that makes child-bearing a reasonably safe adventure.

Perhaps it will be well for the nurse to pause just here for a fresh reminder that the end really to be desired through prenatal care is not so much the mere prevention of death among mothers and infants, as the promotion of health, as well; our charges must be not only saved but saved to mental and physical health, vigor and well-being, capable of being useful, productive citizens. Happily, both life and health are conserved by the same measures, and effort toward either end helps to accomplish both.

Although the inhabitants of a prosperous country like the United States should be a hardy people, the results of medical examinations by the draft boards, during the war, gave us a rude awakening to the fact that they are not.

An appallingly large number of young men who were passing in every day life as normal were found to be physically unfit for military service. And we know that a large part of this unfitness resulted from inadequate care, of some kind, during the weeks and months that comprise the beginning of life.

It can scarcely be doubted that the most critical period in the life history of the individual is the first ten months—the nine months of intra-uterine life and the first month after birth. Good care, then, during this critical period is indispensable in the building of a healthy race. The difficulty in the way of giving this care, at present, seems to be fourfold: educational, economic, social and professional, and may be summed up somewhat as follows:

1.

From the educational standpoint, almost universal ignorance of the need of skilled obstetrical care.

2.

From the economic standpoint, financial inability of the average woman to afford such care.

3.

From the social, or administrative, standpoint, a fairly general failure on the part of public authorities to recognize the situation as one of grave national importance.

4.

From the professional standpoint, inadequacy of available obstetrical service, both medical and nursing.

In many of the large cities women have access to excellent obstetrical and prenatal care; both those who can pay for it and also the poor woman who cannot, though very many in both groups still fail to take advantage of the opportunities that are open to them.

But the city women of moderate means, and those in small towns and rural communities are in general unprovided for. And it is their babies who grow up and later constitute the backbone, weak or strong, of the nation.

Certain foreign countries which have evinced more concern for the welfare of mothers and babies than has the United States have demonstrated that widespread prenatal care is entirely possible and practicable, and they regard it also as an imperative measure toward promoting the national welfare.

The actual origin of this prenatal care is somewhat difficult to locate. There are the consultations for pregnant women instituted in Paris several years ago by Dr. Budin. But Dr. Ballantyne, of Edinburgh, is generally regarded as the father of the prenatal work because of his work on abnormalities of pregnancy and his insistence upon the importance of what might be accomplished through intelligent care and supervision of all women, not alone abnormal cases, throughout pregnancy.

In England for nearly twenty years the supervision and instruction of expectant mothers has been an integral part of the work of midwives who are trained, registered and controlled by government authority. Of late the work among mothers and babies has been so extended that during the war, always a destructive period for babies, the infant death rate was reduced to the lowest figure in the country’s history. This was accomplished partly through a maternity benefit which helped the mother to pay for obstetrical care, and partly through indirect government aid, in the form of: compulsory notification of births; a great increase in the number of “health visitors” and welfare centres, and government grants to local authorities which defrayed half the expense of giving prenatal, natal and postnatal care and of instructing mothers in the care of themselves and their babies. Especial effort has been made to help the mothers in rural sections; more small hospitals being maintained, more physicians being provided and assistance given in caring for older children, during the mother’s absence, if she was obliged to go to a hospital at the time of delivery.

New Zealand also has made marked progress in its work of saving the lives and promoting the health of its mothers and babies, having at present the lowest infant death rate in the world. This has been brought about largely through the efforts of the “Society for the Health of Mothers and Children,” an organization employing visiting nurses, called Plunkett Nurses, in honor of the family by that name which has greatly aided the work.

The outstanding features of this work are educational and preventive; the mothers being instructed from early in pregnancy about the care of themselves and the preparation for, and subsequent care of their babies. Prenatal clinics are maintained and the facilities for hospital care are being steadily increased and improved.

One is impressed by the spirit animating this organization, as expressed in a statement of its “functions,” one of which is as follows: “To uphold the sacredness of the body and the duty of health, to inculcate a lofty view of the responsibilities of maternity and the duty of every mother to fit herself for the perfect fulfillment of the natural calls of motherhood, both before and after childbirth, and especially to advocate and promote the breast feeding of infants.” Work based upon such idealism could not but be effective.

The New Zealand undertaking is regarded as patriotic, rather than philanthropic, and mothers who are visited and cared for are accordingly encouraged to pay for this service, if financially able to do so. The Government supervises and warmly supports the work of this Society and also aids by enforcing the most perfect system of birth registration in the world, without which the results of the work could not be accurately gauged.

