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for Teaching Mid wives

United States Department of Labor
Children's Bureau Publication No. 260
Federal Reserve Bank of St. Louis
Federal Reserve Bank of St. Louis

ÏOÏ&'W r£ (1

for Teaching Mid wives
A N IT A M . JO N E S , R . N .

Bureau Publication N o. 260

* *'


United States Government Printing Office, Washington : 1941
F o r s a le b y th e S u p e rin te n d e n t o f D o c u m e n ts , W a s h in g to n , D . C .
Federal Reserve Bank of St. Louis

P rice 30 cen ts
Federal Reserve Bank of St. Louis


Foreword_______________________________________ ______________________________________
Planning an institute__________________________________________________________________
Teaching equipment______________________________________________________________
The midwife’s standard equipment________________________________________________
Lesson I.— The midwife and her service to mothers____________________________________
II.— Inspection o f the midwife’s standard equipment____________________________
III. — The prenatal period_____________________________________________________
IV. — Making the supplies____________________________________________________ _
V.— The mother’s preparation for delivery_____________ ;________________________
VI.— Making a delivery bed__________ _____ ._____________________________________
VII.— The midwife’s preparation of herself________________________________________
V III.— The hand scrub____________________________________________________________
IX .— Labor____________________;______________________________r d .________________
X .— The soapsuds enema_______________________________________________________
X I.— The care of the baby’s eyes________________________________________________
X II.— The midwife’s management during the first stage o f labor___________________
X III. — The midwife’s management during the second stage o f labor____ _________
X IV . — Some midwife procedures during the second stage o f labor_______________
X V .— The midwife’s management during the third stage o f labor__________________
X V I.— A practice period___________________________________________________________
X V II.— Aftercare o f the mother and baby__________________________________________
X V III.— The birth certificate________________________________________________________
X IX .— A review___________________________________________________________________
X X .— A practice period___________________________________________________________


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Federal Reserve Bank of St. Louis

[Illustrations marked * from New York Maternity Center Association]


F igure


Arrangement of the classroom_______________________________________________
Closed bag__________________________________________________________________
6 •
Open bag, lining over the edge, and each article laid out on the table________
Bag showing arrangement o f contents_____________________
Bag showing closed lining_________________________
Pattern o f lining for bag_____________________________________________________
Completed lining o f bag_____________________________________________________
Midwife’s apron. Three views_____________________________________________
One o f the four muslin cases. Two views_________
Pattern for midwife’s cap--------- -------------------------------------------------------------------14
Completed cap_____________________________________________________________
Pattern o f mask_____________________________________________________________
Folding the cheesecloth for the mask-------------------------------------------------------------------- 15
Completed mask____________________________________ '---------------------------- -----15
Making one gauze sponge for cord dressing. Step 1, two views______________
Making one gauze sponge for cord dressing. Step 2, two views______________
Making one gauze sponge for cord dressing. Step 3, two views---------------------17
Making one gauze sponge for cord dressing. Step 4, two views______________
Completed cord dressing consisting o f two sponges___________________________
Making paper wrapper______________________________________________________
Making paper wrapper______________________________________________________
Placing contents in wrapper. Five views____________________________________
Package completed for sterilization. Five views_____________________________
Doctor’s examination. Ten views___________________________________________
Outcome o f pregnancy in untreated syphilis---------------------------------------------------------- 30
Outcome of pregnancy— syphilitic pregnant women receiving treatment for 5
months or more during pregnancy-------------------------------------- ----------------------30
Model of brassiere supporting breasts-----------------------------------------------------------39
Making newspaper bag. Four views------------------------------------------------------------43
Making newspaper pan. Three views---- ----------;------------------------------------------43
Making newspaper pads. Three views---------------------------------------------------------44
Making sanitary pads. Six views---------------------------------------- — :-------------------45
Making cotton balls. Three views________________________ _________________
Supplies for delivery____________________________________________________ ____
Supplies for the baby________________________________________________________
Board placed under mattress in preparation for delivery._____________________
Room arranged for delivery_________________________________________________
Mattress protected by newspapers----------------------------------------------------------------56
Bed made with newspaper pads and newspaper p a n _________________________
Equipment for scrubbing hands____________________________________ .----------- 62
Two views o f bony ring--------------------------------------------------------------------------------65
Demonstrating first stage o f labor with bag and doll— how uterine contractions
open the cervix. Two views______________________________________________
Demonstrating first stage o f labor with bag and doll— why “ bearing down”
during first stage does not help____________________________________________
Relation o f full bladder and full bowel to position o f baby’ s head------------------77
Preparation for enema________________________ _______________ ______________
Funnel and pinched tube used for enema_____________________________________

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F igure 44.

Giving enema-----------------------------------------------------------------------------------------------Care o f the baby’s eyes____________________________________________________ _ ^
Putting drops in the baby’s eyes_____________________________________________
Equipment in kitchen for second stage o f labor______________________________
Equipment in bedroom for second stage of labor_____________________________
Mother “ pushing” _____________________________________________
Opening sterile package. Four views________________________________________
Supplies on table in delivery room___________________________
Opening sterile package_____________________________________________________
Birth o f the head. Four views______________________________________________
Holding up baby by his heels________________________________________________
Position o f baby before cord is cut___________________________________________
Feeling the throbbing cord__________________________________
Tape with knot at one end___________
Tying first loop o f square knot. Step 1_____________________________________
Tying first loop of square knot.Step 2, two views. __________________________
Tying first loop o f square knot. Step 3_____________________________________
Tying first loop o f square knot. Step 4_____________________________________
Tying first loop o f square knot. Step 5________
Tying first loop o f square knot. Step 6 _____________________________________
Tying second loop o f square knot. Step 1, two views________________________
Tying second loop of square knot. Step 2___________________________________
Tying second loop o f square knot. Step 3___________________________________
Two cord ties in place___________________________________________ ____________
Picking up scissors to cut cord_______________________________________________
Cutting cord between ties___________________________________________________
Looking for bleeding from stump____________________________________________
Retying cord_______________________________________________________________ .
Putting on cord dressing____________________________________________________
Cutting ends o f tape______________________________________________________
Applying second sponge_____________________________________________________
Applying binder_____________________________________________________________
Baby in receiving blanket____________________________________________________
Baby in bed_________________________________________________________________
The afterbirth. Two views_________________________________________________
Placing mother on clean newspaper pad_____________________________________
The first nursing____________________________________________________________
Nursing the baby___________________________________
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This ma.niifl.1 was prepared by Anita M . Jones, R. N ., nurse-midwife,
assistant director of the Maternity Center Association, New York City,
for the use of nurse-midwives and others responsible for the supervision
and instruction of untrained midwives under the auspices of State and
local health departments, to teach them: (1) to use aseptic techniques;
(2) never to interfere with the delivery of the baby; (3) to call the doctor
at the first sign of danger. As the number of women being delivered by
untrained midwives, though considerable, is reported to be steadily
decreasing, this plan of instruction for midwives is directed only toward
meeting the acute need for improving the standards of the untrained
midwives now practicing until they can be replaced by nurse-midwives
or physicians. Thus it may have a place in improving the maternity
care offered in a transition period, while efforts continue toward putting
into practice throughout the United States a standard of maternity care
that calls for skilled medical and nursing services for every mother, or at
least the services of the nurse-midwife in localities for which it is not
practicable to provide skilled medical services.
It is hoped that this manual will assist the nurse-midwife in the
technical teaching and supervision which she gives to the practicing mid­
wives who have not had special training and preparation. It is not in
any way a textbook on midwifery, nor can the classes for midwives that
are based on it be considered as “ courses in midwifery.” It is written
simply, with frequent use of colloquial terms, so that the nurse-midwife
will be able to present her instructions in language that the midwife will
understand—the midwife who is without training and without formal
education, who often can neither read nor write.
Undoubtedly there are many untrained midwives now practicing
who cannot be taught all the material in this manual. Even when
untrained midwives have been taught according to this manual they
will not be adequately trained attendants at delivery. It is hoped, how­
ever, that their work will be less hazardous to the patients than it now is,
because they will have been given some instruction in the elementary
principles of personal hygiene and asepsis as well as improved techniques.
Their responsibility for securing medical examinations for the women
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in their care and for calling a doctor when any abnormal condition
develops is of course constantly stressed.
As the midwife usually works alone, the procedures have been
developed as far as possible so as to show her how to maintain good stand­
ards while working without assistance during normal labor and delivery,
usually in very simple surroundings.
It is realized that the standards for equipment and procedure recom­
mended here are in some instances below those required in States where
the practicing untrained midwives have had supervision and instruction.
Frequent revisions to raise the standards set forth in the manual will be
essential if it is to continue to be useful.
Sincere thanks go to the doctors, nurses, and midwives whose coop­
eration made the preparation of this manual possible; to the Maternity
Center Association of New York City for permission to use cuts from its
publications and for consultation and criticism during the preparation of
the text; and to the National Tuberculosis Association, the American
Social Hygiene Association, and the National Society for the Prevention
of Blindness for criticism of the text relating to their respective subjects.
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Manual for Teaching Midwives
Planning an Institute
This manual covers the classes, demonstrations, practice periods, and
teaching equipment for an institute for midwives. The teaching will be
more successful if the following conditions are assured when the institute
is being planned.
a. A small group of midwives.

