Part 9

In the medical officer’s room should be kept the instruments, to which a fully qualified head midwife also has a key. The medical officer keeps the notes of cases, &c., and of instruction to the pupil midwives in this room.

The few, very few, drugs needed in a good lying-in institution are kept here, or in the head midwife’s sitting-room.

A waiting-room is necessary.

There must be a room where the head midwife can examine a woman, to know if labour is imminent.

This might be done in the medical officer’s room or the waiting-room.

13. _Segregation Ward._

A ward is unfortunately necessary, completely isolated, where a sick case, brought in with small-pox or erysipelas or the like, could be delivered and entirely separated from the others, or where a case of puerperal fever or peritonitis (though such ought never to arise after delivery in a properly constructed and managed institution) could be transferred. But if, unfortunately, puerperal fever should appear in the hospital, no new admissions should be allowed until the buildings have been thoroughly cleansed, lime-washed, and aired.

The segregation ward must have a nurse’s room, and a provision of sink, slop-sink, &c.

14. _Kitchen._

The kitchen should be well placed, conveniently near, yet sufficiently cut off from the main corridor by a neck of passage and intermediate offices.

_SITE._

The site of a lying-in institution must be open, airy, surrounded with its own grounds, not adjoining or near to any other building, still less to any hospital or any nuisance or source of miasm. But it must be in the immediate vicinity of any large centre of population from which the lying-in women come.

And this involves the question of receiving-rooms.

Should there be a receiving-room, as well as a waiting-room?

The lying-in woman’s name is put down for admission some time beforehand.

Lying-in hospitals differ as to their rules whether or no to admit women any time before labour is imminent. If they are not so admitted, they often have to be sent back again home.

It is now believed to be the soundest principle that the fewer days a lying-in woman spends in a lying-in institution, beyond the time she is actually under treatment, the better; and this involves that she should not be admitted till labour is imminent—even at the risk of the infant being born in cab or lift (which _has_ happened).

Lying-in institutions must (unfortunately) be, therefore, in the immediate neighbourhood of great towns or centres of population.

[Even those London Boards which are building their excellent new workhouse infirmaries in the country, are forced to keep their lying-in wards in the old workhouses in the town.]

The difference, however, as has been shown by our statistics, is not so great between the mortality of women lying-in at home in the country and in the town as should make us pronounce against lying-in institutions in great centres of population—provided they have a large and entirely isolated area completely to themselves, perhaps a proportion of two acres to fifty beds.

But this involves another question.

A large proportion, alas! of workhouse lying-in women (we have seen two-thirds at Liverpool[21]) are unmarried. Of these many have no home.

It is difficult to send these women back again, even if labour is not actually imminent. And it is impossible to send them out after delivery, till recovery is fairly confirmed.

In workhouses the question is solved by women being admitted into the body of the house during pregnancy, and discharged into the body of the house, if not to their own homes, when quite convalescent.

In Liverpool Workhouse fourteen days after labour the lying-in women are thus discharged. Fourteen, eighteen, twenty-one days, are the average of a woman’s stay in the lying-in division in London workhouses.

A soldiers’ wives’ hospital takes in no unmarried women to lie-in.

Civil lying-in institutions almost invariably have to make exceptions and take in unmarried women.

In workhouses they are not the exception, they are the rule. Married women are the exception.

It is to be observed that married women will rarely come in an hour before, or stay an hour after it is necessary, in any lying-in institution.

Ten to twelve days is ‘the average period of hospital treatment’ in Colchester, Woolwich, and other soldiers’ wives’ lying-in hospitals. ‘Women of this station of life cannot, as a rule, be prevailed upon to submit to longer detention,’ it is added.

The average number of days in King’s College Hospital lying-in ward was sixteen. None were permitted to leave under fourteen days. Twenty-one days were _allowed_, in ordinary cases. It is feared this might be too long; but so very many weakly, half-starved women sought admission, that to send some away sooner was ‘to ensure a breakdown,’ it is stated.

In a civil lying-in institution it would not be by any means desirable absolutely to exclude single young women _primiparæ_; it would be grievous to some of these poor things to be sent among the (often hardened) wretched women of the workhouse. The whole question of these poor young women—unmarried mothers of a first child—is full of difficulty. It would never do, morally, to make special provision for them. And for this very reason we seem bound to receive such, conditionally, into well regulated lying-in institutions, and afford some kindly care to prevent, at the very least, their sinking lower. But it would not be right to leave any admissions for single women in the hands of any young assistant, or morally inexperienced person.

The principle appears to be that, if pregnant women are to be received some time before and kept some time after delivery, the excess of time should not be passed in the lying-in wards, but in separate accommodation.

