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Midwifery practice of the
Present Day, and the training required for it.

A paper read at the Medical & Physical Society on November 30th,

by

J. S. FAIRBAIRN.

(Continued.)

II. THE PRACTICE OF THE PRESENT DAY.

FROM

ROM what has been said in regard to the subject of training, you will recognise that the man who is most up-to-date in his midwifery work is the man who has learnt most successfully to apply what he has learnt in the surgical wards and theatres of the hospital to the lying-in room. Still it is manifestly impossible to conduct the ordinary maternity case as if it were a surgical operation. I have already said that it is more difficult to carry out the technique as thoroughly as at an operation because both clean and unclean work have to be done at the same time, and because of difficulties in household arrangements and of the public not being educated up to the level of modern requirements. What is required is to bring all that is essential and practicable of hospital methods into the lying-in room. To begin with there is the assistant in the shape of the nurse. The ordinary monthly nurse has often very little idea of surgical cleanliness, and in practice a certain amount must be left to her, especially in regard to preparation and after-treatment. If you are fortunate enough to know of a few reliable women, who have had sufficient training to do all that you may require of them, then you should insist as far as possible on your patients taking one of your nomination. If the patient is left to herself in this matter she will choose some worthy creature who is sympathetic' and no bother in the houseprobably because she does not make trouble for the servants by asking for cans of water and adding to the household washing. In the country and smaller towns it may be difficult to get a woman with sufficient training except from a distance, but in the bigger towns there are plenty of good nurses to be found. If this has been done the preparation of the patient and the preparatory cleansing at the onset of labour may be left to the nurse, otherwise the doctor must see to this himself. The same thing holds good for the arrangement of the room. Most nurses trained or untrained wear a washing dress and as the medical attendant must not expect from them more than he is prepared to do himself, he must not be

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content with rolling up his coat sleeves or at most removing his professional frock coat (in case it is covered with wool and fluff), and turning up his shirt sleeves. From the patient's point of view it is evident that a man doing general practice will be safer if he is enclosed in a clean overall. This ought to be an essential.

The cleansing of the hands is done as for a surgical operation and therefore needs no further mention here. But do not forget that the rule that is impressed on you so constantly at operations-to keep the hands out of the wound as far as possible-has an application in midwifery work also; as few vaginal examinations as possible are to be made in order to minimise the danger of infection and that means that the more skilled you become in abdominal examination the better will your technique be. Rubber gloves are as valuable in obstetrics as they are in surgery. It is almost as easy to make a vaginal examination with gloves as without, and to my mind it is actually easier to apply forceps with gloved hand. Their smooth surface does away with any need of a lubricant of doubtful asepsis, and more of the hand can be passed into the pelvis, so that the blades of the forceps can be more easily guided into position. In a difficult high forceps operation the gloves can be removed before traction is applied if they interfere with the grasp on the handles. I have had so little experience with gloves in internal version that I cannot speak as decidedly as in the case of forceps, but what experience I have had makes me think that their disadvantages are more than counterbalanced by the ease with which the smooth covered hands can be passed into the uterus. Perhaps the greatest advantage is in their use in manual delivery of the placenta. When the hand has to be passed not into the amniotic sac as in the operations of the second stage, but into the naked uterine cavity the risk of infection is greater than in any other obstetric operation. Therefore it is well worth while carrying gloves, if it is only for the peace of mind which their use brings after a case in which it has been necessary to put the hand into the uterus to remove the placenta. There is one other occasion on which they ought always to be used, and that is when it is necessary to explore the puerperal uterus on account of retained portions of placenta, or owing to the development of sapræmic symptoms. They do not interfere with the touch to any appreciable extent, and they not only avoid the danger of introducing a fresh infection, such as a septic infection on the top of a putrefactive, but they prevent the soiling of the operator's hands, a most important matter in the case of a man who has much midwifery work to do, and may be the means of carrying infection to other patients. Therefore I strongly advise all of you to carry gloves with you to your cases,

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and to use them in all operative procedures even if you do not use them for examination purposes.

Before leaving the question of hands it may be worth while to say a few words on the matter of a lubricant. It is now generally agreed that the antiseptic in oily compounds is ineffective, and certainly the carbolised vaseline as ordinarily used has no place in a strict technique. The chief value of such material is in the protection to the fingers of the attendant in the case of infection from the patient. The great advantage of lysol is that it forms a soapy solution, and thus acts as an efficient lubricant as well as a disinfectant, but there is rarely any need to use anything of the sort as the hand can be passed straight from any lotion into the vagina. If anything is used sterilised glycerine, or glycerine and perchloride, are best.

Now as regards instruments. As private patients should be given the same advantages as hospital patients, all instruments should be boiled before use, and in the patient's house. As a fish-kettle, or other means of boiling instruments as large as forceps may not be available, this means that a large steriliser must be carried, and with it a lamp and spirit so as to be quite independent of the resources of the household. This is no great trouble if you do not start with the idea that the ordinary O.C. bag is the proper size for midwifery work. The bag must be big enough to take the steriliser, which can be packed with all sorts of things so as to economise space. Those who have to work in small houses where there is not much room for all their apparatus, or who are frequently involved in carrying their bag themselves so that the weight is a matter of considerable moment, may adopt the less satisfactory plan of boiling the instruments at home, and carrying them in a sterilised cover to the patient's house. After boiling they ought to be dried with a clean towel, and be wrapped in another with its ends pinned up so as to prevent soiling in the bag. The linen case so often used is not satisfactory if the instruments are not boiled just before use, as it cannot be considered aseptic by any stretch of the imagination.

