Document 11: Anne A. Stevens, "The Work of the Maternity Center Association, reprinted from the Transactions," 10th Annual Meeting, American Child Hygiene Association, November 11-13, 1919, Asheville, N.C., WCCNY Papers, Archives and Special Collections, Hunter College, New York, N.Y. (WCCNY microfilm, reel 20, frames 209-31).

Introduction

       In this paper presented to a professional group, Anne Stevens described the work of the Maternity Center Association. The Association sought to extend the innovations of her center throughout the city.

 

THE WORK OF THE MATERNITY CENTER ASSOCIATION

ANNE A. STEVENS, R.N., New York City

       You will probably remember that at the suggestion of a committee of obstetricians, Manhattan was divided into ten zones, and it was planned to establish maternity centers and substations in each of these ten zones; each center to be the focus of an educational campaign for maternity care for that zone, to conduct doctor's clinics where medical supervision will be given all patients who have not engaged their own physician or registered at a hospital until such time as they can be persuaded to do so; the nurse in charge of each center together with nurses in cooperating clinics to reach practically every pregnant mother in the zone, to teach her the need for medical and nursing care throughout the pregnancy, teach her what and how to prepare for her baby, help her arrange for her care at time of confinement and keep in close touch with her until she really knows how to care for her baby. It was planned that each center consist of an examining room where a doctor's clinic could be held once a week or oftener, a dressing room for patients in order to assure them privacy and a waiting room, made as nearly like a comfortable sitting room as possible, where there could be a continuous exhibit of a model baby's bed, layette, toilet tray, etc., and a bed properly made for the mother's delivery. This work was to be financed and directed by this voluntary organization of citizens called the Maternity Center Association, only until some time as a demonstration could be made so convincing as to assure an adequate appropriation of public moneys to carry it on. (See Exhibit 1, page 11.)

       When the association was formed, the New York Milk Committee took the entire responsibility for the work in two of the zones. The Women's City Club continued to finance the work in the zone where they established the first Center, but put the actual nursing under the direction of the Maternity Center Association.

       When a nurse begins work in a new district she first learns every facility for maternity care which that district affords. She then visits every organization whose workers might come in contact with pregnant mothers of that district. By every organization, I mean, of course, settlement houses, church clubs, district offices of relief organizations, schools, dispensaries or clinics, and all nurses, such as school nurses, baby health station nurses, visiting nurses, etc.

       To these workers she explains the need for supervision throughout pregnancy and asks that they report all pregnant mothers with whom they come in contact to the Maternity Center, either as already under their care or as in need of care.

       With patients referred in this way as a nucleus the nurse begins work in the district and while visiting these patients she canvasses the district in her effort to learn of every pregnant mother early in her pregnancy. She asks her patients and the janitresses of tenement houses about other patients; in short, she leaves no stone unturned in her effort to learn of every pregnant mother.

       On the first visit she makes to these patients they automatically divide themselves into four classes:

    1. Those who have made no arrangements for care at the time of delivery.
    2. Those who have engaged a private physician for care at the time of delivery.
    3. Those who have engaged a private midwife for care at the time of delivery.
    4. Those who have registered with a hospital for care at the time of delivery.

       The first group of patients, those who have made no arrangements for care at the time of delivery is, of course, the nurse's greatest responsibility. She aims to secure for that patient a complete physical examination by a physician and to learn all she can of the environment in which the patient lives, so as to be able to advise the patient as to the best arrangements for her to make for her care at time of delivery.

       The method the nurse uses to accomplish this aim differs with practically every patient. It is based on the fundamental of getting the confidence of the patient, in order to teach her the need for supervision throughout pregnancy. She may find it necessary to make many friendly visits before even mentioning a doctor's examination or any real nursing care. She may find inviting the patient to see the demonstration at the Center, or to come in and get help in making baby clothes,the best way to gain the confidence of the patient. She may find that she can at once begin with a nursing visit or have the patient come in for the next doctor's clinic.