II. _MANAGEMENT._

Construction, however, in a lying-in institution, holds only the second place to good management in determining whether the lying-in patients shall live or die. And without such management, no construction, however perfect, will avail.

And the first elementary principle of good management is to have always one pavilion of four or eight beds, according as it is of one floor or of two, standing empty in rotation for purposes of thorough cleansing. _A fortiori_—one delivery pavilion on each floor is always to be vacant alternately.

The pavilion to be in rotation unoccupied for the purposes of cleansing must necessarily be the _whole_ pavilion, with all its sculleries and ward offices, since the process of cleansing is—turning out all the little furniture a lying-in ward ought ever to possess, bringing in lime-washers, possibly scrapers and painters, leaving doors and windows open all day, and even all night.

Every reason for having each ordinary pavilion ward completely separate, and individually _pavilionised_, applies with tenfold force to the delivery ward. Each must be complete in itself, with all its appurtenances and bye-ward for extreme cases, as a little pavilion. There is no possibility for properly cleansing and lime-washing the delivery ward _not_ in use, unless this be the case.

_One_ delivery ward, however spacious and well arranged _constantly_ used, would be a centre of deplorable mischief for the whole institution. This makes _two_ delivery wards for each floor of the institution indispensable, to be used alternately for the whole floor at given periods.

_N.B._ Liverpool Workhouse with 25 lying-in beds, exclusive of delivery beds, has had an average of 500 deliveries _a year_ for eleven years. A civil lying-in hospital in or near a large town is generally _just as full as it is permitted_ to be. Five or six hundred deliveries or more _a year_ might be reckoned upon; occasionally three or four deliveries a night. Sculleries will be _always_ in use, _day and night_. All this renders it imperative that an inexorable rule should be made and kept to, viz. that every lying-in pavilion should be vacant in rotation, each delivery pavilion alternately, for thorough cleansing.

2. The second elementary principle of good management is to remove every case of _illness_ arising in the institution, and every such case admitted into the institution, at once to an isolated sick ward or infirmary ward.

This is _must_, not may.

Though we should have no puerperal fever or peritonitis in a building of this _make_, yet unfortunately other institutions will send in (say) erysipelas or small-pox patients seized with labour.

Sad experience tells that this unprincipled practice has often proved fatal to many other inmates of the lying-in institution, turning an institution into a hospital.

Every sick case should therefore be completely isolated, in a separate sick ward, from the lying-in women. And if admitted before delivery, her delivery should take place in this separate ward.

_N.B._ The nurse’s dinner and meals may be prepared in the general kitchen and sent to her. The patient’s arrowroot, gruel, &c., must be made, and her beef-tea warmed, in the ‘sick or segregation’ building, and all linen must be sent to the ward well aired.

Is it desirable to connect the ‘segregation’ ward by any covered passage with the rest of the lying-in institution?

There is much to be said for and against.

The ward, it is to be hoped, will not often have to be used at all.

But small-pox has appeared after labour.

There might be danger in taking a patient from the institution to this ward through the open air, in all weathers, unprotected by any covered passage.

On the other hand, when once the patient is in the ward, complete isolation is by far the best, for the sake of all the others.

And there is by no means the same necessity for a passage as in the other parts of the institution where any night there may be three or four ordinary delivery cases to be conveyed through the passages.

A covered ambulance for sick cases is not, however, a nice thing, though often suggested.[22]

3. The first two may be called universal and essential principles of good management in every lying-in institution, large or small, however perfectly constructed.

Here is a third, hardly less essential, wherever there is more than one bed to a ward, viz. to remove a lying-in woman three times during her stay in the institution.

The average course of an ordinary case may be reckoned thus:—

Seven or eight hours in the delivery ward. Five or six days in the lying-in ward. Nine or ten days in the convalescent ward.

The nearer wards to the delivery ward in use should always be made the wards for women immediately after delivery; the farther wards for the same women when removed for their convalescent stage.

In a single-bed ward the woman may remain in her own ward from after her delivery till her discharge; that is, no further removal after her delivery is necessary.

4. Cases of extreme exhaustion after delivery, which are better out of the delivery ward yet cannot be moved many yards, should be carried _in their beds_ to the bye-ward adjoining the delivery ward, till they are somewhat recovered.

These must have a constant watcher by them.

5. In a lying-in institution about three times the quantity of linen and bedding for each patient is necessary of what is used at a general hospital.

The day’s and night’s provision of linen is kept in each ward scullery, and in the scullery of each delivery ward in use.

The linen-store in the store-room, and the bedding-store, need to be very complete and ample.

