Practical Asepsis in Midwifery

Kai Tiaki : the journal of the nurses of New Zealand, Volume XV, Issue 2, 1 April 1922, Page 57

Practical Asepsis in Midwifery

A Lecture Delivered by Dr. Agnes Bennett.

A lecture on practical asepsis m midwifery was given at the Red Cross Rooms, Wellington, on March 14th, by Dr. Agnes Bennett. About 100 midwives were present. Miss Maclean, Director, Division or Nursing, was m the chair. The lecturer said: "] have had considerable difficulty to come to a decision as to what 1 would talk about to you to-night, and as this lecture is the outcome of the statistics that have recently been published on maternal mortality, 1 think it is only right to ourselves, as New Zealanders, to say that those of us who have considered the matter pretty closely do not feel perfectly certain that these statistics which place us third, practically, m the countries of the world as regards the highest maternal mortality, are quite correct. We w r ho have studied those statistics da not feel absolutely convinced that we take such a bad position m regard to maternal mortality. Nevertheless, there is a maternal mortality of some six deaths per thousand; that is to say, that of every thousand children born probably six mothers die. Well, certainly this seems bad, and we each must try and lessen it and make it better; but we are not convinced that our maternal mortality, compared to that of other countries, is really so bad. "I am very sorry indeed, for the sake of our patients, that so much has been made of this maternal mortality m the papers. As a matter of fact, only one woman m about 160 has even a chance of death, and m St. Helens Hospital here we have m 15 years had only 20 deaths. "During the last 20 years, the cause of puerperal sepsis has been discovered — probably a little earlier than 20 years ago — and we have had all these 20 or 30 years to modify our procedure with regard to childbirth, m order to lessen the. maternal mortality and to improve our conditions; and 1 do not think that we as practical participators m scientific research, have come up to the mark, m

that we have not done better for our tvomen m childbirth. "To-night, 1 thought 1 would base my remarks on the subject of what I will call 'practical asepsis.- 1 am not one m favour of very strict and complete sterilisation at the time of childbirth. 1 think it makes things too expensive, and we must, m regard to expense, save our women as much as possible. We must have efficiency, but we must also have economy. Of course we would like all that sterilisation and absolute asepsis, but for the sak^ of the State and for the sake of making childbirth as*easy a process for the mothers as possible (because naturally the poor woman cannot face a very expensive childbirth frequently), I think that we have to modify our procedure m order to meet the economic needs of our patients — modify it to a certain extent ; and tonight my practical asepsis is goimg to deal with what 1 consider a fair economic procedure for the majority of our mothers to encounter at the time of childbirth. "Now, what is sepsis/ We find that the larger proportion of our maternal mortality is due to sepsis. Well, sepsis is an. invasion of the body by micro-organ-isms, and now that we know how these micro-organisms live and where they live, of course we can set to and practically keep them m abeyance and get rid of them m just the same way as we can keep weeds from a garden. These organisms will take up their position and grow m exactly the same way as weeds will take up their position and grow, even m a little garden, if not frequently cleaned up. "Now, the particular little heaps of dust that these micro-organisms grow on are such material as bloodstains, vaginal iischarge, or milk oozing from the breast remaining on clothes close to the breast. Any organic discharge lying anywhere is a good growing-ground for these organisms, and the more growing-ground these have, the more strength they get into

their growth, they grow more powerful and more quickly and they can do more harm. Unfortunately, the organisms are so small that they can float about m the air, and the consequence is we may have an absolutely clean bloodstain ; but let this bloodstain remain on a bowl, a cloth or sheet, or on the floor, and at once the organisms float on to it from the ail 1 and begin to grow; but if these organisms had not found those discharges they would have remained m the air and remained innocuous. If you transfer thesv 1 to a raw surface, you can produce this disease of sepsis. In stuffy rooms, or m unventilated places, these organisms accumulate, and they become fai* more numerous than m a clean place. On the top of a mountain there are practically no septic organisms. So that means that habitual cleanliness and habitual ventilation means a great deal m keeping down the organisms, and there is no doubt that it is absolutely a necessity for all nurses and midwives. Cleanliness of their clothes, cleanliness of the rooms they sleep m, and habitual cleanliness, means a great deal m keeping these organisms at bay. Now we know so much of these organisms that we can make little gardens m test tubes, and we can watch and see exactly what kills them and what keeps them from growing; and the only one thing that really kills them is heat of boiling water or hot air. We can dry sterilise — a prolonged baking m an oven sterilises. Better still is the dry sterilisation we gel m the ordinary hospital sterilisers, and m the ordinary hospital sterilisers. Heat is the only complete steriliser that we "It is interesting to look at confine ments as they took place m, some of the native races, and see if they have any of the procedure which we have developed for keeping free of these organisms. Well, probably some of you have had something to do with the Maoris, and T believe it is their procedure — or it was m the old days — for the woman m labour to go a little apart from the village, out into the forest, and she used to hang on to a branch, and she dug a small hole m the. ground — sometimes she took another woman with her. She knelt over this