Because the midwives are, for the most part, unused to learning from
group instruction the group should be kept small enough for the supervisor
who is conducting the institute to give individual attention to each mid­
wife. This is practically impossible if there are more than 15 in the
group, and it can be done most satisfactorily if there are not more than 10.
It will be necessary, therefore, to hold institutes for each group of 10 to 15
midwives in the area covered by the State or county supervisor of midwives who is giving the institute. In selecting the town and the group for
each institute the transportation facilities that will be available for each
midwife should be considered so that her capacity to learn will not be
reduced by the fatigue of long, tiresome travel.
b. Simple informal classes.

The talks should be so ^simple and direct that the midwives will feel
free to discuss their problems and question anything that is not clear to
them. Their confidence must be gained in the first session so that they
will lose any suspicion they may have had of the new and unknown. Thenlanguage and expressions may be used until they have learned the few
commonly accepted medical terms that will make it possible for them to
report intelligently to the doctors.
c. Realistic demonstrations.

The setting for each demonstration, especially those on management
during labor, should reproduce as far as possible the situations in whicd
the midwife will work. This means that the teaching equipment should
include only those things which the midwife will find in the homes, will
teach the mother to prepare, or will bring with her in the midwife’s
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standard equipment. The housefurnishings can probably be assembled
locally; the other articles have been planned so that they will pack for
easy transportation in the supervisor’s car. As patients cannot be pro­
duced to order for a demonstration, nor the actual processes of labor and
delivery delayed or interrupted to allow tune for questions and special
emphasis, dolls must be used instead of a mother and a baby. Dolls
especially made for demonstration purposes are best, but home-made
rag dolls may be used. A cord fastened to a doll’s abdomen with adhesive
may be used as an umbilical cord.
The midwife’s standard equipment should be exactly like the equip­
ment the midwife is expected or required to use—spotlessly clean, freshly
laundered or well pressed with a hot iron, in perfect working order, and
conveniently arranged for use. The cap and gown should fit the super­
visor who is demonstrating just as the midwife’s should fit her, and every
article should be like those in the standard equipment in size, shape, and
quality. The packages should be marked “ For demonstration only” so
that they can never be mistaken for packages from the midwives’ bags
ready to use. The supervisor’s wash dress should be fresh, clean, and
simple; and rings, bracelets, and beads should not be worn. Finger nails
should be short and rounded. Whenever possible the supervisor should
act the part of the midwife, talking to one doll as if it were the mother and
carrying out each procedure with perfect technique; she should describe
graphically procedures that cannot be acted. It will take unagination
and some rehearsing to make the demonstrations realistic. They should
be prepared carefully and presented dramatically.
d. Practice periods supervised.

The work of each midwife as she practices the various procedures
should be closely supervised so that no errors can creep into her practice
unnoticed. If such errors are not discovered until later, they may have
become fixed as bad habits that will have to be broken or they will spoil
the new skills that the supervisor is aiming to help the midwife develop.
N o midwife should leave the institute until her technique is correct; if she
makes a mistake, the supervisor should see that she immediately repeats
the procedure and keeps on trying until she does it correctly.
If a midwife is unable to master certain techniques within the time
allotted, a plan should be made with her for continuing the supervision
until she does, and her permit to practice should be withheld until that
time. A license should not be issued to a midwife who cannot learn these
simple techniques.
Opportunities should be definitely planned to observe midwife tech­
nique on actual deliveries in the home, in order to assure the supervisor
that the standards taught are being put into practice.
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e. Adequate quarters.

The quarters for the institute should include a clean, light room large
enough to seat the midwives comfortably and leave plenty of space to
arrange the furniture to resemble a kitchen and an adjoining bedroom,
both with space enough to move about in freely (fig. 1).

a□□a oo n
□ □ □ ao




The local workers informed in advance.

All arrangements for the institute should be made by the State health
department. The local hospital staffs, medical societies, doctors, and
public-health nurses whose work may bring them in contact with the mid­
wives should know in advance about the institute and should have copies
of the manual. In this way they will know what the midwives are being
taught and will be stimulated to help them and to keep the supervisor in­
formed of points and procedures that need further emphasis or a new
Teaching Equipment
To Be Obtained by the Local Nurse.

A. Furniture.
a. One large kitchen table.
b. Six kitchen chairs.
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c. One four-burner or four-hole kitchen stove or a box painted to look
like one.

d. One single or double adult-size bedstead with springs, mattress, one
pillow, six blankets, and one quilt.

e. One table leaf or a clean, strong, smooth board about 1 inch thick,
12 inches wide, and as long as the width of the bed, to put under
the mattress to prevent sagging.
/ . One dresser.
g. Two small tables or stands.
h. One lamp.
B. Miscellaneous.
i. A stack o f clean old newspapers at least 1 foot high.
j. A supply o f large sheets or a roll of wide wrapping paper to make
clean covers for the kitchen table at least twice a day.
k. Three or four dozen small sheets of wrapping paper to make covers
for sterile packages.
l. One new, unopened roll of toilet paper.
m. Three flatirons, bricks, or sandbags to use for warming the beds.
n. Twelve new cakes of white soap.
o. Eight saucers, two cups, two plates, and two teaspoons.
p. Onewashtub.
q. One can of evaporated milk for making cocoa.
r. One roll or package of paper towels.
s. Strong rope to tie chairs together for baby’s bed.
T o Be Carried by the Supervisor.