England and New Zealand, as countries, have pointed the way toward accomplishing a nation-wide reduction of maternal and infant mortality and morbidity by making provision for widely organized prenatal care. They recognize the problem as one of public concern. They get at the heart of it: ignorance on one hand and poor or inadequate care on the other. They apply a practical solution, comprising a system of preventive, instructive prenatal care, together with improved and increased facilities for medical and nursing care at the time of delivery and afterward.

This country has been strangely laggard in making widespread, organized effort along these lines, to safeguard its mothers and babies, through prenatal care. But sporadic, volunteer effort has been made in certain cities, and has been crowned with brilliant success.

The first of these attempts in this country was made in Boston, in 1909, with a maternity nurse working under the auspices of the Women’s Municipal League. The work, which was established by Mrs. William Lowell Putnam, was designed to show what could be accomplished by intensive work in a small group of city mothers, and suggest the feasibility of its extension to larger numbers.

“The routine, which has been evolved through a five-year experiment by the Prenatal Committee of the Women’s Municipal League,” says Mrs. Putnam, “has reduced the infant deaths, among those cared for by a third to one-half, as compared with cases not receiving this care. Still-births have been cut in half. Premature births have been reduced to seven-tenths of one per cent. These results were obtained by supervision during pregnancy only, and at a cost of less than $3.00 per patient; an expense which the patients were always encouraged to meet if possible.

“The success of this venture proved to be so satisfactory that the Boston workers have gone still further toward supplying the needs of mothers and babies by adding to the prenatal care, care at the time of birth and afterwards until the mother is again on her feet. Through the courtesy of one of the largest Boston hospitals, a clinic is held weekly in its Out-Patient Department. The hospital is in no way responsible for the clinic, simply lending the room in which the clinics are held. The medical care at the clinic and in the patients’ homes is given by obstetricians from the staff of the Boston Lying-in Hospital. Medical examinations are made during pregnancy at the clinic, and a nurse visits and instructs the patient during the period of expectancy, always under the direction of a physician. The delivery is performed in the home by a physician connected with the clinic, at which the nurse also is in attendance. She visits the mother and baby twice daily for three days subsequent to the delivery, gradually making her visits less frequent thereafter. The doctor pays from two to four postnatal visits, as may be needed. For this prenatal, natal and postnatal, medical and nursing care, $40.00 is the entire amount charged, and the work is self-supporting with the nurse’s time filled. Prenatal care, alone, is given if desired by a physician and with visits at the clinic included; the charge for this service is $10.00.”

I refer to the work in Boston, particularly, as its inauguration by Mrs. Putnam marked the beginning of this branch of public-health work in this country, though to-day the same kind of service is available to expectant mothers in many of the large, and some of the smaller cities. Visiting nurse associations, the country over are giving postnatal and infant care (in some instances, excellent prenatal care, too), often providing for or assisting with the deliveries, and effecting an enormous saving of life and health by so doing. But the number of patients who are cared for by each organization is relatively so small that even the aggregate of the work done reaches a pathetically small proportion of the mothers and babies in the country as a whole who need care.

The first comprehensive effort, in the United States, to meet the need of all expectant mothers in an entire community, was inaugurated in New York City, in 1918, by the Maternity Centre Association, the chief function of the organization being to coordinate the work of agencies already in existence.

This Association was formed as a result of the work of the Maternity Protective Committee of the Women’s City Club and the Maternity Service Association of Physicians and Hospital Superintendents.

The form of organization, purpose and methods of work of this association may be studied with profit, for having been started on a small scale as an experiment, it now constitutes a demonstration of how, through co-ordinated effort, prenatal and obstetrical care may be extended almost indefinitely to expectant mothers in urban districts, and at a low cost.

The purpose and scope of the work are described by Miss Anne Stevens, its former Director, who tells us “that it is the aim of the Association to cover completely the need for maternity care, prenatal, delivery and postnatal, in a given community, by providing for every woman in that community, medical supervision and nursing care from the beginning of her pregnancy until her baby is one month old. This is being attempted, not by establishing another medical and nursing agency, but by establishing a centre through which the maternity work of every hospital, private physician, midwife and nursing agency in the community may be co-ordinated and developed to its fullest extent; a centre at which there will be a complete record of every pregnancy in that district; a centre from which the whole community may be educated to realize the need of and to demand adequate medical supervision and nursing care for every woman and her baby before and after birth.”

It is not, then, an experiment in prenatal clinics, many of which have been conducted, both in New York and elsewhere; but it is an experiment in its attempt to provide adequate care for every pregnant woman in the community from the beginning of her pregnancy until her baby is a month old.