       On this first visit the nurse makes, she meets with all kinds of receptions, from the patient who says, "I don't want a nurse; I always had a midwife; never had no trouble," to the patient who considers the nurse's visit a real godsend and is anxious to do everything the nurse asks her to do. These are the extremes. I might add that this last kind of reception is decidedly less frequent than the first, and that the majority falls somewhere in between.

       Although we consider that ideal supervision throughout pregnancy consists of an examination by a doctor as early in pregnancy as possible and frequent return visits to the doctor and nurse, when the patient fails to respond to that extent, we deem the next best thing to be to continue to visit that patient at regular intervals so that she may at least have the nursing supervision. At present, all patients are seen by either a doctor or a nurse once in two weeks up to the seventh month of pregnancy and once a week after the seventh month. On each of these visits the nurse follows as much of a definite nursing routine as the patient will allow. This routine includes analysis of the urine, listening to the foetal heart, asking the patient about or looking for every one of the signs or symptoms which are familiarly called the "danger signals of pregnancy." No patient is dismissed because she fails to follow advice, but the nurse continues to advise the next best thing until she finds the thing which that patient will do.

       During all this nursing supervision, the nurse works with every other organization toward the solution of the social problems she may find in the home, for she considers not only the physical condition of the patient, but the peace of mind of the patient, of equal importance and her responsibility. During this time she also teaches the patient as much as she can about the preparation for her baby and its care after birth. (See Exhibit 5, page 18.)

       All this nursing care is given by a combination of visits which the nurse makes to the patient's home and visits which the patient makes to the nurse during her office hours at the Center. The basis of decision as to whether the nurse will visit the patient or the patient visit the nurse is first of all the attitude of the patient and then her convenience. The nurse never asks a patient to come to the Center until she feels she has gained the confidence of that patient. She never asks a patient to come to the Center for nursing care, if that visit would work a real hardship on the patient in the form of dragging with her several children under school age or long distance travel, or any real physical discomfort.

       The advantages of this combination of visits are several. First, the nurse learns the patient in her own surroundings, not as an isolated patient, but as a part of her environment, then when the patient comes to the Center she sees the exhibits, meets other patients, gets away from her own little rut and at the same time makes it possible for one nurse to care for more patients in a given time because the patient does the traveling. The patient gets more complete nursing care, for the blood pressure is taken at the Center, as nurses do not carry blood pressure apparatus in their bags.

       If any patient fails to come to the Center as she has promised, the nurse visits her for the nursing due that day and tries again to get the patient to come to the Center for the next visit.

       If abnormalities develop during pregnancy, the nurse arranges for immediate medical supervision for that patient, either in the hospital or at home. Often when, from the clinic physician's standpoint, the patient can only be adequately cared for in a hospital, and the patient either can't or won't go to the hospital, the nurse persuades that patient to engage a doctor and then either makes daily visits herself or refers the patient to the nursing service of the Henry Street Settlement. Many cases of beginning toxaemia needing rest in bed and special diet have been cared for in this way with perfectly satisfactory results.

       The next responsibility of the nurse in the care of these patients is to advise as to their arrangement for care at the time of delivery. This advice is based on the physical condition as learned by the doctor's examination, whenever the patient has had one, and the environment in which she lives and the facilities for care. For instance, if we consider the physical condition only, we might urge hospital care as the best for her from an obstetrical standpoint, but if we find by having her leave home, the home might become disrupted, we modify our advice to fit that patient's individual home problems.

       If there is no home problem to be considered, it is usual to advise hospital care for primiparae, also for all patients who develop abnormalities and all patients with a history of difficult labors or previous abnormalities.

       Even though there are free hospital beds to care for less than 30 per cent of the pregnant mothers of Manhattan each year, we have as yet found little difficulty in securing hospital care for patients who most need that hospital care. This doesn't mean hospital beds for every patient who wants to go to a hospital. We find an increasing desire on the part of the patients for hospital care, and when it is not possible for them to get hospital care we find the patient less dissatisfied when she can have a doctor from a hospital outdoor service take care of her. Frequently she is willing to pay for this care on the same basis as she would pay for hospital care.

