Part 8

TABLE XV., _abstracted from_ TABLES III. _and_ X., _showing Comparative Mortality among Lying-in Women in Hospitals and at Home_. ┌──────────────────────────────────────────┬──────────┬──────┬────────┐ │ │ │ │ │ │ │ │ │ Deaths │ │ │ │ │ per │ │ │Deliveries│Deaths│Thousand│ ├──────────────────────────────────────────┼──────────┼──────┼────────┤ │Total for all hospitals │ 888,312│30,394│ 34│ │Total delivered at home │ 934,781│ 4,405│ 4·7│ ├──────────────────────────────────────────┼──────────┼──────┼────────┤ │Excess of deaths per thousand delivered in│ │ │ │ │ hospitals │ │ │ 29·3│ └──────────────────────────────────────────┴──────────┴──────┴────────┘

The evidence is entirely in favour of home delivery, and of making better provision in future for this arrangement among the destitute poor.

_CAN THE ARRANGEMENT AND MANAGEMENT OF LYING-IN INSTITUTIONS BE IMPROVED?_

Must we, then, surrender the principle of lying-in institutions altogether, and limit the teaching of midwifery nurses solely to bedside cases at home, notwithstanding the well-known difficulties of teaching pupils at the beginning of their course elsewhere than in an institution? We will try to reply to this question; and, in doing so, perhaps some light may be thrown on another question, viz.: how to improve existing lying-in establishments so as to reduce the mortality in them.

Evidence sufficient has been collected to show that no one panacea will enable us either to possess a perfectly healthy building, or to improve existing hospitals.

Much has been written about the saving effect of small hospitals; but it is certain, from what has been already said, that the small-hospital idea is not sufficient of itself. It is, however, a very important idea, because all hospital problems are simplified by subdivision of the buildings. So far as we know, every one who has carefully studied the subject has given a preference to small lying-in establishments over large ones; but we should certainly be disappointed if we trusted to smallness of size alone for reducing the mortality.

The evidence further shows that in any new plan infirmary wards must be kept quite detached from lying-in wards. They should be in another part of the ground, and should be provided with their own furniture, bedding, utensils, stores, kitchen, and attendants.

The same arrangement, at least in principle, should be carried out at all existing lying-in establishments, and every case of disease should at once be removed from the lying-in wards to the infirmary, and be separately attended there.

In our proposed midwifery school the whole attendance would be supplied by midwives and pupil midwives, with a physician accoucheur, to make his visit twice a day, to be sent for in time of need, and to give instruction to the pupil midwives by lectures and otherwise; and in this way we should escape the dangers of introducing medical students.

Applying the same principle to lying-in wards to which medical students are admitted, there can be no doubt that a responsibility of the very gravest kind attaches to all teachers and managers of lying-in hospitals who do not satisfy themselves that students admitted as pupils have nothing to do, either with general hospital practice, or with anatomical schools, during the period. Midwifery instruction should be treated as a matter quite apart.

What has been already said need scarcely be repeated, about the dangers of connecting midwifery wards with general hospitals. The simple facts are sufficient to show that all midwifery wards of this class should be at once closed.

As a general result of this enquiry, applicable to all lying-in wards, the evidence shows that very much indeed of the success depends on good and intelligent administration and management.

Suppose that all these precautions could be carried out, will the cost and difficulty of giving effect to them necessarily lead to the abolition of all accommodation for midwifery cases, or for teaching midwifery?

We reply, No. The facts already adduced clearly show what may be done in this matter.

They prove, in the first place, that lying-in women should, as a rule, be delivered at home. And, as a consequence, that whatever provision may be made for cases of special destitution, or for midwifery teaching, such provision should be assimilated as far as practicable to the conditions which surround lying-in women in fairly comfortable homes.

These conditions are realised, and in some instances no doubt improved on, in the better class of workhouse lying-in wards, and of lying-in huts for soldiers’ wives.

The favourable results arrived at in many of these institutions appear to show that a little more care would lower the death-rate still further.

In every instance where it is considered necessary to organise lying-in accommodation by voluntary effort, the same principles should be kept in view.

The success which has attended Waterford Lying-in Hospital, already mentioned, shows how much may be done in rendering such accommodation a real boon to the poor.

A single hut, like the Colchester Hut, erected in a needy locality, would supply, and that safely, all the accommodation wanted. But for a training school of midwives and midwifery nurses other accommodation is required, and of a far more costly character.

It is true that any sort of building may be leased or bought and altered, or added to, and told off as a training school; but after what has been said, to take such a course would be to ensure killing a certain number of mothers for the sake of training a certain number of midwives. If we are to have a training school at all, we must, before all things, make it as safe for lying-in women to enter it as to be delivered at home; and having made up our minds what is necessary for this purpose, we must pay for it.