After labour all that is required is to see that the patient is cleaned up properly, and that the pads are changed frequently throughout the lying-in time, and that the vulva is well washed over after the bowel or bladder is evacuated. Under ordinary circumstances a vaginal douche is unnecessary, and intra-uterine douches are only indicated on those occasions when the hand has been passed into the uterine cavity, as for the removal of the placenta, apart from those occasions on which it is done for hæmorrhage. As only the mechanical effect is needed, boiled water or some harmless disinfectant is best.

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There is no object to be gained in going further into details of this kind, as all of you are familiar with them, but I would like to spend a few moments on the question of puerperal infection. Some of you may think, if not now, certainly after you have been in practice some years, that all this striving after the introduction of hospital methods into private practice is an unnecessary labour, as otherwise puerperal troubles would be much more frequent. At any rate you will meet many men who will say so, and will tell you that they have done hundreds of cases without all this bother, and have never had any ill results. That they have escaped disaster is no argument and statistics show that the death-rate from puerperal sespis outside the lying-in hospitals has been unaffected by the introduction of antiseptic methods, whilst in the hospitals it has almost reached vanishing point. Dr. Boxall recently prepared some interesting and very striking figures on this point. For the purpose of comparison, he took the septic death-rate of the York Road Hospital from 1879 to 1904, and compared it with the general septic death-rate in England and Wales during the last three years for which the figures were available, 1901 to 1903. This is a very severe test for the Hospital, as it includes the very early years of antiseptics, and the hospital naturally has more difficult cases than the average of outside practice, and among them a good many cases sent in in the course of labour, after prolonged and ineffectual attempts at delivery have already been made. The statistics show that in over 11,000 cases the hospital death-rate from sepsis was 1 in 799; and if the cases in which interference had been begun outside were excluded, the rate was only 1 in 1,398. The figures from 1888 to 1904 are even more striking, as the death-rate for all cases in hospital was only 1 in 2,068, and if only those conducted from the commencement of labour in hospital are considered, the rate was nil. For England and Wales the death-rate from puerperal sepsis for the three years mentioned was 1 in 490, or 13ths greater than that in the York Road Hospital for 25 years, and if the cases sent in in labour are excluded, the general death-rate is nearly three times the hospital death-rate. This is sufficiently striking evidence of the need for a general adoption of hospital methods, and it becomes still stronger if you consider what the Registrar General's figures include. His figures only represent the fatal cases, and many of these are recorded elsewhere rather than under puerperal fever. For instance, many of such deaths are signed up as pneumonia, typhoid fever, thrombosis, and so on, for puerperal septicemia does

⚫ See the Journ. of Obstet. and Gynæc of the Brit. Emp. for May, 1905. The figures are well worth studying as the returns for a large number of years have been analysed and compared with the Hospital records. The cause in Child-bed is divided into Puerperal Septic Disease and the Accidents of Childbirth. The first is the one chiefly considered,

not look well on a death certificate, and the medical profession is not exempt from the failings of the rest of mankind. Also these returns give no indication of the cases that recover, in other words, of the morbidity, and with the improvement in the treatment of puerperal sepsis, the disease is not as fatal as it was. You have only to think of the number of cases of puerperal abscess and pelvic inflammation that you see in Adelaide, to understand how much serious trouble results from infection at child-birth in addition to the actual mortality.

All this may be summed up by saying that whereas before the Listerian era the lying-in hospitals were death-traps, they are now far safer places for lying-in than private houses; on the other hand, the antiseptic methods have as yet shown no sign of diminishing the puerperal death-rate throughout the country as a whole. This is not entirely the fault of the medical profession, as the worst figures come from places like Glamorganshire, where the women are largely attended by ignorant midwives. Still, this is not enough to explain the whole difference; Dr. Cullingworth pointed this out in a Presidential Address at the Obstetrical Society, when he showed that many of the better class districts in London were among the worst offenders in this respect. The truth of the matter is that outside practice has failed where the hospitals have succeeded; the explanation must be that the strict technique is essential if this, the most evidently preventable of preventable diseases, is to be stamped out in the country as successfully as it has been in the hospitals. The necessity of learning these methods from the commencement of his practical midwifery work is perhaps the strongest argument for training the student in hospital before allowing him to undertake cases in the district.

Now that I have described the training for and the methods to be adopted in modern midwifery practice, I have very little time left to tell you much of the details of the work. It is another disadvantage of your not having hospital instruction in this branch of your profession that you get little opportunity of learning by watching the methods of your teachers. You have to learn by yourselves how best to apply your theoretical teaching, so I will try and sketch a few points in which private practice differs from work in the district. Mr. Rudyard Kipling says

"The Colonel's lady an' Judy O'Grady
Are sisters under their skins,"

and you will find that there is little difference between one woman in labour and another, whether she happens to live in Lambeth or Belgravia, although the Colonel's lady expects rather more from her accoucheur than Judy O'Grady does from the O, C. To begin with,

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