Chapter IV: Part 4

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

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

The matron must have two rooms.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

_DESCRIPTION OF SKETCH-PLANS OF PROPOSED INSTITUTION._

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

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

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

_PLAN III_

SCALE ¹⁄₁₂₀

_M & N HANHART, LITH._

_W. F. OMMANNEY,
L^T. R. E._
]

_PLAN IV_

SCALE ¹⁄₁₂₀

_M & N HANHART, LITH._

_W. F. OMMANNEY
L^T. R. E._
]

PLAN III.

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

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

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

PLAN IV.

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

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

PLAN V.

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

This plan gives a sketch of an arrangement of pavilions, offices, quarters, &c., forming a complete lying-in institution and training school. As already stated, such an institution must, from its very objects, be situated in a town where land is scarce and valuable, and this is a chief difficulty in erecting it. Hence it has been necessary to keep the different parts as close together as possible, and yet not to crowd them so as to interfere injuriously with the external ventilation. The mere architecture, as will be seen, has been subordinated to this necessity, but it must be borne in mind that utility, and not architectural effect, is to be sought for.

In the centre of the plan project the quarters for pupils, on three floors, ten quarters on each floor. They are arranged in this way to enable the reliefs to be taken from one floor at a time. Behind these, in the same block, are quarters for matron and midwives, waiting-room, surgery, stores, kitchen, and pupils’ dining-room. The general entrance is in one side of the centre block. The two front pavilions, on either side the centre, contain the delivery wards, two on each floor. Each delivery pavilion contains a ward for three beds on each floor, with its bye-ward and offices. Only one delivery pavilion will be in use at one time. While one pavilion is in use, the other will be vacant, and undergoing ventilation and cleansing. These delivery wards are connected with the centre, and with all the pavilions on each floor by a nine-feet corridor, with crosslight and ventilation. Fire-places are shown for warming in winter. On the ground floor are three four-bed wards, with offices, on each side, on the construction shown on Plan III. There will thus be twenty-four lying-in beds, and six delivery beds (but three delivery beds and 20 lying-in beds only in use at the same time) on the ground floor. The second pavilion from the front, on each side, is only one storey in height, so as to afford a freer circulation of air among the pavilions in the space within which it might be necessary to place them.

As a consequence of this arrangement there would be only four lying-in wards, of four beds each, on the upper floor, together with a delivery ward at each side (one delivery ward to be used at a time).

A special detached ward for febrile cases is shown behind the building.

The total accommodation in an establishment of this size would be sufficient for 6 simultaneous deliveries and 32 to 36 lying-in women. There would be 6 delivery beds always resting, and 4 or 8 lying-in beds always unoccupied. There would be training accommodation and facilities for 30 pupils.

_PLAN. V._

PLAN

OF A

LYING-IN INSTITUTION.

FOR 40 (32 TO 36 OCCUPIED) BEDS.

WITH TRAINING SCHOOL FOR 30 PUPIL MIDWIVES.

_W.F. OMMANNEY L^T. R. E._ _M & N HANHART, LITH._
]

REFERENCE.

A _Administration_

B _Kitchen and Stores._

C _Delivery Pavilions._

D _Ward Pavilions_

E _Segregation Pavilion_

APPENDIX.

_MIDWIFERY AS A CAREER FOR EDUCATED WOMEN._

MY DEAR SISTERS (or rather, Chers et très-honorés Confrères),

While all that we women think about is to have the same education as men in medicine, must we not feel the women’s medical movement to be rather barren when it might be so fruitful?

But public opinion in England is not free enough for a coward to dare to say what she thinks, unless at the risk of having her head (figuratively) broken.

Is there not a much better thing for women than to be ‘medical men,’ and that is to be _medical women_?

Has not the cart been put before the horse in this women’s medical movement?

Here is a branch so entirely their own, that we may safely say that no lying-in would be attended but by a woman if a woman were as skilful as a man—a physician accoucheur.

Yet, instead of the ladies turning all their attention to this, and organising a midwifery school of the highest efficiency in both science and practice, they enter men’s classes, and lectures, and examinations, which don’t wish to have them, and say they want the same education as men.

Then, is there not an immense confusion as to whether they are ever to be called in as medical attendants to men?

‘No,’ say those lady doctors who have at all thought out the question. ‘We wish to be educated as if we were going to attend men, but we should think it an insult to be called in to attend men.’

Why not adjourn for a century, or for half a century, the question whether _all_ branches of medical and surgical practice shall be exercised by women, even upon women? It is a question which may safely be left to settle itself.

But here is a matter so pressing, so universal, so universally recognised, viz., the preferable attendance of women upon women in midwifery, that it may really be summed up thus:—Although every woman would prefer a woman to attend upon her in her lying-in, and in diseases peculiar to her and her children, yet the woman does not exist, or hardly exists, to do it. Midwives are so ignorant that it is almost a term of contempt.

The rich woman cannot find fully qualified women, but only men to attend her, and the poor woman only takes unqualified women because she cannot afford to pay well qualified men.

