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.)
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.
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.
At least 8 hours every night with windows open.
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.
Wash all over every day with warm (not hot) water, but do not get into a tub after the seventh month.
Do not wear round garters or any tight bands. The nurse will show you how to make suspender garters.
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.
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.
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.
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.
Tray—fitted with:
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
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:
Requirements:
Room for examining, and dressing room, screens, running water, gas, near a toilet, urinalysis facilities, good light,
| Chair | 1 |
| Desk | 1 |
| Blotting pad | 1 |
| Blotter | 1 |
| Ink-well | 1 |
| Penholder | 2 |
| Pens, | |
| Erasers, | |
| Ink | 1 |
| Pencil | 1 |
| Red Pencil | 1 |
| Rubber bands | |
| Office: | |
| Clips | |
| Ruler | 1 |
| Waste basket | 2 |
| Hand blotters | 12 |
| Ink, Red and Black | |
| Charities Directory | 1 |
| Map of Manhattan in Sanitary areas | 1 |
| Report on vital statistics | 1 |
| Babies’ Welfare directory | 1 |
| Guide Cards Baby Health Station | 1 |
| Examining Room: | |
| Table | 1 |
| Pad | 1 |
| Pillow | 1 |
| Foot bench | 1 |
| Shelves or side table for supplies, etc. | 1 set |
| Garbage pail | 1 |
| Pelvimeter | 1 |
| Tape measure | 1 |
| Stethoscope | 1 |
| Tenaculum | 1 |
| Scissors | 1 |
| Bivalve speculum | 1 |
| Uterine Dressing Forceps | 1 |
| Blood Pressure machine (Tycos) | 1 |
| Thermometers | 3 |
| Thermometer Glasses (1 for cotton) | 2 |
| Enamel jars for tampons and pledgets | 2 |
| Large basin | 1 |
| Small basin | 1 |
| Erlenmeyer flasks for green soap and Lysol | 2 |
| Medicine Glass | 1 |
| Hand Scrub | 2 |
| Rubber gloves, No. 7½ | 6 pr. |
| Absorbent cotton | 1 lb. |
| String | 1 ball |
| Spatulæ | 100 |
| Hemoglobinometer (Tahlquist) | 1 |
| Needles (skin) | |
| Wassermann Set from D. of H. | 1 |
| G. C. Smear Set from D. of H. | 1 |
| Culture tubes from D. of H. | |
| Bandages (Ace) | 6 |
| Sterilizer | 1 |
| Sterilizer burner | 1 |
| Metal Shelf or table for Gas sterilizer | |
| Scott Tissue Towels | 6 |
| Urinalysis outfit | 1 |
| Test tube rack | 1 |
| Test Tubes | 12 |
| Test Tube holder | 1 |
| Urinometer | 1 |
| Sterno | |
| Matches | |
| Enamel Measure | 1 |
| Dish (Chamber) | 1 |
| Litmus | |
| Acetic Acid 2% | |
| Toilet paper | |
| Funnel | 1 |
| Filter paper | |
| Covered pail | |
| Linen: | |
| Sounding towels (for use in listening to F. H.) | 6 |
| Sheets | 6 |
| Pillow cases | 3 |
| Doctor’s gowns | 2 |
| Dusters | 6 |
| Gown’s for patients | 12 |
| Covers for tables | q.s. |
| Laundry bags | 2 |
| Towels | 6 |
| Sewing Bag: | |
| Cotton 70 | |
| Cotton 30 | |
| Needles, assorted | |
| Thimble | |
| Tape measure | |
| Tape | |
| Safety Pins | |
| Plain Pins | |
| Drugs: | |
| K Y | |
| Lysol | |
| Green soap | |
| Boro Glycerin | |
| Alcohol | |
| Iodin | |
| Albolene | |
| Breast Tray: | |
| Castile soap in dish | |
| Small bowl | |
| Bottle of albolene | |
| Jar of cotton balls | |
| Soft toothbrush | |
| Exhibit on Table: | |
| Patterns for baby clothes. | |
| Complete layette. Slip and petticoat open in back. | |
| Basket for baby bed. | |
| Pad (of felt or hair mattress). | |
| Rubber. | |
| Pillow cases. | |
| Blanket (crib). | |
| Doll (baby) dressed. | |
| Suspender garter for mother—abdominal support with garters. | |
| Patient’s bed prepared for time of delivery, newspaper pads. | |
| Toilet Tray: | |
| Jar of boiled water (for washing mother’s nipples). | |
| Jar of oil (mineral oil best). | |
| Jar of boric acid—2% for baby’s eyes. | |
| Jar of breast swabs. | |
| Jar of small swabs. | |
| Absorbent cotton in container (hair receiver). | |
| Soap in dish. | |
| Soap with safety pins, instead of pincushion. | |
| Jar for clean nipples. | |
| Bottle and nipple, or cup and spoon for giving baby water. | |
| Bottle of boiled water (day’s supply boiled fresh each day) and kept corked. | |
| Newspaper cornucopia for waste. | |
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.