Standards for adequate prenatal care, upon which to base the work, were formulated by the Maternity Service Association of Physicians. The nurses worked with these standards as a guide and gradually developed detailed routines, as a result of frequent conferences over the difficulties and problems arising in the course of their daily work among the patients.

These various adaptations were, of course, approved and authorized by the Medical Board of the Association. Because these routines meet the doctor’s requirements so satisfactorily, and have been evolved out of the experience of many nurses, concentrating their best efforts upon this work, they are copied on pages 423 to 436 with the belief that they will be suggestive, and perhaps save time and effort for those who may wish to inaugurate similar work.

Every effort is made by the Association to reach all of the expectant mothers in the ten zones into which, for the purposes of the work, the Borough of Manhattan was divided by the preliminary committee^[14] called by Dr. Haven Emerson, who at that time was Commissioner of Health for New York City. This Committee was called for the purpose of surveying the obstetrical facilities of Manhattan, and offering suggestions as to how they might be utilized in an effort to decrease the persistently high infant mortality.

Patients are reported for care by hospitals, dispensaries, clinics, relief agencies, church clubs, settlements and the like and are discovered in various ways by the nurses on their rounds.

The nurse’s first visit to a patient is little more than a friendly one. In fact, she may have to make several such calls before she is able to so far win the patient’s confidence and friendship that she will consent to place herself under supervision. For in addition to obtaining her verbal consent, the establishment of this sympathetic relationship is found to be necessary before the nurse can feel sure that the patient will freely tell of her symptoms and follow the advice given.

Before making plans, or talking to the patient about prenatal care, the nurse ascertains what arrangements, if any, the patient herself has made for care at the expected confinement. She finds that the expectant mothers fall into four groups:

1.

Those who have registered with a hospital.

2.

Those who have arranged to be cared for by a physician.

3.

Those who have arranged to be cared for by a midwife.

4.

Those who have made no arrangements of any kind.

The nurse’s relation to a patient registered with a hospital for delivery depends upon the scope of the work of that particular institution. Some hospitals will register patients early in pregnancy, and assume the entire medical and nursing care and supervision from that time until after the baby is born. The Maternity Centre nurse, obviously, has no responsibility for these patients. But she does give nursing care and instruction to patients registered with hospitals which have not facilities for prenatal clinics or visiting nurses to send into the patients’ homes. The hospital resident, in these cases, assumes responsibility for medical supervision of the patients and receives a report from the Maternity Centre upon each nursing visit; and the nurse in turn urges the patient to return to the hospital, periodically, to see the doctor, in accordance with instructions received from the hospital.

This form of co-operation has proved to be so satisfactory that many hospitals now do not wait for the Maternity Centre nurses to discover patients registered with them, but each day notify the nurses of newly registered patients and ask that they be given the routine nursing care and supervision by a Maternity Centre nurse.

When a nurse finds, upon her first visit to a patient, that she has engaged a physician to attend her at the time of confinement, she gives no advice, but sends to the doctor a form letter, prepared by the Medical Board, offering to nurse that patient according to the routine of the Maternity Centre Association if he wishes, and to report to him upon each nursing visit. A very small percentage of physicians refuse this offer of assistance, the majority accepting it with eagerness. Patients who have engaged their own physician for delivery, naturally, are not asked to go to the Maternity Centre clinics for medical examination or advice, but are invited to go for the nurse’s instructions, and to attend the group conferences that will be described later.

If the patient belongs to the third group, having engaged a midwife, the nurse goes in person to see the midwife, as letters are usually of little avail. She asks the midwife to bring her patient to the clinic, explaining that, though midwives are taught to conduct deliveries, they are not taught to make the examinations that are now known to be so important to the future welfare of mothers and babies, but that such examinations can be made at the clinic by the doctor. If the initial examination discloses any abnormality, this fact is explained to the midwife and also that the rules governing her practice forbid her caring for such a patient. The nurse, midwife and patient then plan for adequate care at the time of delivery. In this way the nurses win and retain the confidence and good will of the midwives; and since these women exert a powerful influence over their patients and their families, their co-operation is of considerable value in persuading the patients to accept more skilled care than midwives can offer.

If, on the other hand, the initial examination does not disclose any abnormality, the midwife is simply asked to allow the nurse to visit the patient at regular intervals, in a supervisory way, and to have the patient report to the clinic doctor for his periodic observations and advice. The intelligent midwives, who speak English, are usually co-operative, but the others are sometimes suspicious and persuade their patients to refuse the nurse’s supervision.