The bedding, that is, the mattress and blankets, of any one bed in the delivery ward should not be used for more than three or four delivery cases in succession without undergoing some process of purification—and this quite independent of any accident, the mattress of course being protected by Macintosh sheeting.

_III. TRAINING SCHOOL FOR MIDWIVES._

The few words which will here be added on the management of a midwifery training school are not at all to be understood as a manual for practical instruction, which it is quite impossible to introduce here, but as simply treating of the management, in so far as this determines some constructive arrangements as imperative, and others as to be avoided.

No charity or institution, I believe, could possibly bear the expense of a single-bed ward, or even of a four-bed ward lying-in establishment, for a pretty constant succession of thirty-two patients, unless there were a training school.

[Thirty-two single-bed wards, an administrator would say, would require sixteen nurses, independently of midwives!!]

Even with a training school, the first year would be one of great difficulty, since all well managed training schools ‘take in’ pupils as much as possible at only two periods of the year, so as never to have the whole of the pupils fresh hands at once. But the _first_ batch must necessarily be all fresh hands. A raw girl cannot be turned in to sit up with a newly-delivered woman and new-born infant. And a midwife cannot be spared to each girl all to herself, to teach her how to handle an infant. [That is, in each single-bed ward.]

The whole nursing service of a large four-bed or one-bed ward lying-in institution is so complicated, so different from that of a general hospital with its 20 or 32–bed wards, that it is difficult to provide for.

In even guessing at what the nursing accommodation should be for so completely new an experiment as a lying-in institution of 40 beds in single-bed or four-bed pavilions, we must begin by stating the probable requirements, the whole being tentative.

The staff would have to be at least as follows:—

One matron.

One head midwife.

One assistant midwife.

One deputy assistant midwife (for the first year).

To establish a really good training school,

Thirty pupil midwives.

[Two experienced good nurses in addition might be necessary for the first year.]

One cook.

One housemaid.

One or two other female servants, such as scourers—or more (number required depending on the flooring used).

Though this staff appears enormous, it is calculated upon the plan of giving only one night nurse to every four beds,—upon the supposition that 32 occupied beds will give a constant succession of cases, enough to provide instruction for almost as many pupil midwives;—upon the principle that for systematic instruction there must be a fair number of pupils; as, if every moment of their time is occupied in active duties, they cannot be well trained;—and also upon the obvious fact that it would be impossible, from its extravagance, to nurse such a construction without pupils.

[For the _second_ year, if a portion of the pupils are to be made thorough midwives, and their time of training two years, possibly the deputy assistant midwife, and probably both the nurses, might be dispensed with.

The second-year pupil midwives ought to be quite competent, each to be in charge of two or three first-year’s pupils and several patients, taking these patients from the beginning, and teaching pupils to handle new-born infants, look after ordinary lying-in cases, and the like; and most excellent practice it is for the young teachers.]

As to scourers, the nature of the floors decided upon will determine what are wanted.

Also, none of the midwives can be expected to be housemaids, even in their own rooms. They have too much to do. The pupil midwives would be expected to clean their own bed rooms, but not to scour, either for the patients or for themselves.

There must be a common room for pupil midwives. Here they take their meals in detachments. Head midwife, as a rule, with first detachment; matron carving. Here they receive lectures and instruction from the physician accoucheur.

The matron must have two rooms.

The head midwife may have two rooms. She will expect to have her tea in her own room.

The head midwife, her assistants, and all her staff, should be lodged in a central position, and there should be ready means of communication with these quarters, both by bells and speaking tubes, from each pavilion and delivery ward.

A regular night service in a lying-in institution being impossible, the head midwife, when she goes her last round at night, say between eleven and twelve P.M., stations other watchers for any emergency arising besides those now to be mentioned, who are for the night nursing of ordinary cases.

For this one pupil would probably be told off for each four wards or beds, and one extra for the whole floor, who must not be an inexperienced pupil. Her duty would be to visit each pavilion on her floor, and to have all in readiness in the delivery ward for cases coming in at night—a not infrequent occurrence.

The head midwife would also arrange for the special care of any critical case at once, on the patient being conveyed to her own ward, or to that adjacent to the delivery ward.

In so large and therefore busy a lying-in institution, it would not be desirable to call up all the pupil midwives to every case coming in the night. They would be appointed day by day alternately, and the number told off for the purpose would be called to any case coming _that_ night.

It is therefore most desirable that the sleeping-rooms or compartments (each with its own window) of the pupil midwives should be arranged in at least three reliefs, so that the occupants of one dormitory, or relief, could be called by a bell from the delivery ward ringing into that dormitory without needlessly disturbing others.

In so large an institution the head midwife even cannot attend every night case.