One copy of the midwife manual for each midwife.
One standard midwife equipment. (See p. 6.)
One doll to represent the mother.
One doll to represent the baby.
One doll with flexible cotton body and bald smooth head in a snug-fitting
canvas bag closed with a double drawstring.
Three dozen paper packages containing the cord ties, cord dressing, and
cotton balls. Each package should be a perfect replica of the sterile
package in the midwife’s standard equipment but need not be sterilized.
It should be marked “ For demonstration only,” so that it cannot be
mistaken for a sterile package.
One roll of gummed tape for sealing the packages (F).
One spool of tape for making cord ties like the ones in the packages (F).
One-pound roll of grade-A absorbent cotton for making cotton balls.
Two dozen pieces of unbleached muslin 46 inches long and 36 inches wide
for covers for newspaper pads.
Six muslin covers for newspaper pads.
Four sanitary pads made of old muslin, each wrapped separately in paper.
One bag o f clean white rags of various sizes for making wipes and sanitary
pads, and for lining one thick newspaper pan and the receiving blanket.
One ball of strong, white string for attaching to the baby doll for practice
in tying the cord and in tying square knots.
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One roll of 2-inch adhesive tape for attaching the cords to the baby doll.
Four‘dozen boxes of silver-nitrate ampules and needles.
Two hand scrub brushes like the one in the standard midwife equipment.
Two wooden nail sticks like the one in the standard midwife equipment.
Four dozen birth-certificate blanks.
One enlarged copy of a birth-certificate blank 60 inches long and 40 inches
wide for putting up on the wall.
Two dozen sharpened pencils.
One large teakettle.
One large cooking kettle with a lid.
Two 2-quart saucepans with handles and lids.
One long-handled dipper.
Six medium-sized hand basins.
Four 10-quart buckets that will fit one inside the other.
One 1-quart enamel pitcher.
One large flat tin baking pan and a smooth board covered with a news­
paper and placed across the end of the pan to make an improvised
One pair of ordinary household scissors.
One iron holder.
One covered jar of lard.
One covered jar of sugar.
One small can of cocoa.
Eight sheets.
Four pillowcases.
Four towels.
Two washcloths.
Three nightgowns.
One kimono.
Two pairs of stockings (one white).
One pair of bedroom slippers.
One comb.
One tooth brush.
Supplies for the baby:
a. One shirt open down the front (size 2).
b. One band made of outing flannel 6 by 27 inches.
c. Six diapers 27 by 27 inches.
d. One dress, kimono style, open all the way down the back.
e. Three baby blankets 36 by 36 inches.
j. One flannelette square, 36 by 36 inches.
g. Two small, soft washcloths.
h. Two soft old towels.
i. One baby bed— a box 30 inches long, 18 inches wide, and 12 inches
j. One clean quilt for folding to make the mattress for the baby bed.
k. Oilcloth or rubber pad to cover mattress.
l. One pillowcase for covering the folded-quilt mattress and pad.
m. One mosquito-net cover for the baby bed. (See pp. 49-50.)
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n. One baby tray (see p. 53 and fig. 32) 12 by 15 inches, containing—

Five covered glass jars. (See p. 50.)
One pint bottle for baby’s boiled water, with stopper.
One nursing bottle, 4-ounce size.
Two nipples.
One rubber cap for nursing bottle, or sterile cotton as
Six large safety pins.
Six small safety pins.
One pint of mineral or cottonseed oil.
One covered soap dish— a saucer with a cup turned
upside down over the soap.

The M idw ife’s Standard Equipment

The standard equipment for a midwife includes the articles that she
will carry with her when she goes to deh'ver a mother and the bag in which
they are to be carried. It is described here in detail so that the supervisor
can assemble sample equipment for teaching purposes and be prepared
to teach the midwife how to get her own equipment ready.
The bag and contents could be furnished or sold to the midwife by
the State or county health department. They might be made according
to specifications and sold by some reliable store at the State capital or the
county seat. Perhaps the local Red Cross or some woman’s club or
sewing circle would make the gowns, caps, and so forth, according to
specifications, and give or sell them to the supervisor to give or sell to the

Fig. 2.— CLO SED B A G .

The Bag.

The standard bag is 14 inches long, 6 inches wide, and 10 inches deep.
It is strongly made of top-grain cowhide that is durable and water
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repellent. The frame is strong and is so constructed that it can be closed
tight or opened wide so that the contents can be removed easily. The
frame hinges are so stiff and tight that the bag cannot spring closed but
will hold itself open until it is closed purposely. It is unlined so that an
inexpensive lining which can be removed for laundering can be used with­
out adding unnecessary weight or cost (fig. 2).
Contents of the Bag (fig. 3).

A. A separate muslin lining.
B. A muslin-covered package containing a midwife apron.


C. A muslin case containing—
a. Cap.
b. Towel.
c. Mask.
d. Soap.
D. A covered sterilizing basin containing—
a. Hand scrub brush.
b. W ooden nail cleaner.
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E. A muslin case containing the following enema equipment:
a. Enamel funnel.
b. Rubber tubing one-fourth inch in diameter and 18 inches



c. Glass connecting nozzle.
d. Rectal tube, size 26 French, 16 English, 19 American.
A muslin case containing—
a. Two sterile paper packages each containing—
(1) Two cord ties.
(2) Cord dressing.
(3) Six cotton balls.
b. Two boxes of ampules of silver-nitrate solution.
One pair of blunt-point scissors that are sharp and tight.
One safety pin for fastening scissors to lining.
A muslin case containing—
a. Birth-record book.
b. Birth certificates.
c. List of registrars.
d. Instruction sheets.
e. Pencil with sharp point protected by a metal cap.

A . The lining is a box-shaped bag having a twilled-tape double drawstring
and made of heavy unbleached muslin that will stand many launderings. (See p. 10.)


It can be closed tight to protect the contents when the bag is to be closed, and fastened
over the edge of the open bag to protect it (figs. 4 and 5).
B , O, E, F , I. The cover and cases are all made of the same heavy un­
bleached muslin, each one in the size that will protect its contents. (See p. 13*.)
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B> C -a . The apron and cap are made of heavy unbleached muslin and are
large enough to cover completely the midwife’s street dress and hair while she is
caring for the mother. (See pp. 10, 13, and 14.)
C -b . The towel is 12 by 18 inches of huckabuck or crash (not bath toweling
because that will not fold so flat nor look so fresh and clean when ironed).
C -c . The m ask, made of four thicknesses o f fine-weave bleached cheese­
cloth, is large enough to cover the midwife’s mouth and nose well. The ties are long
enough to hold it securely in place. (See pp. 13, 15.)