CHAPTER II. _CONSTRUCTION AND MANAGEMENT OF A LYING-IN INSTITUTION AND TRAINING SCHOOL FOR MIDWIVES AND MIDWIFERY NURSES._

To apply all this experience to the construction and organisation of a school for midwives and midwifery nurses[20] is the next thing:—

Everybody must be born, and every woman, at least in this kingdom, is attended at the birth of her child by somebody, skilful or unskilful. Except in the case of multiple births, there are therefore as many attendances as there are births in the Returns of the Registrars-General.

This it is which makes the subject of midwifery nursing of such paramount importance.

Lying-in is an operation which occurs in England to seven women out of a hundred annually. In 1868 there were 786,858 children born alive in this country, wherefore for the midwives and midwifery nurses to be trained there will always be occupation and custom enough; whereas the occupation and custom for a surgical operator is, it is to be hoped, comparatively small, except in Franco-German wars. Even there we may trust that 7 out of 100 had not to undergo an operation. Certainly to 7 out of every 100 annually a surgical operation in England does not occur.

Between midwifery nursing and all other hospital nursing there is this distinction, viz.: the operator is herself the nurse; and the head-operator (or midwife) ought to be a woman, and _is_, in Paris and Vienna, and elsewhere.

Lying-in patients are to be compared to surgical (or operation) patients, _not_ to medical patients, and _should_ be perfectly well in health.

Since lying-in is not an illness, and lying-in cases are not _sick_ cases, it would be well, as already said, to get rid of the word ‘hospital’ altogether, and never use the word in juxtaposition with lying-in women, as lying-in women should never be in juxtaposition with any infirmary cases.

As to amount of work, necessary administrative conveniences and the like, a lying-in institution is to be compared to a surgical, _not_ medical hospital, or rather to a hospital for operations.

It has been already shown that great improvements are required in the manner of keeping midwifery statistics, and that many data are wanting for this purpose. It would be altogether wrong to deal with these statistics on the same principles as if they were general hospital statistics. Lying-in is neither a disease nor an accident, and any fatality attending it is not to be counted as so much per cent. of inevitable loss. On the contrary, a death in childbed is almost a subject for an inquest. It is nothing short of a calamity which it is right that we should know all about, to avoid it in future. A form of record is appended (Table XVI.), which appears to afford the means of registering the required information.

I. _CONSTRUCTION OF A LYING-IN INSTITUTION._

What then, first, should be the principles of construction for a lying-in institution, in order to combine safety for the lying-in women with opportunity of training for the pupil midwives? And,

1. _How many Beds to a Ward?_

Not more than four.

Or single-bed wards might be arranged in groups of four.

Also, it must always be borne in mind that four beds mean eight patients. There are two patients to each bed (unless it is meant to kill the infants) to use up the air, which is besides used up by a necessarily far larger number of attendants than in any general hospital. For, during the time the mother is incapable of attending to the infant, the infant is incapable of attending to itself. Also, an exhausted mother, and feeble, almost lifeless infant, cannot ring a bell or make themselves heard. Indeed, an infant which cannot cry is in the greatest danger.

TABLE XVI.—_Proposed Registry of Midwifery Cases._

NOTE.—Should any death take place in a woman discharged from the institution within a month from the time of her delivery, a record of this death, its date, and cause, to be entered in the column of Remarks. In the same column should be entered remarks on abnormal configuration, or on abnormal conditions of health which might influence the result of the delivery.

For all this provision must be made. There are scarcely two points in common between a lying-in institution and a general hospital.

2. _How many Wards to a Floor?_

Only one four-bed ward, or four one-bed wards in a group.

3. _How many Floors to a Pavilion (hut or cottage)?_

Two, at most. In every alternate pavilion better only one floor, unless the pavilions be so far apart as to cover an extent of ground which would make administration almost impossible, and cost fabulous.

_How many Beds to a Pavilion or Hut?_

There would therefore be no more than eight beds, and in each alternate pavilion no more than four beds.

_How many Pavilions or Huts to a Lying-in Institution?_

Not more than four two-floored pavilions, two one-floored pavilions, and two two-floored delivery pavilions; unless, indeed, building space can be given, with all its cost and administrative difficulties.

4. _How much space to the Bed?_

The _minimum_ of ward cubic space for a lying-in woman, even where the delivery ward is, as it ought always to be, separate, is 2,300 cubic feet in a single-bed ward, and 1,900 cubic feet in a four-bed ward.

[In ordinary army wooden huts, where the air comes in at every seam, this space may be less.]

