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.
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.]
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:—
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).
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.