C -d . T he soap for the midwife to use when scrubbing her hands is a new
cake of white soap in the original wrapper. What is left she can use when laundering
the things from her bag after a delivery.
D . The sterilizing basin with cover for boiling the scissors is of enamelware (which will not rust), 8 inches long and 3 wide.
B-1o» The hand scrub brush for the midwife to scrub her ban da with is a
bristle brush that will keep its stiffness in spite of many boilings.
D -b . The wooden n a il cleaner for the midwife’s use when scrubbing her
hands is an orangewood stick that can be scrubbed clean and boiled without getting
rough or soft.
E -a . The enam el funnel in the enema equipment has an 8-ounce bowl and
a stem 3 inches long that can be depended upon not to slip out of the rubber tubing.
E -b . The rubber tubing in the enema equipment should be of good-quality
surgical tubing so that it will stand a great deal of boiling before it softens.
B -c . The glass connecting nozzle in the enema equipment is the same size
at both ends. One that has a pointed end is more likely to break or slip.
E -d . The rectal tube in the enema equipment is of medium size. It is of
good-quality rubber so that it will not soften when boiled.
F -a . The wrappers for the sterile packages are of tough, heavy wrapping
paper sealed with gummed tape. (See pp. 17, 18.)
2 4 9 1 3 7 °— 41-------2
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F -a -1 . The cord ties are of woven tape one-eighth inch wide cut in 12-inch
lengths, strong enough to hold and long enough to tie easily.
F -a -2 . The cord dressing is made of two gauze “ sponges” (see pp. 16-17) 4
inches square, to give adequate protection to the cord stump.
F -a -3 . The cotton b alls for wiping the baby’s face are the standard largesize absorbent-cotton balls. (See p. 45.)
F -b . T he am pules o f silver-nitrate solution are the “ eyedrops” supplied
free by some State departments of health in boxes containing two wax ampules of
solution and a needle for opening them. (See p. 84.)
G . T he cord scissors are 5 inches long, strong, and sharp, with a tight screw
so that they will cut easily and with blunt points so that there will be no danger
o f hurting the baby.
H . T he safety pin is the ordinary medium-sized pin with a good clasp, for
pinning the scissors to the bag lining.
I -a . A birth-record book in which the midwife can keep a record of her
cases may be supplied by the department of health. The supervisor should inform
the midwives what is the practice in their State.
I -b . Birth certificates for reporting births are supplied by local departments
of health. The midwife will send to the proper registrar a certificate for every baby
she delivers so that the State will have a record of the birth.
I—c . The list o f registrars supplied by State departments of health informs
the midwives with regard to the district covered by each registrar.
I -d . The instruction sheets are all the directions supplied to the mid­
wives by the supervisors.
I -e . The pencil for the midwife to use in filling in her records should have a
metal cap to protect the point.
Making the Supplies.

Scrub the hands thoroughly before working on these supplies. Wash and
iron the unbleached muslin before using. Eight yards will make the bag lining,
apron, and cap, and the muslin cases.
The lining (A).— Take one strip of muslin 42 inches long and 15 inches wide
and two strips 17 inches long and 9 inches wide (fig. 6).
Stitch 1 to la , 2 to 2a, 3 to 3a, 4 to 4a, 5 to 5a, and 6 to 6a; half an inch is
allowed for each seam. Trim the seams close. Turn the bag and make all the seams
French seams. After this stitching has been done trim the top edges even and put a
1-inch hem around the top of the bag.
A t each end of the bag work a buttonhole through one thickness o f this hem.
Through one o f these buttonholes run a drawstring o f good-quality twill tape 54
inches long. The tape should go through the hem all the way around the bag so
that both ends o f the tape come out o f the same buttonhole. Sew the ends o f this
tape together and tack this seam securely to the hem under this buttonhole. Pull
the tape through the buttonhole at the other end o f the bag so that it forms a loop
and fits smoothly in the hem.
Through this buttonhole from which the loop now extends, run a second draw­
string 54 inches long, sew the ends together and tack this seam securely to the hem
under the buttonhole, pushing the loop o f the other drawstring out o f the way so
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as not to catch it in the stitching. Pull the second drawstring through the button­
hole at the opposite end o f the bag so that it forms a second loop. The bag will
close when the two loops are pulled (fig. 7).
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The m idw ife apron (B).— An apron with kimono sleeves requires two
lengths of muslin cut long enough to allow 2% inches for the hem.
If the midwife is large she should add a straight strip to each sleeve in order to
have the sleeve long enough to reach just below her elbow. The apron should come
well below the hem of her dress and well up to the neck line. There should be a
belt— a 4-inch strip of muslin folded, stitched, and turned— stitched to the center
front of the gown at the waistline. The neck should be bound with a straight strip
2 inches wide and fastened with tape ties 10 inches long sewed to each end o f the
neck band. The edges of the sleeves should be hemmed and should have pleats
stitched in to make the sleeves fit at the elbows (fig. 8, three views).

Fig. 8.— MIDW IFE’S A PRO N .
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The cover for the apron is a piece of muslin 24 inches square with a

narrow hem.
T he m u slin cases (C, E, F , and I) are like envelopes 10 inches long and 7
inches wide with a 7-inch flap. T o make each case take a strip o f muslin 23 inches
long and 12 inches wide. Hem it all around. T o make the pocket, fold on AB




shown in figure 9, bringing C to E and D to F.
from FD to B.


Stitch the two ends from EC to A and

The cap (C -a ).— Cut out a circle of material 12 inches in diameter. A plate
o f this size can be used to make the circle. Measure off a strip of material 8 inches
wide and 1% inches longer than is needed to fit around the head. Seam the ends of
the band together. Mark the circle of material into fourths. D o the same with the
head band. Put the marks together. Pleat or gather the circle onto the band
evenly between the marks (figs. 10a and 10b). Turn the band and hem it down flat.
The m ask (C-c) is made of fine-weave, bleached cheesecloth folded to make
four thicknesses 9 inches long and
inches wide. Cut a 6-inch strip off a double
cheesecloth roll so as to have a double piece of material 18 inches long and 6 inches
wide with selvages on one side and the fold on the other (fig. 11). Turn in one-fourth
inch on each of the two raw edges. Fold the material in half from end to end (fig.
12). Gather the sides, ADBC and XY, until they are 3 inches wide. Cut two pieces of
tape 9 inches long and bind the top and bottom edges of the mask. Cut two pieces
of tape each 29 inches long and bind the sides, leaving 13 inches at each com er for the
ties (fig. 13).
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Fig. 10b.— COM PLETED CA P.
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The cord dressing (F -a -2 ).— Cut two pieces o f surgical gauze 16 inches
square. From each piece make a 4-inch square “ sponge” as follows:
Step 1.— Fold side AB on dotted lines to center. Fold side CD on dotted
lines to center (fig. 14, two views).




Step 2.— Fold side EG on dotted lines to center.
lines to center (fig. 15, two views).

Fold side FH on dotted

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Step 3.— Fold in half on dotted line, forming a rectangle 4 inches by 8
inches (fig. 16, two views).



Step 4.— Fold in half again on dotted line, forming a square 4 inches by
4 inches, with all raw edges folded inside (fig. 17, two views).



Cut one sponge from one com er to the center. The two sponges, the one with
the cut laid on top of the one without the cut, make one cord dressing (fig. 18).


Making the Sterile Package.

Make a paper wrapper as follows:
Take a 16-inch square piece o f clean, tough wrapping paper as a cover.
Fold b y bringing C to within 1 inch o f A (fig. 19).
Crease paper well so that the cross line will be well indicated (fig. 20).
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Open the wrapper (fig. 21, five views) and place on it at the center of the crease
Two cotton balls.
One cord dressing (two 4-inch sponges, one split and the other not split).
Tw o cord ties, each laid separately on top of the dressing so that it can be
picked up without touching the other one.
Four cotton balls laid on top of the other supplies.