       If the patient wants to be delivered at home, we urge her to engage her physician early and the nurse makes sure that she understands about the visiting nurse service of the Henry Street Settlement, discussing with her the value of such service, even if she has a practical nurse, its cost and her ability to pay and, when possible, deciding on the exact fee, which decision is passed on to the Henry Street nurse.

       It is in the care of the patients to be delivered at home, that we probably meet our greatest problem. It is here we have to provide some one to take the mother's place in the home while the mother stays in bed the necessary time after the baby is born or while she gets some of the necessary rest previous to delivery.

       In the district which is being financed by the Women's City Club there is available a fund to provide so-called working housekeepers to meet this need. These working housekeepers are paid directly from this fund 30 cents an hour, a luncheon allowance of 25 cents, and carfare, and the patient pays whatever she can into this fund.

       For this purpose the nurses have a list of women, usually the wives of skilled workers whose own children are partly grown and who are anxious to do part-time work in an effort to provide something extra for those children, such as music lessons, seasons' gymnasium courses, phonograph records, etc. These women are, of course, good housekeepers and clean workers and it is not infrequent for a woman who failed to keep her house orderly to show much improvement in the management of her home after she watches the work of the working housekeeper.

       I cannot emphasize too strongly the tremendous need for these working housekeepers. Careful prenatal supervision is almost wasted if the mother must get up and care for her home immediately after delivery.

       If a patient has made up her mind to have a midwife, but has not actually engaged that midwife, we, of course, do not advise her to do so, but try to steer the patient to free or part-pay Outdoor Service of hospitals when indoor care is not practical or necessary for that patient.

       Here again we meet the same tremendous need for some one to take care of the home while the mother stays in bed. This, to a large extent, the midwife does. She comes in every day and gives the baby his bath and she does, after a fashion, perform certain household duties. The prejudice of our foreign born mothers in favor of the midwife we can easily overcome when we can teach her the possibility of getting a woman physician or having a nurse come with the doctor at the time of delivery. This latter can be done in one district where the Visiting Nurses Service of the Henry Street Settlement provides a twenty-four hour service of nurses for attendance at deliveries in the home. But we find the decision to have the midwife to be largely an economic one, since she gives, no matter how inferior it be, not only the medical, but nursing and household service.

       Each patient that the nurse has had under actual care up to the time of delivery and any patients reported by the hospitals when dismissed and any patients who will let us know when they leave the hospital are visited for post-natal follow-up work. This means one visit to learn whether or not the mother can adapt her instructions on the care of the baby to the actual presence of her own baby in her home. If not, the nurse makes the visits necessary to teach her. She then visits the patient or the patient visits the nurse once a week until the baby is one month old. The value of continuous supervision to keep a well baby well is carefully explained to every mother and unless the baby is under the care of a private physician, the mother is urged to register her baby at the Baby Health Station. (See Exhibit 6, page 19.)

       The value of birth registration is also explained and discussed with the mother, and the nurse makes every possible effort to have a copy of the birth certificate in the hands of the mother before she dismisses the case.

       The need for a post partum examination not later than six weeks after the birth of the baby is also explained and urged. The patients who were delivered in hospitals, which provide for post partum examination, are urged to return to the hospital and those patients who would not otherwise have a post partum examination are urged to go to the Maternity Center doctor. When the patient has either had this examination or refuses to have it and the nurse feels she cannot persuade her, the patient is dismissed.

       Nurses are just beginning to give some group instructions to the mothers at the Center. This group instruction is planned as follows: One week the nurse demonstrates to the group the handling of the baby, dressing and undressing, bathing, and explains the reason for making each piece of the layette as the model is made and the reason for including each article that is included on the toilet tray and shows them how to make boric solution and swabs. In short, every detail in the daily care of the baby is gone over. The next week this same group of mothers returns to the Center and the mothers demonstrate to the nurse. They actually dress and undress the baby, explain how to make boric solution, how to prepare sterile water and how to give it to the baby. Many of the mothers return several weeks in succession and many a mother returns with her three-weeks'-old baby to make sure that has not forgotten any of the points the nurse tried to teach her before the baby came. Most mothers who come to these demonstrations are primiparae who are eager to learn all they can about their babies.