hole, delivered the child with her own hands, and the placenta was buried m th c ground and no one touched it. Any discharge at the time was left m the forest ; there were no vaginal examinations, and the child was, of course, not clothed; and, therefore, sunlight and fresh air played freely about the mother and child, and there was very little death from sepsis. "The use of the upright position has gone out too much. T think it would be a useful thing if patients would realise thai they could quite well manage their own babies at the time of birth if they were kneeling. The modern left lateral position, of course, changes things very much. We have to give the amount of help which civilisation has demanded, and civilisation has rightly demanded as much help as possible for the woman at this painful period, but this position has considerably increased the danger of sepsis. Now we have to fight all the time these invisible germs that I have been talking about, and the hard part is that we fight so often, and so often successfully, that we do not realise that we have a fight at nil. In our early .days we thought a great deal more of asepsis than later on, when we begin to think, perhaps, the dangers have been magnified. "It was a curious thing, many years ago, that two maternity hospitals m the cities of Paris and New York wer? over slaughter-yards, and the organisms ' had every chance to grow on thfc offal of the slaughter-yards, causing epidemics of sepsis; and it was nothing m these waves of epidemics to have 80 or 90 women m these hospitals die, and people used to gen quite frantic over it. Even T remember hearing of an epidemic m a maternity hospital and the panic it caused. "Now the way to fight those germs is to exclude all possibility of their living on organic matter m close proximity, and I think the next thing we have to consider, apart from our surroundings, cleanliness, and so on, is the skin. First of all, the nurse's own akin; and secondly, the skin of the patient. Now every nurse should know how to take care of the skin of her own hands. You know the skin is

an organ — it is a membrane that covers the whole of our bodies and practically binds us together. The use of soap constantly on the hands eventually dries the skin until there is no natural grease left m the skin and it becomes hard and little cracks appear. These are known as chaps. These chaps are very dangerous, and m them the organisms find' growingground. The skin requires moisture and grease, and if you are constantly removing these things you have to add them artificially, and there is no doubt about it thai glycerine and water art' invaluable m restoring the skin; but, of course, the glycerine will not restore the sebaceous material, and for this the best thing is lanoline. The way to treat your hands m winter is to treat them alternately with lanoline and glycerine, drying them thoroughly; then put a little glycerine and water on them, and m that way the most tender skins can be kept m most supple, smooth order. The drying of the hands carefully is most essential, as if you leave a certain amount of moisture on your hands it makes the hands colder than they would be naturally. Dry your hands thoroughly, and treat them with grease and glycerine and water, and you supply the things you have taken away. "Nails often become a very serious question to a nurse. If you have an inflammation at the root of the nail, the only way to get at it is to lift up the quick and get some packing at the root of the nail. Thus you have a chance of getting at the inflammation. There are nurses and surgeons who have had to give up their nursing and surgery on account of these troubles, and the only way to get rid of them is to work away until you can get at the source of the inflammation and keep it packed with sterile material, and give the inflammation a chance to throw out the discharge, and then you liave n chance of getting rid of it. Hang-nails are also a source of infection, and the only way to get rid of them is to treat your hands m the way I have told you. "With regard to hand-washing, there is no question but that the best kind of washing is under the running tap. Tt is a curious thing that m some nations they

would never think of washing their hands m a basin of water. They would rather pour water over their hands from a disli or bowl. If there are micro-organisms hanging about your hands, and you wash pour hands m a bowl of water, you are apt to take them out of the bow] of water with the organisms on them. "Now with regard to the skin of the patient: 1 am not going to deal with the bath and the preparation she should have. There is no doubt that the skin of the vulva is a bad source of contamination, and it is quite possible, m the majority of cases where sepsis occurs thai the organisms are carried from the vulva up to the vagina. We have got to be as careful of the patient's skin as of our own hands. There is no doubt about it that the best plan is to give the vulva a thorough dabbing over with iodine, after thorough washing and cutting the hair. It is a mistake to try to rub m iodine. It is better to dab it. "It does not do to iodine the patieni only some two or three hours before the perineum is stretched. You must iodine the patient at the time that the perineum is stretching. Of course, every nurse should realise how, m using swabs, you must put your clean swab on the spot that you want to be swabbed, and swab away from it, i.e., never swab towards the vulva. "Now just one word about douching. There are some people who do not realise what the vaginal fluid does. There arc so many different organisms m the vagina that they have been termed vaginal flora. A good many of you have heard about this so-called Bulgarian organism — which is the old method which the Bulgars used for fermenting their milk. They never minded what sort of milk they drank. They milked their sheep, cows, camels, etc., and mixed it all together, and the resulting sour milk contained lactic acid, which killed all other organisms. This same lactic acid is found m the vagina, and protects the vagina from all other organisms. Hence we must not douche away this protective fluid. "Although we have entirely given up the process of douching, there are still people who think it is right to douche the