Wrap the package (fig. 22, five views) ready to be sterilized:
Fold on the crease XY.
Fold D toward B with the fold along EH close to the edge of gauze squares
Fold B over beyond EH with the fold along FG close to the edge of the gauze
squares inside.
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Step 1

Step 2

Step 3

Step 4

Step 5

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Fold B toward G with the fold along EH.
Fold B toward H along FG.
Fold A toward H G on IJ close to the edge of the gauze squares inside.
Fold A toward IJ on EF.
Seal A with a 3-inch strip of 1-inch gummed paper.

Step 1

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To sterilize the package.— Put in a slow oven beside a large raw potato.
When the potato is well cooked the package will be sterilized.
Packing the Bag.

The articles in the bag are wrapped or put in cases to keep them clean
and arranged in the packages so that they are convenient to use. They
are always packed in the bag in the same place and order so that the midwife
can put her hand on the thing she wants without fumbling through the
bag or handling all its contents.
Before a new bag is packed it should be wiped clean inside and outside
with a clean cloth wrung out of hot, soapy water, rinsed with a cloth
wrung out of clean, hot water, and then dried with a clean cloth. The
new lining, apron, wrapper, cap, towel, mask, and muslin cases should be
washed, boiled, dried in the sun, and ironed with a “ spitting” hot iron.
The sterilizing basin and cover, funnel, glass connecting nozzle, scissors,
and safety pin should be scrubbed clean, rinsed with boiling water, and
dried thoroughly. The hand scrub brush and the nail stick should be
washed with soap and water, rinsed thoroughly, boiled, and set in the sun
to dry. The rubber tubing and the rectal tube should be washed clean
with soap and water, rinsed, and dropped into boiling water to boil for
3 minutes.
Place the bag, with the lock toward you and the contents on a table
covered wdth clean paper Open the bag wide so that it will stay open.
Insert the lining, open it wide, and draw it over the edge of the bag.
Put the muslin case (I) containing stationery and pencil against the
far side of the bag—the side to which the flap fastener is stitched. (See
fig. 4, p. 8.)
Pin the scissors (G -H ) to the right end of the lining.
Put the muslin case (F) containing the sterile dressings and silver
nitrate next to and in front of I.
Put the muslin package (B) containing the apron next to and in
front of F.
Put the muslin case (E) containing the enema equipment next to
and in front of B.
Put the muslin case (C) containing the cap, towel, mask, and soap
next to and in front of E.
Put the sterilizing basin (D) containing the nail stick and hand
scrub brush on top of all the packages.
Release the bag lining from the edge of the bag and draw the strings
tight (fig. 5, p. 9).
Close and fasten the bag.
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Lesson I.

The M idw ife and H er Service to M others
M ost State laws define a midwife as any person other than a licensed
physician who shall attend, or who shall bargain, contract, or agree to
attend, any woman at or during childbirth. Many States require a mid­
wife to apply for a permit before engaging in practice. The authority to
issue midwife permits is usually vested in the State department or board
of health.
A midwife when licensed is permitted to deliver only well mothers
of full-term babies. Even where licenses are not required she should
deliver only well mothers of full-term babies.
The M idw ife’ s Relation to the M other

In many communities the midwife has special prestige because the
service she renders is connected with the mystery associated in the minds
of many people with the birth of a baby. Because the mothers are her
neighbors and friends she usually knows about all the coming babies
almost as soon as the mothers do. Her influence with the mothers through­
out pregnancy is therefore a real force that can be used to improve
maternity care.
The Doctor’ s Examination

It is of first importance to teach the midwife why every pregnant
woman should have a complete medical examination early in pregnancy.
If she understands that no matter how much training and experience she
may have had she can never safely care for a mother who has not had this
medical examination, she will use her influence to persuade the mother to
go to a doctor in his office or to a clinic early in pregnancy.
Explain that the line between sickness and health—danger and
safety—is so very narrow that a doctor can know the condition of a
woman only after he has made a complete and thorough examination
(fig. 23, 10 views).
The modern midwife does not attempt to deliver a mother if she
knows that the mother has any disease. When the doctor finds disease
early in pregnancy, his examination will save the midwife from getting
into trouble through caring for a sick mother. And the midwife can help
the mother tremendously by urging her to follow the doctor's advice and
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, Doctor
Listening to fetal Heart

Fig. 23.— DO CTO R’S EX A M IN A TIO N .

doincj u rin a ly s is

by explaining to her that it is the sickness we do not know about that is
bad. The sickness a doctor finds early he can usually control, even if he
cannot make the mother well enough for the midwife to deliver her.
When the doctor advises medical care at delivery, the midwife will help
by explaining to the mother why she cannot deliver her.
The doctor may find not illness but some weakness that can be entirely
overcome by the right care during pregnancy. Then the mother, instead
of getting sick as pregnancy progresses, will get well because the doctor
found the weakness in time and the midwife helped the mother to follow
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his advice. Under these circumstances, if the doctor consents, the mid­
wife may deliver the mother.
It takes skillful measurement by a doctor or an X -ray picture of the
bones of the birth canal to learn whether or not there is room in the
mother’s body for a full-term baby to be born without the help of instru­
ments or surgery. If there is room, the midwife will gain confidence
through knowing it. If there is not room, knowing it well ahead of time
and planning for good hospital care may save the mother’s and baby’s
So the intelligent midwife who understands how much she herself,
as well as the mother and the baby, can benefit by the doctor’s examina­
tion of the mother will spare no effort to get every pregnant woman to a
good doctor early in pregnancy.
Be sure that the midwife understands how to get in touch with the
county or city health unit when there are no private physicians to examine
the mothers in her community.
Registering or Promising To Care for a M other

Before promising to care for a mother at childbirth a midwife should
know that it is safe for her to attempt the delivery, should be reasonably
sure that the mother is pregnant, and should know about when to expect
the baby. The doctor is the only one who can tell whether or not the
mother is well and has room for a full-term baby to be bom without
instruments. The midwife will explain to the mother these reasons why
she should go to the doctor for a complete examination before the midwife
can make plans to deliver her. The midwife may even take the mother
to the doctor to be sure she does not put off going. She should see that
the mother goes to the doctor for another examination in the eighth
month of pregnancy.
First the midwife can discuss with the mother the sym ptom s and
signs of pregnancy so as to be reasonably sure she is pregnant:
A. Missing monthly periods.
B. Tenderness and fullness of the breasts; tingling or prickling sensations
in the breasts.

C. Sick stomach, usually in the morning but sometimes in the afternoon or
the evening.

D . The abdomen (belly) getting bigger from week to week.
E. Feeling the baby m ove after the fourth or fifth month.