But why should the midwives be ignorant? and why (in the great movement that there is now to make women into medical men) should not this branch, midwifery, which they will find no one to contest against them—not at least in the estimation of the patients—be the first ambition of cultivated women? Is there any rational doubt that, suppose there were a man and a woman, both equally versed in midwifery art and science, the woman would be the one sent for by all lying-in women?

There is a better thing than making women into medical men, and that is making them into medical _women_.

Surely it is the first object to enable women, by the most thorough training, practical and scientific, to practise that branch of the art of medicine which all are agreed should be theirs, _not_ ‘like men’—for nearly all the best men are agreed how deficient are the practical training and opportunities of medical students, especially in midwifery, which deficiency yet does not prevent them from obtaining diploma, license, all they want, in order to practise—_not_ ‘like men’ then, but like _women_, like women who wish to be real physician accoucheuses; that is, to attend and to be consulted in all deliveries, abnormal as well as normal, in diseases of women and children, as the best accoucheurs attend and are consulted.

Sensible women say, ‘But the only means to obtain a scientific education _is_ to enter men’s classes.’

_Is_ that the case?

Is the student’s scientific and practical education all that could be wished?

Could there not be given (and _is_ there not given, in some Continental schools?) a far more thorough and complete scientific education, as well as practical, where there are none but women, in a midwifery school, without all this struggle and contest, which raises questions so disagreeable and ridiculous that a woman of delicate feeling shuns the indelicacy of the contest—_not_ the indelicacy of the occupation?

The parody, the _qui pro quo_, is a curious one.

The indelicacy of a man attending a woman in her lying-in is by necessity overlooked.

The indelicacy of a woman attending with men in medical classes is made much of.

Would it not be far better to get rid of both at once? to have women—trained with women, by women—to attend women—trained in all branches of a scientific and practical midwifery education?

But let no one think that real midwifery education can be less complete and thorough for a woman than it ought to be for a man, if women are really to be physician accoucheuses.

And let no one think that two or three courses of lectures—a month, three months, six months at a lying-in institution, conducting twenty, thirty, or one hundred labours—will make a woman into a (real) midwife.

One hundred labours may be normal, requiring no interference but that which a good midwifery nurse can give. The one hundred and first may be abnormal and may cost the patient her life or health, the attendant her reputation and peace, if her education has been nothing but the few lectures, the few weeks, the few labours.

Let us suppose for a moment that, leaving aside the ordinary talk of giving a woman a ‘man’s medical education,’ good or bad, we imagine what a college might be to give the whole necessary training—medical, scientific and practical—to make real midwives, real physician accoucheuses.

There must be first, of course, the lying-in institution, the deliveries conducted by fully qualified head midwives, of whom enough perhaps exist already for this purpose, who will give practical instruction to the pupil midwives at the bedside.

There must be a staff of professors, to give scientific instruction in midwifery, but also in anatomy, physiology, and the like; in pathology and pathological branches; above all, in _sanitary_ science and practice.

Dissections and post-mortem examinations will have to be practised. It need not be said that these must be at a quite different time and place in the ‘course of education’ from the training about the lying-in patients.

Probably all these professors, or nearly all, must at first be men.

Probably in time all these professors, or nearly all, will come to be women.

The course of education, before the end of which no pupil can receive the certificate of a fully qualified midwife, must certainly not be less than two years.

_Is_ this merely an ideal? _Is_ it an Utopia? Have we never seen it in practice? Could it not be put in practice in practical England?

Seen it in practice we have—save and except the _sanitary_ practice, which is wofully deficient—on the continent of Europe.

And lady professors there have been in midwifery on the Continent quite equal to the most distinguished physician accoucheurs in this or in any other country; who took their place among these, among the Sir James Simpsons and the Sir Charles Lococks, as _of_ them, and not outside of them, in all midwifery matters, scientific as well as practical.

The names of Madame Boivin and Madame Lachapelle, of Paris, are known to all Europe. And there are many other names of lady professors in midwifery and of midwives, not known in England at all, who take their uncontested places on the continent in practice, in consultation, in teaching, as a Sir James Simpson here. They teach in midwives’ colleges, and imperial and royal ladies _are_ sometimes, and often wish to be always, attended by them.

_Note._—A society has already existed for several years, the object of which, according to its programme, is ‘to provide educated women with proper facilities for learning the theory and practice of midwifery, and the accessory branches of medical science.’

The programme states most justly that, for want of these, for want of ‘proper means of study,’ of ‘any public examination,’ ‘any person may undertake the duties of a midwife.’

Let us look what the ‘proper means of study’ are which it provides.

They are—1. Attendance upon lectures during two winter sessions. 2. Attendance ‘during the intervening summer’ upon clinical practice at ‘_a_’ lying-in hospital or maternity charity, with personal attendance upon at least _twenty-five_ deliveries!