vagina before labour and after labour. It is not right to douche unless for special purposes. If you have had to do a great deal of manipulation, then you douche for fear you have introduced organisms on the arm that lias had to go into the vagina, or on the hand that has had to go into the uterus. Apart from operations such as this, it is not right to douche the vagina. "The only way we have of killing the organisms is by boiling, and then the question comes of sterilising instruments,, Of course all nurses are called upon to sterilise forceps sooner or later. Some people think that it is not really necessary to boil the forceps, that if you want to sterilise your forceps you must have a special fish-kettle, or something of that kind. Now you can sterilise them m a big iron kettle, first of all putting the handles down and boiling them thoroughly. Then take a sterilised cloth, and catch hold of the handles with the sterilised cloth, and they put the forceps m the water and thoroughly boil them. What is better still is to have a proper sterilising basin, and it is very easy to have a sterilised towel and wrap them up m this towel. "I think we might divide the nurse's duties into three periods, and we will call these the ante-natal duties, the duties at the time of birth, and the post-natal duties. T think the pre-natal duties are very much neglected by both nurses and doctors, and I would like to impress upon you the need, if you knoAv you are to have a confinement m a private house, of going to that house and inspecting the house. You should go to the house beforehand, and see what they are going to give you for the labour. You should demand either a single bed with a fairlyhard mattress, or you should demand boards to put across the springs of the ordinary double bed. The nurse should also see that there is decent daylight and nio-ht-light m the room. There is a mistake which is often made, and that is that macintoshes are not large enough. There should also be space to move round the room, and you should persuade your patients to move a little of their furniture m those rooms where you have little space.

"Finally, for the pre-natal care, I should say that the preparation of what we call the 'sterilised kit' is important. The poorest woman can generally provide romo clean rags and a pillow-slip. These can be sewn up m separate bags and put into the pillow-slip, which is also sew T n up, and these are boiled. The whole is hung up on a line to dry, and put away till nurse undoes the tightly-stitched bag. Tf every woman was looked upon as having to prepare such a convenient kit, nobody would think it a hardship. The SAvabs should be put m order, and there should at least be one sterilised draw-sheet and a sterilised cloth to put over the table m a case Avhcre there is an operative procedure. There is no hardship m that. Old sterilised linen must be used for pads and burnt. It is a mistake to use toAvels for pads. If possible, it is good to have two squares of old sheeting sterilised, for the doctor and the nurse to Avear. Of course sterilised overalls are the ideal type of garment, but tfc is difficult for nurses and doctors to always have a sterilised gown. "Now for the duties at the time of birth. If there is no sterilised kit ready for you, you should at once boil up some swabs on reaching the patient's house. There is one thing you will always want, and that is sterilised swabs m preparation for the confinement. One should also have sterilised pads for the first two or three days: there is no question about it. "With regard to -the labour itself, of course the question always comes to the nurse: Is the nurse to make a vaiginal examination? My advice is never to make a vaginal examination without the permission of the doctor. Avoid vaginal examinations, for the greatest source of trouble m all our septic^ cases is from vaginal examinations. Undoubtedly many people do not realist the value of putting the ear down to the abdomen and hearing wheiv the heart is. The procedure of a nurso should be this: she comes, to a patient and sees that the patient is fairly well on m labour. She should then warn the doctor that she is working for — that the padent is m this condition, and ask the doctor if he wishes her to make a vaginal

examination ; but do not make that vaginal examination without authority, and warn your doctor that he is likely to be wanted within a few hours. 'I do want you to realise the danger oi fgecal matter.' The only way to deal with it is to have dozens of swabs, and every time the slightest bit of faecal matter appears, to wipe it away. Do not run any risks; 30, 40 or 50 swabs are not too many. "When you are putting the iodine on the vulva, great care must be taken to apply it thoroughly, as it is xory difficult to introduce the forceps aseptically and without touching* the outside skin. "During the time the doctor is introducing the forceps is the time you have to help the doctor all you can. It is a very difficult job for the nurse to do this at this moment, and I think the whole thing is fraught with difficulty for tne nurse. She must be very quick, and as soon as the child is born she must lift the

patient on to her back and slip round to the other side and tie the cord. You must watch what your doctor wants and follow his ideas. Every good soldier has to follow his leader exactly and give up his own ideas. i( I have repeated what a great many 3f you know, and perhaps it has been fairly boring to a great many of you; but T think if anyone can go away with a fresh idea, it is of importance to the community; and I hope that you won't think it has not been worth your while coming. "Next week T propose to deal with the subject of diagnosis without vaginal examination, and if there are any of you who would like to ask questions or to suggest subjects for the next lecture, T am willing to answer any question or accept any suggestions/ Miss Maclean proposed a hearty vote of thanks to Dr. Bennett for her lecture, and this was carried by acclamation.