       To avoid confusion in the minds of mothers, all organizations whose nurses teach the care of babies have adopted a uniform technique and this is followed, in these demonstrations.

       To the second group of patients, those whom the nurse on her first visit finds to have engaged a private physician, she gives no treatment or advice, but sends a form letter from the Medical Board to the physician asking permission to nurse that patient and to report to him every nursing visit. If he refuses to have the nurse visit the patient, she dismisses the case. I might say the percentage of physicians who refuse to have out nurses visit their patients is very small. (See Exhibit 7, page 20.)

       With the physician's permission the nurse gives the nursing care to his patients in exactly the same way as described above. She never asks that patient to come to the doctor's clinic at the Center, but she does have her come to the Center for her nursing care.

       If the patient is one of the third group, the ones who have engage a private midwife, the nurse personally visits that midwife. (Form letters are impractical, as few midwives read English.) The nurse then asks the midwife to bring her patient to the Center, explaining that the midwife is taught to do deliveries, but she is not taught to examine the patient's heart and lungs or to estimate the general condition of the patient and that now all good obstetricians realize that such an examination is very necessary for the health of the mother and the coming baby.

       If at this first examination the doctor finds any abnormality he does not tell the patient; he either tells the midwife or the nurse explains to the midwife exactly what the doctor has found and points out that it is contrary to the rules governing midwifery for her to handle the case. She asks the midwife to come with her to the patient and discuss other arrangements for her care at the time of delivery.

       If at this first examination the doctor finds no abnormality, the midwife is asked to allow the nurse to visit the patient at regular intervals and have her report to the doctor's clinic in accordance with his advice.

       We find that midwives are very suspicious of the nurses and firmly convinced that the nurses mean to take their patients away from them. Those few midwives who speak English and get a clear idea of what the nurses are doing give no trouble, but those midwives who do not speak English and even through an interpreter do not seem to get a clear idea of what the nurse is doing, agree with the nurse when she is there, but when the nurse leaves, promptly tell the patient to have nothing to do with the nurse.

       If the patient is one of the fourth group, those who have registered with a hospital, the nurse's further action depends on the individual hospital. We have almost as many different working agreements with hospitals as there are hospitals in Manhattan.

       Some hospitals assume the entire nursing and medical supervision of patients as soon as they register them and will register patients early in pregnancy. With patients registered at these hospitals the Maternity Center nurse has no further contact. For those hospitals that have not the physical capacity to conduct clinics in sufficient numbers to make this supervision possible, nor visiting nurses to send to the patients in their homes, the Maternity Center Association gives nursing care to their patients on the same basis as to a private physician's patient. The hospital resident assumes the responsibility for medical supervision of the patient and receives the reports on each nursing visit, and the nurse in turn urges the patient to return to the hospital for her medical supervision in accordance with instructions received when she is registered.

       Several hospitals do not wait for the nurse to discover patients registered with them, but report each day those registered at their clinic, and ask that the nurse assume responsibility for the nursing care.

       All agencies doing district prenatal nursing have adopted a uniform standard of work and are using the same record form. (See Exhibit 8, page 20.)

       For every patient she nurses, the nurse keeps a tabulated record form which she fills in at each visit, and which is passed on when the patient is transferred to another organization. A duplicate of this record is filed in the Central Record Office and kept up to date by daily reports which each nurse sends to that office.

       The nurses of some cooperating organizations do not send in daily reports of visits to the Central Record Office, but send the finished record after the case is dismissed, so that the number of uniform records to be studied and analyzed may be as large as possible.

       The Central Record Office also serves as a clearing house for all maternity work and prevents any duplication.

        

EXHIBIT 1

A PLAN FOR MATERNITY CARE

Maternity Center Association

18 West 34th Street, New York City

 

SOME FACTS ABOUT THE NEEDLESS LOSS OF LIFE IN CHILD-BIRTH

(Supplied by the Federal Children's Bureau of the U.S. Department of Labor and the New York City Department of Health.)

 

Maternal Deaths

  1. More women of child-bearing age (15-45) die in the United States from causes incident to child-bearing than from any other cause except tuberculosis. For women, maternity is a scourge second only to the White Plague.