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
Post-Partum Orders:
Post-Natal Orders:
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.
The preventive value of post-partum care is now so generally recognized that maternity care by visiting nurses is given not only in the larger cities, but is being extended even to rural communities. The routine of the Visiting Nurse Society of Philadelphia, under the direction of Miss Katharine Tucker, may be taken as an example of effective post-partum care, in which daily visits by a nurse bring to large numbers of patients the minimum of necessary attention. As the same kind of work is effective and possible in smaller communities, the routines and instructions used by the Philadelphia Society are reproduced on pp. 439 to 445. These include
In normal maternity cases, a visit is made once a day for eight days. After that time, if the mother is up and about and the baby is in good condition, the nurse visits at least once a week for supervision until the fifth week, when the case is transferred automatically to the Child Welfare Nurses under the City. If, however, there is any complication with either the mother or baby, the nurse continues daily visits or twice daily as indicated by the condition, until both mother and baby are normal. Instruction to the mother in the care of the baby is one of the important phases of the maternity nurse’s program.
The points observed and recorded on the bedside cards are: condition of breasts, urination, condition of bowels, character of lochia, position of uterus, T.P.R. or any abnormality. If there is any rise in temperature or other abnormality noted, the physician is called by telephone and the situation reported.
Any one can call the nurse—children, husband, neighbor, doctor, social worker,—and a nurse is sent out on every call. A doctor must be in charge of every case, and if one has not been engaged when the nurse gets there, she sees to it that one is procured. The only exception is in cases delivered by midwives, in which instances the nurse gives any necessary care and supervision, having it clearly understood that if any abnormality occurs, she will first notify the midwife and then the midwife or the nurse will immediately call a doctor.
The doctor ordinarily brings his own equipment for delivery. The contents of the nurse’s bag is the same for delivery as for post-partum care, except for the addition of the nurse’s gown, extra towels and silver nitrate. Perineal pads, cotton, boric solution, etc., are supplied at cost, or free of charge if the patient is unable to pay. Bed linen, nightgowns, layettes, etc., are provided for patients who cannot procure them.
The cost per visit to maternity patients averages one dollar and the cost for services at the time of confinement averages five dollars. Miss Tucker says of the maternity work:
“A complete maternity service which includes prenatal work, service at time of confinement, post-partum care and subsequent supervision of mother and baby is essential if adequate results are to be accomplished. Anything less than this complete service does not give full protection to the life of the mother and the baby. The Philadelphia Visiting Nurse Society has found that the inclusion of service at time of confinement has given a tremendous stimulation to both their prenatal and postnatal service. In the branches where a delivery service has been added, the prenatal service has increased fourfold. Both doctors and patients are enthusiastic and see far more reason for instruction and supervision from a nurse who is going to see the case through than from one who drops out at the crucial moment. It certainly has strengthened our whole maternity service, both as to results accomplished and in our relationship to the doctor and to the community.”
1. Uniforms.
Except in the case of substitutes during their first six months and staff nurses during their probation period, all the nurses are required to wear the uniform of the Society.
2. Bags.
Lost articles to be replaced at the expense of the nurse.
New equipment may be obtained only in exchange for the worn-out one.
Notebooks, charts, other papers, and pencils to be kept in the long pocket.
Instruments to be boiled before and after dressings.
Brush to be boiled twice a week and after all infectious cases.
3. Thermometer Disinfection.
To be washed before and after using in running water if possible.
After using wrap in cotton soaked in alcohol and leave until the work is finished. Then wash with green soap under running water.
4. Routine in the Home.
General Care:
Partial Care:
Extra articles to be carried in bags: gown, 2 towels, clamps, 2% silver nitrate solution.
The doctor should be called at the same time as the nurse. This should be ascertained when call is taken over telephone.
If the nurse arrives first, she should judge from the progress of labor whether an urgent call should be sent for the doctor and how much time she will have to spend in preparation for the delivery. Unless directed otherwise by doctor, the nurse should proceed as follows:
Have a supply of boiled water and pour some in covered vessel to cool.
Take necessary articles from bag, wash hands, put on gown.
Prepare patient by giving enema, sponge bath, braiding the hair, putting on clean white stockings and a gown which can be rolled up around waist.
Make bed with tight sheet, oilcloth and draw sheet, protect with pads made of many thicknesses of newspaper, covered with old muslin.
Protect floor with newspapers, and place basin for placenta. On bedside table, place alcohol, green soap, glass of boric acid solution, silver nitrate, basin containing scissors, clamps, catheter, medicine dropper, cotton gauze, cord tape and dressing, perineal pads, hypodermic, thermometer. Basin of lysol within reach. Prepare a place for baby by covering pillow with blanket and placing hot water bottle. Have olive oil (warmed). Get baby clothes, also gown and binder for mother.
Scrub hands and cleanse patient locally with green soap and water and put on sterile pad.