For the patients in the fourth group, those who have made no arrangement for care at the time of delivery, the nurse is even more responsible. The plans for these patients include three fundamental requirements: a complete physical examination; the correction of physical defects, so far as is possible, and a study of the environment and social status of the patient; this in order to adapt the care during pregnancy and at the time of delivery to each individual’s condition and circumstances.

From time to time the nurse explains to the patient, as much as she can, about pregnancy and the changes that accompany it and the reasons for the advice that is given, in order to secure her intelligent co-operation. Experience has taught that it is not enough to advise the patient to do thus-and-so because the doctor thinks best. But if she understands that examination of her urine, for example, may disclose conditions that can be cured, but which if neglected may cause headaches, or convulsions, she is much more likely to provide a specimen for examination than if she is asked for one without explanation.

The care of each patient is a tactful adjustment of the prescribed routine to the condition, habits and temperament of that patient. It is carried on through a combination of visits which the nurse makes to the patient’s home and visits which the patient makes to the nurse at the Maternity Centre in her district. The advantages of this combination of visits are, that the nurse first knows the patient in her own home, and can help to plan for the desired care with the conditions of this home in mind, and perhaps evolve from the patient’s simple belongings the equipment needed for her care; also that at the Centre it is possible to assemble the patients and give them a certain amount of informal group instruction. There is at each Centre a doll model of a baby; a model of a baby’s bed (Fig. 144), showing that a box or a basket may be used with entire satisfaction; a model of the mother’s bed, prepared for delivery at home and protected with newspaper pads; a complete layette (Fig. 145) to show the mothers how simple such an outfit can and should be; patterns for making each garment and some one to help the women to make them; a breast tray (Fig. 146) and a baby’s toilet tray (Fig. 147), so complete and yet so simple that no woman with a few chipped or cracked cups to spare need be dismayed.

In the course of this group instruction the women are taught how to prepare for, and later care for their babies. One week, the nurse demonstrates to the group how to handle the baby, dressing and undressing or bathing it; or explains the reason for making each article in the model layette, or the purpose and use of each article on the toilet tray, and shows them how to make boric acid solution and swabs. In short, each detail in the care of the baby is gone over. Every alternate week the mothers demonstrate to the nurse. They dress and undress the doll model; explain and demonstrate how to make boric acid solution; how to prepare sterile water and give it to the baby. Many of the mothers attend the classes for several weeks in succession, and frequently a mother returns with her three-week-old baby to make sure that she has not forgotten any of the details of infant care which the nurse tried to teach her before the baby came.

A patient is not asked to go to the Centre for any reason if she seems very reluctant to go; or if her going is inadvisable for physical reasons or if it would entail great hardship, because of young children who would have to be taken with her, or left at home alone. But when they can go, it simplifies the work and enables each nurse to supervise a larger number of patients than if she did all of the traveling and visiting.

Each patient is seen by a doctor or a nurse every two weeks until the seventh month of pregnancy, and once a week after the seventh month. At each visit the nurse follows as much of the prescribed routine as is possible; this routine consists of testing for albumen in the urine; taking the systolic blood pressure; listening to the fetal heart; questioning the patient and looking for the objective symptoms of complications. During these visits to the homes the nurses are able also to help their patients assemble entirely satisfactory outfits for the care of their nipples, consisting perhaps of jelly glasses, cheese jars, or handleless cups. And they help to find a place on the shelf where this little equipment may be kept undisturbed and always ready for use. When it comes to the measuring of urine, they explain that the regular size tomato can holds just a quart, and is therefore quite as satisfactory for that purpose as a costly graduated glass measure.

No patient is dismissed for failure to follow advice; the nurse continues her visits, unless the patient positively refuses to admit her, and she continues to advise, adjusting and modifying the ideal routine and persuading the patient to do as much as she can, or will.

If abnormalities develop during pregnancy, the nurse arranges for immediate medical care, either at the patient’s home or in a hospital. If the clinic doctor feels that the patient should have hospital care, but she will not or cannot go to a hospital, she is persuaded to engage a doctor, and a nurse from the Centre helps, as a visiting nurse, to take care of the patient in her own home.

The next responsibility of the nurse is to advise the patient in arranging for care at the time of delivery, this advice being based upon the patient’s physical condition, the circumstances of her home life and the available facilities for care. Although hospital care may be the ideal for all patients, from an obstetrical standpoint, the mother cannot always be removed from her home with safety to the family circle. Her physical and social conditions therefore are considered together; if there is no complicating home problem, it is usual to advise hospital care for primiparÆ and for all patients who have, or develop abnormalities, or have a history of previous difficult labors, complications or abnormalities.