As it is a principle that superficial area signifies more than cubic space, the surface of floor for each bed should not be less than 150 square feet per bed in a four-bed ward, and in a single-bed ward not less than 190 square feet, because this is the total available space for all purposes in a single-bed ward. This space has to be occupied, not only by the lying-in woman and her infant, and perhaps a pupil midwife washing and dressing it at the fire, but often by the midwife, an assistant, possibly the medical officer, and pupil midwives. In a four-bed ward there is space common to all the beds.

_The Delivery Ward._

Ought to be separate in every lying-in institution; _must_ be separate in an institution of more than four or five beds, though in separate compartments.

Every delivery bed should have a superficial area of not less than 200 square feet, and a cubic space of not less than 2,400 cubic feet.

5. _How many Windows to a Bed?_

One at least to each bed. Two beds and two windows on each side of the four-bed ward.

In a single-bed ward the bed should not be placed directly between window and door. And it must never be in an angle. There must be room for attendants on both sides the bed.

This is still more essential in a delivery ward. Each bed should be lighted on _both_ sides by windows, and should have at least five feet of passage room on either side.

6. _What are healthy Walls and Ceilings and Floors?_

Oak floors, polished; furniture also; impervious glazed walls and ceilings, or frequent lime-washing.

All that has been so justly said as to the necessity of impervious polished floors and walls for hospitals applies tenfold to lying-in institutions, where the decomposition of dead organic matter, and the re-composition of new organic matter, must be constantly going on.

It is this, in fact, which makes lying-in institutions so dangerous to the inmates.

And it may literally be said that the danger increases as the square of the number of in cases.

Lying-in ‘infection’ is a very good illustration of what ‘infection’ really means, since _parturition_ is not infectious or ‘contagious.’

The excessive susceptibility of lying-in women to poisonous emanations, the excessively poisonous emanations from lying-in women—these constitute a hospital influence on lying-in cases brought together in institutions, second to no influence we know of exercised by the most ‘infectious’ or ‘contagious’ disease.

The death-rate is not much higher among women lying-in at home in large towns than in healthy districts. Therefore the agglomeration of cases together and want of management required to meet it must bear the blame.

As to floors, the well-laid polished floor is _a sine quâ non_ in a lying-in institution, where, with every care, slops, blood, and the like, must frequently be spilt on the floor.

7. _What is a healthy and well-lighted Delivery Ward?_

There must be two separate delivery wards for each floor of the whole lying-in institution, so arranged and connected _under cover_ that the lying-in women may be removed after delivery to their own ward. And for this purpose the corridors must admit of being warmed during winter, especially at night, so as to be of a tolerably equable temperature.

Unlimited hot and cold water laid on, day and night, W.C. sink, bath-sink, clean linen, must be close at hand.

In a pavilion hospital one single-bed ward should be attached to each delivery ward, for an exhausted case after delivery, till she is able to be moved to her own ward.

The delivery ward should be so lighted and arranged that it can be divided, by curtains only, into three if not four compartments.

No woman being delivered should see another delivery going on at the same time.

The delivery bedsteads stand in their compartments.

Each delivery bed should have window light on either side, and also ample passage room all round and on both sides the bed.

Care should be taken that no bed should stand exactly between door and window, on account of draughts.

The curtains, of washing material, are only just high enough to exclude sight, not high enough to exclude light or air, and are made so as to pull entirely back when not wanted. Each area enclosed by the curtains should of course be sufficiently ample for pupils, attendants, and patient; also for a low truck on broad wheels covered with india-rubber, to be brought in, on which the bedstead with the clean warm bedclothes is placed, and the newly-delivered woman conveyed to her own ward.

[A woman very much exhausted would be carried in the delivery bed to the bye-ward attached to each delivery ward.]

The reason why there must be two delivery wards for each floor of a lying-in institution, to be used alternately, one ‘off,’ one ‘on,’ is that one delivery ward on each floor must be always vacant for thorough cleansing, lime-washing and rest for a given period, say month and month about.

It is understood that newly-delivered women cannot be removed from one floor to another. And it is quite necessary to have the means of keeping a corridor, along which a newly-delivered woman is to be moved, at a proper temperature.

The position of the delivery wards should be as nearly as possible equidistant from the lying-in wards, and should be such that the women in labour, on their way to the delivery ward, need not to pass the doors of other wards.

A separate scullery to each delivery ward is indispensable; such scullery to be on at least an equal scale to that of ward sculleries. Hot and cold water to be constantly at hand, night and day. A sink-bath is desirable for immediately putting in water soiled linen from the beds and the like.

The scullery should contain a linen-press, small range with oven, hot closet at side of the fire-place, sink with hot and cold water, &c. A small compartment should contain a slop-sink for emptying and cleansing bed-pans, and a sink about six inches deep and sunk below the floor, which is intended for filling and emptying a portable bath, and which when not required for this might be used for soaking linen, &c.