Together they can figure when to expect the baby by counting
back 3 months from the first day of the last menstruation and adding to
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that date 1 year and 7 days. Example: If the last menstruation began
January 1,1934, counting back 3 months would bring us to October 1,1933.
If we add 1 year and 7 days we have October 8, 1934, as the expected date
of confinement.
Symptoms That Should Be Reported to a Doctor

Impress upon the midwife that, when the mother is well to begin with,
pregnancy should be a normal, healthy experience but that it sometimes
is not, and she must watch for signs of trouble. Pregnancy puts a strain
on every structure in a woman’s body, and sometimes, even when she was
well early in pregnancy, she becomes ill as pregnancy progresses because
this strain is too much for her heart or her kidneys or some other organ.
Or some disease may develop during pregnancy just as disease develops at
any other time.
Illness seldom comes during pregnancy without giving warning signs
or symptoms, commonly known as the “ danger signals” of pregnancy.
Explain to the midwife that most of these symptoms, if “ taken in time,” can
be controlled by a good doctor. That is why it is so important for the mid­
wife to report to a doctor as soon as she discovers any of the danger signals.
#The midwife who knows about these danger signals cannot fail to
notice or to hear about them if she keeps her eyes and ears open as she
goes about among her neighbors and friends. But she cannot leave to
chance the discovery of danger signals in the mother she has registered.
She is responsible for watching over her life from the day she registers her.
She must see her at least once a month during the first 6 months, every 2
weeks or oftener in the next 2 months, and every week in the last month to
be sure that a doctor is called if all is not going well with her.
Whenever a midwife thinks a doctor should be called, the first thing
for her to do is to urge the family to call the doctor of their choice. If the
family does not or cannot get a doctor, the midwife is responsible for
reporting the situation to the county health unit or the town department
of health. She should not put herself in the false position of seeming to
care for a mother who needs medical attention without having called
a doctor.
Toxem ia.— Explain to the midwife the seriousness of the following
symptoms, which may mean “ kidney trouble” or toxemia:
A. Spots before the eyes.
JB. Inability to see well, haziness before the eyes, blurring o f vision, or

C. Severe or persistent headache.
2 4 9 1 3 7 °— 41-------3
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D. Swelling of the ankles, feet, hands, eyelids, or face.
E. Cramping pains around the pit of the stomach.
F. Scant urine (passing little water, which may have a somewhat dark
color) or inability to void (pass water).

G. Vomiting.
H. Great gain in weight.
I. Muscular twitching. (See p. 38.)

If any of these symptoms appear at any time during pregnancy or
labor, the mother should see a doctor at once. The midwife can help to
prevent serious results by getting the mother to a doctor without delay.
Explain that any of these symptoms means that there is poison in
the mother’s body which may injure or kill her or the baby, or both;
that at the end the mother may have convulsions (fits) and may die.
Take time to make it clear to the midwife that death from toxemia is
almost always preventable and that every mother who has any of the
symptoms of toxemia needs a complete examination by a doctor at once
and treatment under his supervision. The symptoms often clear up
with very simple treatment; without treatment they usually grow worse.
Bleeding— Spotting.— Explain the seriousness of bleeding during
pregnancy. Any bleeding from the vagina at any time during pregnancy,
no matter how slight, must always be reported to a physician. It may
indicate an abortion, extrauterine pregnancy, placenta previa, premature
separation of the placenta, or an obstructing growth. (These terms will
be explained.)
If the bleeding comes early in pregnancy it suggests—
A. Abortion.
B. Extrauterine pregnancy— in which the fetus, or unborn baby, is outside
the uterus, or womb.

In extrauterine pregnancy the irregular vaginal bleeding is sometimes
very slight. It is particularly important that the mother have a skilled
doctor at this time to find out the cause of the bleeding and to pre­
scribe the care she should have. This slight bleeding may be followed by
severe abdominal pain and the faintness and thirst that indicate internal
When there is any bleeding, abdominal pain, or faintness the mother
should be put quietly to bed and kept flat on her back until the doctor
arrives. This timely care may prevent severe hemorrhage or abortion.
An abortion is always serious. Severe complications— spoken of by
the mothers themselves as “ body trouble” —frequently are caused by or
follow abortions. Midwives in good standing do not attend such cases
but use their influence to get the patient under medical care at once. If
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a mother has had an abortion before she calls the midwife, the midwife
can help her most by urging her to call a doctor and by keeping her
quiet in bed until the doctor comes. With the right treatment he may
be able to prevent or lessen the bad effects of an abortion.
Bleeding in late pregnancy suggests—
A. Placenta previa, in which the placenta, or afterbirth, is over the mouth
of the womb.

B. Premature separation of the placenta, in which the afterbirth has tom
loose before the birth o f the baby.

Bleeding in the last 3 m onths of pregancy, if accompanied by
sharp abdominal pain, may mean that the afterbirth is loosening from the
womb and unless something is done to help the mother at once she may
bleed to death. Painless bleeding may indicate that the afterbirth is
at the mouth of the womb, and the bleeding is caused by the tearing of
the blood vessels as the mouth of the womb begins to open.
Any bleeding that occurs during pregnancy or early labor should be
considered an alarming symptom. The doctor should be called at once.
Tuberculosis.— Tell the midwife about tuberculosis (lung trouble)
just as you have told her about toxemia. The symptoms and signs that
mean danger are—
A. Nagging cough—a cough that hangs on.
B. Pain in the chest that is worse when the mother takes a long deep
Spitting up blood.
Loss o f weight— going into a decline.
Loss o f appetite— not being hungry when it is eating time.
Fatigue— being more tired than usual when there is nothing to be tired
6. Fever.


Tuberculosis is a real sickness and it is serious, but if treated early it
can often be cured. A person may get tuberculosis by kissing someone
who has it, by eating from his plate, drinking from his cup, eating with his
spoon. Or he may catch it by getting on his hands, face, or clothes the
drops of spit that the sick person spreads around when he coughs or
sneezes or when he touches things without washing his hands first. A
mother is likely to get tuberculosis in one of these way« if she lives a long
while with a person who has it. If the person who has it is careless, the
mother is almost sure to catch it. She is then very likely to give it to the
baby. A mother with tuberculosis should never nurse nor handle her baby.
The midwife should be taught how to explain to the mother that
“ germs” which cause disease or infection can be transferred (carried) from
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one person to another—some of them from one part of the body to another
part. Not all diseases are caused by germs. And transferred disease
germs do not always cause disease, but the chances are they will
when they are transferred to the moist, warm inner surfaces of our bodies
or into scratches, cuts, and wounds. That is why everyone should
know how to keep from transferring germs. Fingers, clothes, bedclothes,
towels, washcloths, dishes, and so forth, that have touched an inflamed spot
or that have been soiled by a discharge in which the disease germs live
may be the means of transferring the germs to anyone touching these
things unless the germs have first been killed by sterilizing, boiling, sunning, or pressing with a hot iron. Disease germs grow best in moist,
warm, dark places away from sunshine, light, and air. Sunshine and
soap and water, by means of which we keep our houses, our clothes, and
our bodies clean, help to protect us from disease germs and keep us from
transferring them to others.
Pregnancy makes tuberculosis more dangerous, and the pregnant
woman who shows signs of tuberculosis needs constant care from a doctor.
Such a mother may seem to be better during pregnancy; she may gain
weight and feel well and then labor may be too much for her. Sometimes she
cannot get out of bed after the baby’s birth and may die shortly after the
baby is bom . The baby may be infected by the mother.
Explain how hospital care may prevent such a tragedy. Tell the
midwives about a nearby tuberculosis hospital and emphasize that early
and adequate care prevents and cures tuberculosis.
Heart disease.— Tell the midwives about the symptoms of heart
disease. Some of the following symptoms will appear if the heart is not
working properly:

Shortness of breath and cold sweat on exertion.
Blue fingernails.
Gray, ashen complexion.
Swelling of the ankles.
Pain in the region of the heart.
Inability to breathe easily or to sleep com fortably without extra pillows.