Infant Deaths

  1. 12,657 babies under 1 year of age died in New York City in 1918. 35% of these died as the result of conditions arising before birth or accidents at birth, mostly preventable.
  2. 5,818 babies under 1 month of age died in New York City in 1918. 75% of these died as a result of conditions arising before birth or at birth, largely preventable.
  3. The number of still-births reported in New York City in 1918 was 6,793. Only a small proportion are reported and the total loss of life including miscarriages and interrupted pregnancies is very much larger. Hundreds of these losses are preventable.

THE PROPOSED REMEDY

       Careful physicians have so developed the methods of their private cases that maternal deaths from causes related to child-birth are rare in their practice. The basic method used has been early examination and supervision throughout the whole period of pregnancy combined with aseptic delivery and adequate after-care. These same methods have also markedly reduced the number of infant deaths from causes arising before birth and at birth, the number of still-births and the number of miscarriages.

       It is estimated that at least 75,000 pregnant mothers in New York City are entirely without medical or nursing oversight.

The Ideal

       That every pregnant mother in the City of New York shall be brought under medical and nursing supervision; that every child born in the City of New York shall have proper care before birth, at birth and during the days immediately following birth; that the methods by which obstetricians have proven they can reduce the maternal and infant death-rates among their private patients shall be applied generally to the population, to those who can afford to pay for medical service and to those who cannot.

The Method

  1. The Maternity Center Association proposes to conduct a city-wide educational campaign to teach all men and women the need for, and the value of, maternity care.
  2. The Maternity Center Association will urge the adoption of a uniform high standard of pre-natal supervision, obstetrical nursing practice by the hospitals, clinics, and nurses, as well as by the social agencies and health agencies working on maternity problems throughout the city.
  3. The Maternity Center Association will maintain a clearing-house for all maternity work in Manhattan.
  4. The Maternity Center Association will keep records of every maternity patient coming under the care of clinics in the borough and follow up each case so that no woman shall be allowed to go without care by reason of illness, carelessness, or other cause.
  5. The Maternity Center Association will promote and extend the work of every agency working in the borough on the problems of maternity and child welfare.
  6. The Maternity Center Association will secure, through other agencies, relief and assistance for mothers belonging to families where poverty is clearly a menace to the health of mother and infant.
  7. The Maternity Center Association will secure necessary household assistance for the mother at the time of her confinement.
  8. The Maternity Center Association proposes to establish a maternity center in each of 10 zones in Manhattan, as well as a sufficient number of substations when not enough pre-natal clinics exist to serve the needs of the zone.

A MATERNITY CENTER

  1. Will be, in each zone or neighborhood, the center of an educational campaign for maternity care.
  2. Will conduct doctor's clinics where medical supervision will be given to all patients who have not engaged their own physician or registered at a hospital, until such time as they can be persuaded to do so.
  3. Will, through nurses and social workers attached to the Center and co-operating clinics, reach practically every pregnant mother in the zone to teach her the need for medical and nursing care throughout pregnancy, teach her what and how to prepare for her baby, help her arrange for her care at time of confinement, and keep in close touch with her until she really knows how to care for her baby.
  4. Will be, in each zone or neighborhood, the center for promoting health of mothers and babies by every possible means.

THE PROPHESIED RESULT

If this program is carried on in 10 zones it will:

1. Reduce death of mothers --------------------------- 75%
2. Reduce premature births --------------------------- 25%
3. Reduce death rate of infants under 1 month --------------------------- 40%

THE UNUSUAL NEED

       As the war has destroyed adult life and its effects have reduced the number of births, it becomes a patriotic duty of first importance to stop this needless waste of infant life and mother life.

       Our request for support is based not alone on humanitarian grounds but on practical patriotism.

EXHIBIT 2

CLINIC ROUTINE

MATERNITY CENTER ASSOCIATION

18 West 34th Street, New York City.

       The nurse is urged to so 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 Wasserman's, 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 Dressing Room for Patients

       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 is to completely undressed, 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 oedema, 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 him tactfully of any omissions made in his dictation. Conduct examination in the following order: Chest, breast, blood pressure, abdominal, foetel heart, measurements, ankles, vaginal, Wassermans or smears when necessary.