The assistant must be a well qualified midwife, who can take her turn in attending night cases, calling the head midwife if necessary.

Through all this organization, however, as far as possible, each pupil is told off to be in charge of a mother and infant from beginning to end.

And there will always be unfortunately a certain number of cases, each requiring a nurse constantly by her side day and night.

It is obvious that the same woman cannot do this for a succession of days and nights.

But the number of severe cases requiring it would unquestionably be much smaller in a single-bed ward hospital, or in a four-bed ward hut hospital, because of its superior immunity from puerperal disease; though, from the single-bed ward condition, every such case will require a nurse all to itself. And the same nurse cannot be always sitting up day and night.

_N.B._ Repetitions may possibly here be pardoned. The pupil midwife appointed as night watcher for the whole floor cannot be depended upon to attend the bell of any individual watcher. She may be absent at a delivery.

Yet the life of an infant, _e.g._, in convulsions, depends on minutes—on the watcher being able to summon immediate help, hot water for a bath, and the like.

Those appointed to be called in such emergency should therefore be readily communicated with by bells or otherwise, without disturbing others, either nurses or patients.

As there are no sleeping-rooms for any midwife or pupil in the ward pavilions, it is necessary to insist upon this—that there should be every facility for their being rung up or called up at night.

Every pupil midwife ought to have a little bedroom to herself, or at least a compartment with half a window, or better a whole window, to itself. There should be a bathroom and W.C. on each floor in the pupil nurses’ quarters, and a back staircase.

If a small sickroom could be managed for pupil midwives, it would be advisable. Where there are so many, one may be attacked with bronchitis or with scarlatina. She could not, of course, be ‘warded’ with the lying-in women; and it might be undesirable to leave her in her own little room, though this is quite sufficient for any slight illness. The top floor, as securing greater quiet, and a certain degree of isolation, might be the best for this sickroom.

The whole of the pupil midwives’ quarters should have direct and ready means of communication with the hospital proper. Each relief should be independent of the other two, and under the immediate supervision of the official woman, whose quarters are attached to its own.

It need scarcely be stated that an essential part of a Pupil Midwife’s training is to attend lying-in women at their own homes, with the conveniences or rather the inconveniences of those homes. Otherwise the Pupil will be the less fit for her after-work. The last two months of every six might well be given to this. But, as above said, these ‘Notes’ about management, for they are nothing more, simply treat of it as regards construction, and do not refer to the necessary training, either in-door or outdoor, at all.[23]

_DESCRIPTION OF SKETCH-PLANS OF PROPOSED INSTITUTION._

I know of no single building which requires more ingenuity to plan, and has hitherto received less, than a lying-in institution, especially with a training school for midwives attached.

Lieut. Ommanney, R.E., has been kind enough to give his time and mind to the subject—having previously had considerable experience at the War Office in planning female hospitals—and to embody the whole of the working accommodation required for both lying-in institution and school in the thoughtfully arranged sketch-plans, Nos. III., IV., and V.

The estimated cost of these plans is large; but if we must have lying-in institutions at all, it is only ‘penny wise and pound foolish’ to cripple either space or necessary appliances, or the means of regularly and periodically vacating every ward and every ward-office destined for the use of lying-in women.

PLAN III.

This plan shows a lying-in ward unit for the institution, together with its scullery and separate offices, and the relation which these bear to the corridor of communication joining all parts of the hospital on each floor together.

The measurements and other details shown on this plan are the result of repeated and careful consideration of the requirements already described; and it is believed that in practice they would be found sufficient for every purpose.

The four beds shown on it are not the _minimum_, but the _maximum_ number which, judging from all past experience, could be safely placed together.

PLAN IV.

Shows a floor of one of the lying-in ward pavilions, divided into four separate one-bed rooms. This plan also represents a unit, but of another construction. The great advantage of the arrangement is complete separation of cases from each other, so that each room is as far as possible assimilated to a room in a private dwelling-house. To obtain this advantage the rooms are arranged in pairs on each side of a nine-feet passage, having a window at one end and a corridor-window opposite the other end.

Two of the rooms open from the corridor, and two rooms from the passage, but the doors are not opposite each other. In this, as in the four-bed ward plan, the scullery and offices are completely isolated from the rooms by a nine-feet corridor. In this case, also, the measurements and other details have been arrived at after full consideration. This plan would be somewhat more costly than the previous one (Plan III.). The justification of it is found in the fact that it reproduces, in a permanent form, the conditions in Colchester Lying-in Hut, already described. And in this hut there has, as yet, been no death after delivery.

PLAN V.

_A lying-in institution for forty beds (thirty-two to thirty-six occupied), with a training school for thirty pupil midwives and midwifery nurses._