[It is easy to make a rough calculation how many cases of abnormal parturition occur to how many normal. Is it likely that among ‘twenty-five deliveries’ there will be abnormal cases enough to practise the pupil-judgment, the pupil-hand?]

These ladies have not even the advantages which the idlest student can hardly help availing himself of—and _his_ minimum is ‘three years.’ Yet this is the course proposed to enable a woman to ‘practise midwifery,’ even in the sense in which we understand a man to ‘practise midwifery,’—to enable a woman to become a physician accoucheuse (for these ladies are expressly styled ‘accoucheuses’) in the sense in which we understand a man to be a physician accoucheur.

The paper states, doubtless with truth, that these ladies ‘are the best taught accoucheuses hitherto accessible to the English public.’ May we not hope that, in future years, the society will be enabled to give ‘accoucheuses’ still better taught ‘to the English public’?

LONDON: PRINTED BY
SPOTTISWOODE AND CO., NEW-STREET SQUARE
AND PARLIAMENT STREET

-----

Footnote 1:

Exclusive of the case of a poor woman who was delivered in a cab, and
died in the hospital of _post partum_ hæmorrhage.

Footnote 2:

‘So was confined in No. 4 ward.’

Footnote 3:

Patient died 48 hours after delivery.

Footnote 4:

Patient died on her way to the hospital: not included in the
calculated rates.

Footnote 5:

One case had gastric fever on admission, and in two cases puerperal
peritonitis came on after instrumental delivery.

Footnote 6:

In 1868, 69, 70, there were in Liverpool workhouse, 1,416 deliveries,
including 20 premature, and 6 deaths from all causes, of which 3 at
least were non-puerperal. The _total_ death-rate was only 4·2 per
1,000. There were 13 London workhouses in which, in 5 years, 2,459
deliveries, but no deaths in childbed, took place.

Footnote 7:

Exclusive of a fatal case delivered in a cab.

Footnote 8:

One delivery took place in a cab, and the woman died in hospital.

Footnote 9:

Husson, ‘Étude sur les Hôpitaux,’ p. 254.

Footnote 10:

Tables XI., XII., XIII., abstracted from the ‘Statistique médicale des
Hôpitaux de Paris.’

Footnote 11:

This drain was shown on the Plan from which Plate I. is taken.

Footnote 12:

Premature births: Seven months, 8; deaths, 5; six months, 6; deaths,
6; five months, 1; death, 1.

Footnote 13:

1 puerperal convulsions, 1 bowel disease.

Footnote 14:

1 after instrumental labour, 1 metritis.

Footnote 15:

1 heart disease, 1 dropsy.

Footnote 16:

The approximate number of deliveries, 6396, given elsewhere, is rather
under the mark than over, as will be seen by this Table, and is taken
in order to be on the safe side. For, up to the three last years, the
numbers are rather estimated than reckoned from the records. The total
annual average deliveries calculated from different monthly records,
i. e. 10 years of months = 500 in round numbers—1858–1867.

The three years 1868–9–70, for which only there are accurate records,
speak for themselves; and they show that the death-rate is
marvellously low: not higher than in the healthy districts of England.

Footnote 17:

An attempt has been made in certain cases to account for the high
death-rates of lying-in hospitals from the large proportion of
unmarried women admitted. This opinion is directly contradicted by the
experience of Liverpool workhouse, where out of 1,401 deliveries of
women, 936 of whom, or two-thirds, were unmarried, there were only 6
deaths = 4·2 per 1,000 death-rate.

Footnote 18:

In Lambeth and St. Pancras the wards are generally full.

Footnote 19:

These arrangements are commonly the same in civil lying-in
institutions.

Footnote 20:

I call a midwife a woman who has received such a training, scientific
and practical, as that she can undertake all cases of parturition,
normal and abnormal, subject only to consultations, like any other
accoucheur. Such a training could not be given in less than two years.

I call a midwifery nurse a woman who has received such a training as
will enable her to undertake all normal cases of parturition, and to
know when the case is of that abnormal character that she must call in
an accoucheur.

No training of six months could enable a woman to be more than a
midwifery nurse.

Footnote 21:

In some London workhouses it is yet larger.

Footnote 22:

The only difficulty is as to protecting the patient (a lying-in woman)
during the transit in cold or wet weather; but perhaps some cover
might be contrived for the bed or litter on which she is carried,
which would be light, easily removable, and which could be exposed to
the free action of the open air when not in use.

Footnote 23:

For a great part of the foregoing details of management I am indebted
to the valuable experience of her, who, as then Superior of the
nursing at King’s College Hospital, conducted our Training School for
Midwifery Nurses there, so kindly, so wisely, and so well, that its
necessary breaking up was the more to be deplored by all.

------------------------------------------------------------------------

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TRANSCRIBER’S NOTES

● Typos fixed; non-standard spelling and dialect retained. ● Used numbers for footnotes, placing them all at the end of the last chapter. ● Enclosed italics font in _underscores_. ● The caret (^) serves as a superscript indicator, applicable to individual characters (like 2^d).