       Note: Preparation for vaginal examination. Sponge vulva with 1 per cent lysol solution. Give doctor fresh gloves for each patient.

       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 instruments used 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 for five minutes, then to be 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 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; field cards to be filed in date file before the nurse goes off duty.

       Doctor's Duties. Doctor's Record Card Calls for

      1. One complete physical examination including heart, lungs, breast, blood pressure, abdominal examination, foetel heart, pelvic measurements, vaginal examination and Wasserman and G.C. smear on all patients with a suspicious history. Notes on this examination to be dictated to the nurse.
      2. Blood pressure, abdominal; urinalysis; on return visits and provides space for notes on such other observations as he may wish to make.
      3. One post-partum examination on every patient; including a statement on general condition; examination of breasts; vaginal; uterus; perineum; and note on results of any intercurrent disease.
      4. Recording advice given to patient.
      5. Instructing patients when to return to see the doctor. Note: All patients not registered with a hospital or private doctor, to be seen by the clinic doctor once a month up to the seventh month, and once in two weeks, or oftener as the case demands, thereafter.

       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:

      1. Greeting patient; and from her pink card get her field card from file and send to nurse.
      2. Taking temperature--------A record of which is sent on in to the nurse on a
      3. Urinalysis ----------------scratch pad and copied by her on her clinic record.
      4. Helping patient dress and undress.
      5. Care of any children who may come with patients.
      6. See that patient understands when to return and has her pink card so marked before she leaves.

EXHIBIT 3
ROUTINE FOR PRE-NATAL NURSING VISITS
MATERNITY CENTER ASSOCIATION
18 West 34th Street, New York City.

First Visit

       Get acquainted with the patient and get her confidence. Learn if she has made any arrangements for her care at the time of delivery. If doctor or midwife has been engaged, communicate with him or her. If the patient is registered with a hospital, report to the center. If patient is under other nursing care, report that to the center. Always ask to see patient's hospital or clinic card, or any card which she may have been given by any nurse or other visitor.

       Explain simply the reason for an expectant mother's seeing a doctor and nurse early and regularly. Invite the patient to see the center or station. Ask her in a general way about herself, when her baby is expected, other pregnancies, and deliveries, and illness, other members of her family. Direct your conversation so as to get as much data as possible without asking direct questions. Do not attempt a full nursing visit unless the patient meets you more than half way. All patients after the first visit should be seen once every two weeks up to the seventh month, and once every week, or as oftener as the case demands, thereafter. All patients are to be encouraged to come to the center or station for as much of that nursing care as is possible for that individual woman. When a patient is antagonistic or refuses nursing care, do not dismiss the patient. Use discretion about revisiting such patients, but see them as nearly as possible at the regular intervals and give as much nursing care as they will accept.

       In the care of all patients it is the nurse's responsibility to make every effort to solve (by working with every existing agency) such home problems as might affect the health of the mother or baby. In Zone 7, a staff of working housekeepers is on call to take the mother's place in the home while the mother stays in bed the necessary time post-partum. This service is paid for by the patient's contributing what she can toward the salary of the working housekeeper, and by a fund which supplements the money received from the patient, so as to pay the housekeeper thirty cents an hour, twenty-five cents for her lunch, and her carfare when necessary.

       All patients delivered at home or hospital are kept under observation (by the maternity center nurse, or the social service nurse of the hospital) and necessary instructions given, until the baby is one month old, or registered at a baby health station, and until the mother has had or refused to have a post-partum examination, either at the hospital where delivered, or at the maternity center clinic.

       Complete Nursing Visit

       Ask the patient about any aches, pains, troubles of any kind, directing you questions to cover all items on record. Select a table, chair, machine top, or end of mantle, to use as a work table, and place on it:

Paper napkin as cover, Test tube and holder,
Nurse's soap, hand scrub and towel, Urinometer,
Watch, Litmus paper,
Pencil and note book, Acetic acid,
Thermometer, Sterno,
Bottle for specimen, Matches.