Patients who, the doctors think, give promise of having complicated labors and who prefer to remain at home are advised to engage a doctor, and to arrange with the Henry Street Settlement for nursing care at the time of delivery and during the puerperium, as the Maternity Centre nurses do not perform this service.

At one time, however, the Centre provided assistance to patients delivered at home, in the shape of a working housekeeper to discharge the mother’s household duties while she remained in bed the necessary length of time after the baby was born, or in some cases, while she took much needed rest during the latter part of pregnancy. For this purpose the nurses had a list of women who were good housekeepers and clean workers and whose own children were partly grown. These women were glad of an opportunity to do part time work and earn a little extra money. They were paid thirty cents an hour, twenty-five cents for lunch and whatever their carfare amounted to, the patient paying whatever she could afford toward the fund, provided by the Women’s City Club, from which these working housekeepers were paid. This service, which in no wise replaced the nurse’s care, has been temporarily discontinued because of lack of funds, but proved to be so valuable that it will be resumed as soon as possible.

Supervisory postnatal visits are paid to patients, not under the care of the visiting nurse service, who have been under Maternity Centre Association care during pregnancy, as well as to those who have not had this care but are referred to the Centre, by hospitals, upon their discharge. The nurse first visits to satisfy herself that the mother is able to care for her baby and to give any instructions that seem to be necessary. She then visits the patient, or the patient visits the nurse, when she is able, until the baby is a month old, when she is urged to register the baby at a baby health station.

The importance and value of birth-registration is explained to the mother and the nurse endeavors to have a copy of a birth certificate in the mother’s hands before the case is dismissed.

The importance of post-partum examinations, not later than six weeks after delivery, is also impressed upon the patient. Patients who are not to be examined by the doctors who delivered them are given a post-partum examination by a doctor at the Maternity Centre, to make sure that they are dismissed in good condition, or are referred to the proper agency for further care, this being the first step in prenatal care for the next baby.

Is all of this elaborate organization and detailed care worth while?

A recent statement issued by the Maternity Centre Association replies convincingly that it is. It says that during 1920 among women in the Borough of Manhattan not under Maternity Centre supervision:

1.

One mother died for every 205 babies born. (One out of 14 for the rest of the country.)

2.

One out of every 26 babies born, died under one month of age.

3.

One out of every 21 babies was born dead.

Whereas, among women in Manhattan who were supervised by the Association, during the same period:

1.

One mother died for every 500 babies born.

2.

One out of every 51 babies born, died under one month of age.

3.

One out of every 42 babies was born dead.

The Association does not usurp nor supplant, but endeavors to give impulse to public and private agencies alike in affording the best possible supervision and care for expectant and parturient mothers and their babies.

Thus has the stupendous problem in New York been attacked with courage and with gratifying results. Much might be accomplished in smaller and less complex communities with proportionately less difficulty.

But all of the foregoing relates to city dwellers. What about the expectant mothers in isolated and rural communities?

I wish we did not have to say.

Prenatal care is practically unknown among them and there is scarcely any provision for obstetrical care, either. The nearest physician may live miles away and even though one were near, country women and their husbands do not always feel that the expense of employing a doctor, for mere childbirth, is justifiable.

In certain Northern and Western communities, that were considered fairly representative of those sections, conditions have been studied at some length by agents of the Federal Children’s Bureau. They found that about half of the mothers in those communities had no medical attention whatever in childbirth. Untrained women, friends or neighbors, frequently someone’s grandmother, were in attendance. Or husbands or workmen were pressed into service. A few women were entirely alone in their hour of trial. Scarcely a mother among them received prenatal care and instruction worthy of the name.

In the Southern states, the proportion of women delivered by physicians seems to be even smaller than in the North and West, and in some of the mountain regions the conditions are distressing. From one such locality we learn that when a woman goes into labor the first passing teamster is hailed, or perhaps a member of the family hurries down the road for the nearest tanner or blacksmith, or any one else, who in total ignorance will fearlessly rush in to meet the great emergency. The results of this practice—dismembered infants and badly injured or dead mothers,—are too sickening to describe, but may be imagined by any nurse who has seen good obstetrical work and appreciates its value.

From another mountain region in the South comes the contrast in accounts of the work done by Miss Lydia Holman, founder of the Holman Association, as evidence of what skill and desire may accomplish. Something more than twenty years ago this nurse started volunteer visiting nursing among the mountain people, with no precedent to follow and no Board to direct or advise. But there were sick people all about, people needing care, and Miss Holman was not only trained but eager to nurse them, and after all these qualifications are the chief requisites.

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:

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.

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,

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.