When any one of these symptoms appears the midwife should report
the fact to a doctor at once. Unless his advice is followed, the condition
may prove fatal.
If a midwife attempts to deliver a mother who has heart disease, the
mother may become exhausted during labor and die before medical help
can be secured.
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#Gonorrhea— Explain to the midwives that this disease (“ clap” ) is
an inflammation in the birth canal caused by a certain germ. The
symptoms are—
A. . A more or less constant yellow vaginal discharge which stains the
clothing from time to time.

B. Swelling and soreness of the vulva (lips o f the birth canal).
C. Burning sensation when urine is passed.

If one of these symptoms appears, the midwife should notify the
doctor at once and help the mother to make a practical plan for caring for
herself, her clothes, her bedclothes, and so forth.
The midwife should be made to understand that the symptoms
described are not always caused by gonorrhea germs* but whatever the
cause, the inflammation must be treated by a doctor. If the mother does
not have the proper treatment, the germs may spread, she may have
body trouble” after the baby is bom and be sick for years, and the baby
may become blind from having had his eyes infected with these germs
while he was being bom .
The careful midwife will not continue to care for the mother in whom
these symptoms appear until the doctor who is treating her says it is safe.
Syphilis.— Discuss with the midwives the importance of learning
early whether or not the mother has syphilis— “ bad blood,” “ the bad
the bad disorder.
In some parts of the South one of every
three mothers has this dangerous disease. Many of them do not know
they have syphilis, for the early symptoms cause little discomfort and
soon disappear. But the disease persists and attacks their unborn babies,
killing or injuring them, and later causes more sickness and suffering for
the mothers, too.
All this can be prevented, for syphilis can be discovered by a blood
test, and the mother can be given treatments that will protect her baby
from infection and save her from the sickness and suffering. The blood
test is part of that important medical examination which every mother
should have early in pregnancy every time she is pregnant. And the
earlier in her pregnancy she has this blood test the better, because a longer
period of treatment during pregnancy means a better chance of protecting
the baby of a mother with syphilis.
Be sure that each midwife knows how the treatment can be secured in
her community from private physicians or clinics or through the depart­
ment of health or of welfare. She should know, too, that the results of the
treatment are good but come slowly, and that treatment must be con­
tinued for a long period, in many instances for months or even years.
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The intelligent midwife will encourage the mother with syphilis to
take all the treatment the doctor prescribes, after, as well as before, the
baby is bom and to follow his advice in every detail. She will not deliver
a mother who she knows has syphilis unless the doctor who is treating the
mother says she can safely do so (fig. 24, a and 6).


American Social Hygiene Association. 1790 Broadway, New Y ork, N . Y .
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The mother who, either before or since she became pregnant, has had
some treatment for syphilis but not enough to control the disease may,
like the mother who has undiscovered syphilis, infect her unborn baby.
The midwife who cares for the mother may also become infected and may
transfer the disease to others if the mother has an abortion, a dead baby,
or a live premature or full-term baby with the following symptoms:
A. Hash on the baby’s skin; peeling of the skin on the soles of the feet and
palms of the bands.

B. Sore mouth, discharging nose— snuffles.
C. little splits or cracks about the anus (the back passage) and sore

D. Bleeding from the nose, mouth, or rectum or in the skin.

The midwife who is called when a mother has an abortion or who
delivers a dead baby or a live one with one of these symptoms should re­
port to a doctor at once and do exactly as he advises. The mother needs
more treatment. If the baby lives, he should have adequate treatment for
syphilis according to the present standards.
Discuss with the midwives the signs and symptoms of syphilis
that m ay appear in the mother during pregnancy or be discovered
after she is in labor:

Sores, warts, or bard scar on tbe vulva.
Hash on tbe skin.
Sore throat, sore mouth. •
Swollen, tender glands— sore lumps— pain in tbe bones.
Falling out of hair and eyebrows.

When the mother has syphilis she may infect not only her unborn
baby but other children in the family and people in the community. The
midwife attending a mother who has syphilis may become infected and
spread this disease to other mothers or even to her own family. When
one of these symptoms is discovered the midwife should report it to a
doctor at once. If the trouble is found to be syphilis, the midwife should
explain to the mother that she cannot continue to care for her because
special medical treatment is needed.
Emphasize that it is the syphilis which is not discovered in time or
for some other reason is inadequately treated that injures or kills unborn
babies and is transferred to other people. Even though it takes a long
time, syphilis can be controlled, unborn babies can be protected from it,
and those who have the disease can learn how to keep from giving it to
anyone else.
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Sores anywhere on the body that do not heal may seriously infect
the mother at the time of delivery. Such sores should be shown to the
doctor so that they may be adequately treated before the time of delivery.
General sym ptom s.— The symptoms already talked about point
toward definite diseases but sometimes pregnant women have symptoms
which may suggest any one of a number of diseases.
Fever, chills, diarrhea, sores which do not heal readily are such
symptoms. They should be reported to a doctor because in some cases
they may mean that a serious condition is developing.
Calling the M idw ife

Discuss with the midwives how, when a midwife registers a mother,
she can tell her, without scaring her, about the importance of calling
her midwife at once if she is nervous or worried about anything and if
she has any unusual symptoms. Emphasize the midwife’s duty to see the
mother as soon as she can after she is called and to report any serious
symptom to a doctor at once.
See that each midwife knows what she can do to get medical care for
the mother if there is no private doctor available. Make it easy for her
to get in touch with a local or county nurse whenever she needs help or
advice and cannot get in touch with a doctor. The nurse may know of a
doctor who is unknown to the midwife.

Make it clear to the midwives how much more they can do for mothers
today than did the old-fashioned midwife. Years ago midwives did not
know anything about watching during pregnancy for the danger signals;
their care of mothers began with labor. Today the intelligent midwife
will make every possible effort to secure for the mother the protection
afforded by a complete physical examination by a good doctor and to help
her to follow his advice. Even after the complete examination by the
doctor, the midwife, like the public-health nurse, needs to be on the
lookout for danger signal^ constantly all during pregnancy, so that she
can call a doctor if all is not going well.
Symptoms that should be reported to a doctor are—
A. Spots before the eyes.
B. Inability to see well, haziness before the eyes, blurring of vision, or

C. Severe or persistent headache.
D. Swelling of the ankles, feet, hands, eyelids, or face.
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E. Cramping pains around the pit of the stomach.
F. Scant urine (passing little water, which may have a somewhat dark



color) or inability to void (pass water).
Great gain in weight.
Muscular twitching.
Any bleeding or spotting, no matter how slight.
Sharp abdominal pain.
Nagging cough— a cough that hangs on.
Pain in the chest that is worse when the mother takes a long breath.
Spitting up blood.
Loss of weight—going into a decline.
Loss of appetite—not being hungry when it is eating time.
Fatigue— being more tired than usual when there is nothing to be tired
Shortness of breath and cold sweat on exertion.
Blue fingernails.
Gray, ashen complexion.
Pain in the region of the heart.
Inability to breathe easily or sleep com fortably without extra pillows.
Any vaginal discharge.
Swelling or soreness of the vulva.
Burning or smarting when passing urine.
Sores, warts, or hard scar on the vulva.
Bash on the skin.
Sore throat, sore mouth.
Swollen tender glands— sore lumps— pain in the bones.
Fever, headache, or chills.
Falling out of hair and eyebrows.
Sores that do not heal.
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Lesson II.