       Take temperature, pulse, respiration. Thermometer to be washed with soap and water and dried before returning to case. Look for oedema, varicose veins, do not take the patient's word for these symptoms. Apply bandage for varicose veins, patient to pay 65 cents for the bandage, or bandage to be lent to patient as long as needed, washed and returned. Demonstrate the care of nipples, to be done daily after the fifth month, not before. Use cotton ball (or soft tooth brush previously scalded and kept for this purpose), thoroughly scrub each nipple with warm water and soap (white) and dry with a clean towel. Apply albolene, pulling out the nipple. Do not handle breasts. Listen to the foetel heart. If unable to hear, make note on the record--- N.H. If foetel movements are felt by nurse, put an X, and if patient says that she feels the baby move, put XX in the space on the record for recording the foetel heart rate. Get specimen of urine either to take to the station for examination or to examine at once for specific gravity, reaction, and albumen, in accordance with instructions given in Sanders,' pp. 274-286. Have the patient cleanse vulva before voiding, and void in a clean vessel. If any abnormality in amount, color, or specific gravity, or trace of albumen, report to the doctor or midwife in charge of the patient, if patient has engaged one; if not, use every effort to get the patient under the care of doctor. Teach patient to measure the amount of urine voided in 24 hours before your next visit. Empty a milk bottle of water into a suitable vessel and mark the top level of water on the vessel. Then ask patient to void in the toilet on getting up in the morning; then for the rest of that day and night and the following morning on getting up to void in the vessel, and to note so as to report to the nurse, how much above or below the quart mark the total amount of urine comes.

       On the first visit leave the pink card with the date of the next visit. As soon as possible leave the Maternity Center leaflet--Advice to Mothers--after having gone over it carefully with the patient. Note on the record when the leaflet is left. Leave also the list of baby's supplies and mother's supplies. Leave addressed postal to be used in case of emergency or to announce the arrival of the baby. Tell patient about telephoning or coming to the center or station whenever she would like to see the nurse or ask her a question. Then before going to the next patient fill out field card in accordance with instructions; note in pencil the date on which the next visit is due.

Teeth

       On an early visit examine teeth and show how to keep clean. Where possible, urge a visit to the dentist or dental clinic for prophylactic treatment. Explain that it is not wise to have extractions done during pregnancy without consulting a doctor, but that cleaning and temporary fillings may be done with much saving of teeth.

       On one visit about the seventh month ask to see the layette and advise about it, going over the list of baby's supplies. Urge the patient to visit the center and see the model layette and get help in the choice of materials and patterns. Note on record if the layette is not complete by the eighth month. Demonstrate the preparation of the bed for the baby, made from a clothes basket, soap box, or in a baby's carriage, similar to the model at the center. If the patient is to be delivered at home, some time after the seventh month, ask to see the mother's supplies, going over the list. The patient should be discouraged from her usual plan to use the oilcloth from the kitchen table as a bed protector, and especially urged to prepare bed pad like the model at the center. Note on the report if mother's supplies are not complete by the eighth month. Advise about the arrangement of the room for the delivery, and demonstrate the preparation of the mother's bed like the model at the center.

EXHIBIT 4
ADVICE FOR MOTHERS
MATERNITY CENTER ASSOCIATION
18 West 34th Street, New York City.
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.

       DIET: Eat the food you are used to. Do not eat what you know gives you indigestion, or too much at any one meal.

Drink 8 glasses of water every day.

Drink all of the milk you can.

Do not drink any beer, whiskey, wine, or other alcohol. These hurt the kidneys and thus may poison the baby.

Do not eat meat, meat-soup or eggs or drink tea or coffee more than once a day.

       SLEEP: At least 8 hours every night with windows open.

       EXERCISE: 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.

       BATHING: Wash all over every day with warm (not hot) water, but do not get into a tub after the seventh month.

       GARTERS: Do not wear tight garters or any tight bands. The nurse will show you how to make suspender garters.

       CONSTIPATION: 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, stewed fruit, drink no tea, but all the water you can, at least eight glasses, hot or cold. Cook five cents worth of senna leaves with a pound of prunes and eat four to six prunes every day. If you have hemmoroids (piles) hold a 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.