Beyond the scullery, so as to be as far removed as may be from the traffic of the main corridor and the noises of the delivery ward, should be the bye-ward, with not less than 2,100 cubic feet of contents.

8. _Scullery, Lavatory, W.C._

The necessary consumption of hot and cold water is at least double or triple that of any general hospital. Sinks and W.C. sinks must be everywhere conveniently situated.

There must be a scullery to each four beds; the scullery must needs be much larger and more convenient than in a general hospital. There is often more work to be done by night than by day in a lying-in institution.

All the ward appurtenances, scullery, lavatory, &c., must stand empty for thorough cleansing, when the ward to which they belong stands empty in rotation for this purpose, and must not be used for any other ward. For each four-bed ward, or group of four one-bed wards, or for each floor of each pavilion, there must therefore be one scullery, with a plentiful unfailing supply of hot and cold water, with sinks and every convenience. The reason for this is two-fold:—

(1) To allow each scullery, with the other ward offices, to be thoroughly cleansed and whitewashed with its own group of four beds.

(2) The work in a scullery and in all the other ward appurtenances day and night, night and day, is many-fold that which it is in a general hospital scullery.

Besides this, general hospital patients ought never to be allowed to enter the scullery.

In a lying-in scullery the infants, most exacting of all patients, must frequently be in the scullery.

Even under the very best circumstances there are many lying-in cases among weakly women where the mother’s state is such as to render it necessary for a ‘crying’ infant to be washed and dressed elsewhere than in its mother’s ward. These infants are best washed, in that case, in the scullery, which must be so arranged that infants can be washed and dressed without being exposed to a thorough draught, and that nurses and babies may not be hustling one another.

There must be a good press in each scullery. A supply of clean linen and other necessaries will have to be kept in each press in each scullery.

The slop-sink and other appurtenances must be arranged so as to make allowance for the fact that the going backwards and forwards for water, hot and cold, or to empty slops in a lying-in institution—where half the patients can do nothing for themselves, and the other half (the mothers) are supposed to be ready for discharge when they can go to the ward offices for themselves—is more than it is in general hospitals.

Fixed baths are not necessary. But there must be means for filling with hot water moveable infants’ baths at all hours at a moment’s notice, since an infant’s life often depends on immediate facility of hot-water bathing.

And this besides the daily regular night and morning washing of infants.

There must be also a moveable bath for each ward for the lying-in women, with the means for supplying it with hot and cold water and for emptying it. Lying-in patients are not able to use either fixed baths or lavatory.

Glazed earthenware sinks should alone be used, as being by far the safest and cleanest.

9. _How to Ventilate Lying-in Wards._

The best ventilation is from opposite windows. Each window should be in three parts, the third or uppermost to consist of a flap hung on hinges to open inwards and throw the air from without upwards.

Inlet valves, to admit fresh air, and outlet shafts, to emit foul air, must be added to complete the natural ventilation.

10. _Furniture, Bedding, Linen._

As little ward furniture as possible. As much clean linen as possible.

A very large and convenient clean linen-store, light and dry, must be assigned to the matron: very much larger than would be required for a general hospital; but no general hospital in London supplies a good standard for such.

There must be in each scullery, besides, a clean linen-press.

There should be a very ample and convenient place for bedding.

Mattresses, blankets and the like, have to be renewed, taken to pieces and washed—especially those used in the delivery ward—many times oftener than in any general hospital.

The rack for linen should be along the middle of the linen-store.

There should be space for a bedding-rack along one end, taking about three feet six inches from the length of the room for linen. Space for some spare mattresses and bolsters will be necessary; and they should be stowed near to a lift.

A linen-store requires thorough lighting, ventilating, and warming. Three windows are better than one. The linen must of course be kept dry and aired.

11. _Water Supply, Drainage, Washing._

Unlimited hot and cold water supply, day and night, should be laid on all over the buildings.

All drains and sewers must be kept outside the walls of the buildings, and great care should be bestowed on trapping and ventilating them, to prevent foul air passing into the institution.

The washing in a lying-in institution is, it need not be said, very large, and should be conducted quite at a distance. Sink-baths, for immediately putting in water soiled linen, are necessary.

12. _Medical Officer’s Room and Waiting-room._

No dispensary, especially no dispenser, is needed in a lying-in institution.

A medical officer’s room is necessary. The medical officer is not resident. He makes his morning and evening visit, and is called in by the head midwife for any difficult case. He gives instruction, scientific and practical, to the pupil midwives. [These lectures are given in the pupil midwives’ mess-room.]