Assist doctor in any way possible during delivery.
Ask doctor whether he wishes to instill silver nitrate into baby’s eyes. This should be followed by normal salt solution and boric acid.
After delivery, cleanse vulva with warm lysol, put on fresh pad and binder, and make patient as comfortable as possible, giving her something hot to drink.
Weigh, oil, cleanse, dress baby. Unless doctor orders otherwise, instruct mother to nurse every three hours and to cleanse nipples with boric acid solution before and after nursing. The following additional information is to be written on the medical history card of patient attended at delivery:
This technique is given as a general standard but the nurse is expected to use her own discretion in adapting it to the condition of patient, the home surroundings and the wishes of the doctor.
Care of the Baby:
A. Make preparations as for general care.
Have everything ready before the baby’s bath.
Have separate basin for the baby whenever possible.
Test temperature of water with the elbow.
If the room is cold bathe in the kitchen.
Use table whenever possible for the baby’s bath.
If not possible sponge on lap beside the mother’s bed so that she can observe technique.
When cord is off, tub.
Place on paper napkin on third chair, table, or corner of dresser, glass of boracic acid sol., olive oil, warmed, cord powder, and dressings, safety pins, band, absorbent cotton, rectal thermometer, vaseline and alcohol. Have baby’s clothes within easy reach. Protect lap with blanket or bath towel.
Remove clothing.
To protect cord dressing, unpin but do not remove band.
Take temperature first and last visit, and when indicated.
Weigh baby on first and last visit.
Examine carefully for any abnormalities and note when found.
B. Eyes.
Unless there is a secretion, let the eyes alone.
When secretion or redness, wash eyes gently with 2% Boric acid sol. using separate pledget for each eye.
C. Mouth.
Examine mouth.
No treatment unless required.
If necessary to cleanse use cotton wrapped around little finger and dipped in boracic acid.
D. Nose.
No treatment unless required.
If necessary use piece of twisted cotton and boracic acid sol.
Never use toothpicks.
E. Wash face and ears gently with wash cloth or absorbent cotton and dry.
Soap head with hands, rinse with cloth and dry carefully. Soap body with hands, rinse with cloth and pat dry with soft towel. Fold binder across abdomen, protect with hand and turn baby on stomach. Bathe the back. Fold diaper and place under buttocks.
F. Genitals should be carefully cleansed.
In the case of boys, the foreskin should be gently pushed back once in every two or three days, and the parts underneath bathed carefully with absorbent cotton and boracic acid sol., removing the white pasty material which causes irritation.
In the case of girl babies, carefully bathe genitalia. If deposit is difficult to remove, soften with olive oil.
G. On first visit wash umbilicus with 70% alcohol and apply dry sterile dressing. Do not remove this dressing except when soiled. After the first time dress with cord powder. Put on clean binder, pinning on side with safety pins. Oil under arms, buttocks and all creases.
Put on shirt.
Pin diaper.
Petticoat and dress should be drawn on over the feet.
Use hot water bottle filled with warm, not hot, water.
If necessary beer bottle, tightly corked, is a good substitute.
Clear away articles used for the baby.
H. Points to be observed, recorded and reported to the physician if urgent:
I. Instruct the Mother:
J. Do not discharge the baby until cord is off, umbilicus is in good condition and no further nursing care required. Premature babies should be oiled and wrapped in cotton. Premature jackets can be secured from the V.N.S. for 35 cents.
Care of Mother:
Make preparations as for general care.
Extra articles needed:
Take T.P.R.
Give complete bath.
Post-partum dressing:
Douche.
When douche is ordered boil nozzle before and after using.
Boil douche bag before using and wash afterwards—use boiled water.
When sutures, instruct the family how to irrigate after urination and movement of the bowels.
Normal maternity cases should be visited daily until after the 8th day of puerperium and at least once a week for supervision until the 5th week. The case is then transferred to Child Welfare nurse.
Additional visits should be made if the patient is still in bed and there is no intelligent adult to give care, or if the baby’s condition is not satisfactory.
Ingenuity, resourcefulness, and quick wit on the part of an intelligent nurse can almost always apply hospital ideals to circumstances which would at first seem hopeless. It is the nurse’s knowledge of obstetrical nursing and principles, rather than her equipment, that counts in saving lives. The following directions given to visiting nurses, by Cecil A. K. Dawkins, R.N., Supervisor of the Outdoor Department of the Montreal Maternity Hospital, indicate the possibility of clean, efficient care in conditions far from ideal:
“Appliances You Are Likely to Find in Any House:
“Bed, table, chair, two boxes, basin, pail, kettle, saucepan, plate, two cups, spoon, several fair sized bottles, sheet, two towels, pillow, pillow case, handkerchief, newspapers, old clean rags, small package boracic powder, small bottle vaseline, soap, baby clothes.
“Doctor’s bag will usually contain towel, clamps, scissors, ergot, chloroform, creolin, rubber apron, hypodermic syringe, nail brush.