       IMPORTANT: Do not have any sexual intercourse after the eighth 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 eighth month one set of baby clothes, to take with you to put on the baby when you bring it 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 of 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 a set of baby clothes ready for the nurse to dress the baby. Get out supplies needed for yourself.

       Telephone the MATERNITY CENTER if you need a nurse.

 

EXHIBIT 5
MATERNITY CENTER ASSOCIATION
18 West 34th Street, New York City.

MOTHER'S SUPPLIES

2 gowns. Vulva pads or supply of freshly
laundered old muslin.
1 pair white stockings.  
4 sheets. Cotton (absorbent).
6 bed pads. 2 wash-cloths.
  2 towels.
  4 oz. lysol.
  1 bedpan.

       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.

BABY'S SUPPLIES

       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 or suit the individual taste and pocketbook.

12 Diapers 18" x 18". 1 Basket or box for bed 15" x 30".
3 Bands 6" x 27". 1 Felt pad or folded blanket for mattress
3 Shirts, size 2, cotton and wool. 1 Oilcloth case for mattress.
3 Petticoats. 2 Muslin pillow-cases for mattress.
3 Slips. 2 Crib blankets, small size.
2 Squares 36" x 36". 2 Towels.
   Note: The squares are used instead of coat and bonnet until the baby is more than 2 months old. See model at the center. 2 Wash-cloths, old pieces of linen.
1 piece Castile soap.
8 oz. boric acid powder.
1 package absorbent cotton.
1 Oilcloth or rubber 12" x 18". 1 quart oil--sweet or albolene.
12 large safety pins. 1 package toothpicks.
12 small safety pins.

       Tray--fitted with:
       Glass jar for boric acid solution.
       " " " nipple swabs.
       " " " oil.
       " " " small toothpick swabs.
       Dish for soap.
       Cake of soap to stick pins in instead of a pin cushion.
       Newspaper cornucopias for waste.
       Bottle and nipple for giving baby water.

       Covered pail with borax water for soiled diapers.
       Jars for tray may be empty cheese, candy or jelly jars.

        

EXHIBIT 6

ROUTINE FOR POST-NATAL FOLLOW UP

MATERNITY CENTER ASSOCIATION

18 West 34th Street, New York City.

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 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 physician's cases if they dismiss case before baby is six weeks old.

Records of Post-natal Follow-up Patients

       If a patient has been a pre-natal case on whom you have done pre-natal nursing up to the time of delivery, flag record with blue flag, and yellow, if baby is to be seen at home, and put behind date you expect to visit. If patient is due to bring baby to you put blue flag, and white flag on, and file behind date patient is to visit station. If patient is a new case when reported to you for post natal follow up, record her in book as new patient reported in post partum period, and flag in the same way. If patient is one on whom you did early pre-natal nursing, and transferred when she registered at hospital, or dismissed because patient or doctor refused nursing care, use pink instead of blue flag, and do not count as an active case.

 

 

EXHIBIT 7

MATERNITY CENTER ASSOCIATION

18 West 34th Street, New York City.

 

MEDICAL BOARD

Dr. Josephine Baker President, Mrs. John S. Rogers
Dr. J. Clifton Edgar Treasurer, Mrs. Arthur S. Burden
Dr. Ralph W. Lobenstine Assist. Treas., Stephen G. Williams
Dr. Herbert B. Wilcox Exec. Sec'y, Christina C. Miller

        

Dr._______________________

__________________________

New York City.

My Dear Dr._______________:

       Mrs. ____________ who has engaged you for her care at delivery, has been referred to this association for nursing care.

       In order to make the work of the nurses of this association of a uniformly high standard, the Medical Board has adopted the enclosed routine for the nurses to follow.

       May we not have your cooperation in our effort to teach the women of the community the need for, and value of, medical supervision throughout their pregnancy?

       May we have your permission to instruct our nurses to visit Mrs. ____________ in accordance with our routine, and report each visit to you?

       A prompt reply on the enclosed slip will be greatly appreciated.

Cordially yours,

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