Inspection o f the M idw ife’s Standard Equipment

T o teach the midwife about the contents and orderly arrangement of
the standard bag.
T o give her an appreciation of what is observed in the inspection of a

A bag containing the midwife’s standard equipment. (See p. 6.)
Table with a clean paper cover.
Hand ba^in, bucket of water, dipper, soap in a dish, paper towels.

Place on the table your closed bag, which is in perfect condition and
perfectly packed. Speak of the appearance of the outside of the bag—
clean, water repellent, tightly closed, all seams tight, fastening and handles
good so that the bag will protect the contents from dirt and weather and
will not break when in use.
Wash your hands. Open the bag. Show how it will stay open.
Call attention to the clean lining, show that it fits, that it is of the right
size to protect the edges of the bag, that the tapes are strong enough and
long enough to tie securely.
Lift out the packages one at a time. Speak of the condition of the
bag—clean and in repair. Show how the size and shape are correct for
holding and protecting its contents; nothing sticks out or falls out when a
package is taken from the bag. Tell why each package is packed in the
bag as it is.
Open each package in turn as it is lifted out. Comment on the ar­
rangement or folding of the contents. Show how the size is correct.
Note that washable things are freshly laundered. Test the other things
to see that they are in good condition.
Open the sterilizing basin. Show the dry brush and stick and explain
why they and the basin must be dry before the basin is covered.
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Examine the sterile packages. Explain why they must be tight and
correctly folded. Break the seal and open one to show the arrangement
of the contents. Examine the contents and explain why they are made
as they are. Be sure to point out that this opened package is no longer
sterile. It must be sealed and sterilized again before it can be used at a
Examine the scissors to show that the screw is tight and they are
sharp and clean. Tell why they have blunt points and must be tight.
Emphasize the importance of the record forms that the midwife
must keep. Show a sample of each form properly filled in and explain
each item.
Explain about the inspection of the midwife’s bag and how much it
shows about her and her way of working.
Repack the bag, explaining again about the arrangement.
Give each midwife an opportunity to take part in packing and un_
packing the bag and in explaining its arrangement and contents.
Be sure that each midwife knows where she can get or how she can
make each article in the standard equipment, and ask her to bring her
bag with her to the last session when all bags will be inspected.
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Lesson III.

The Prenatal Period

W hat is a midwife?
Where does she get her legal right to practice?
W hat type of mother does she care for?
How would a midwife figure the date of delivery?
W hat should a midwife do if called on an abortion case?
W hy is a complete examination by a doctor and following his
advice important to the expectant mother?
W hy is a complete m edical examination of the expectant mother
a special protection to the m idwife’s reputation?
W hat danger signals appearing during pregnancy need im m e­
diate attention from a physician?
W hy should a w om an’s blood be tested early in pregnancy?
W hat should be done if the blood test shows that a mother has
W ho gives treatment for syphilis?
W hat responsibility has the midwife for a patient who has
O f what importance is this to the baby and to the m idw ife.
Everyday Living

Discuss with the midwife, so that her influence with the mothers can
be used to good purpose, the simple, homely, day-to-day needs of all
pregnant women. The 40 weeks, or 280 days, of pregnancy while the
baby is living and growing in his mother's uterus (womb) are spoken of
as the prenatal period of his life. Pre means before and natal means
birth; so prenatal means before birth.
This prenatal period of the baby's life is a time of preparation for the
mother. She should live so as to gain all the strength she can for the hard
work o f carrying, delivering, and nursing the baby. Everything that is
good for her will help the baby that is within her body to grow strong.
F o o d —Tell the midwife what to teach the mothers about the food
they should have. Every mother should know the importance of her diet
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during pregnancy. Before the baby is bom he gets all his nourishment
from his mother. It is her food that is used to make his body. During
at least the first 6 months after his birth, too, it is best that his mother’s
breast milk should supply most of his nourishment.
By eating properly the mother can help to prepare for the delivery
and improve the chances of being able to nurse her baby. Her strength at
delivery is largely dependent on the food that she has eaten all during
pregnancy. Every muscle, bone, and blood vessel, the blood, and the
nervous system are improved by good food. Tell the midwife why the
mother should eat simple, adequate meals and not eat anything that she
knows may give her indigestion. Too much food at one meal is not good.
All food should be eaten slowly and chewed well.
Explain the value of including the following foods in the diet during
pregnancy and the nursing period. This kind of adequate diet is also good
for each member of the family.
M ilk.— Milk is good to drink or to use in soups, cocoa, vegetables,
and puddings. One quart of milk a day will provide calcium (lime),
which is necessary for building bones and teeth. Evaporated milk is
easier to keep in warm weather and usually costs less than fresh milk.
When mixed with an equal amount of water, evaporated m ilk has the
same food value that the same amount of fresh milk has. Buttermilk or
skim milk (fresh or dried) may be used as part of the required amount of
Other liquids.— Everyone who is well needs at least eight glasses o f
liquids each day. By liquids are meant milk, water, lemonade, orangeade,
tea, and coffee. Moderate use of tea or coffee is not harmful to most
Vegetables are rich in miherals and important vitamins that help to
build bones, teeth, muscles, and good red blood. A t least two vegetables
in addition to potatoes should be eaten every day.
Tender vegetables are good to eat raw. Other vegetables should be
cooked only until they are tender; overcooking destroys part of their value.
The least possible amount of water should be used, and all juice that
remains when the vegetables are done should be used in making SOup or
gravy. This “ pot liquor” is full of valuable mineral salts and should not
be thrown away.
Fruit. Two fruits should be eaten daily if possible. Tomatoes
(raw, cooked, or canned) may be eaten in place of fruit.
Cereal.—A serving of whole-grain (dark) cereal or whole-grain
bread should be part of every day’s food. Water-ground com meal is a
whole-grain cereal.
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Egg and m eat.—An egg and one serving of meat, fish, or poultry
should be eaten daily if possible. Cheese and dried beans or peas may
take the place of meat now and then.
Other foods.— Once the important foods already listed have been
included in the diet, other simple, easily digested foods can be added to
satisfy the appetite and give the mother energy to do her work.
Sleep.—A t least 8 hours of every night should be spent asleep in bed
with the windows open if the pregnant mother is to get sufficient rest.
Rest and exercise.— Some regular housework is good exercise, but
every pregnant mother needs to lie down several times a day if only for 5
minutes at a time. A t least an hour’s rest during each day is necessary.
A walk or some rest out of doors each day is excellent; fresh air is good for
the mother and the baby. If the mother cannot spend any time out of
doors, she should keep the windows open while she does her indoor work.
Warn her about the danger of unusual or heavy work. It might hurt the
Bathing.— If possible, an expectant mother should have a com­
plete bath with warm water and soap every day. After the seventh
month she should not get into a tub but should take a sponge or shower
bath instead.
Clothing.—The expectant mother should wear loose, comfortable
clothing hung from the shoulders. She should not wear garters around
her legs nor any tight bands. She should not roll her stockings, for if they
are rolled tight enough to hold them in place above or below the knee they
will impede the circulation. A well-fitting maternity corset or abdomi­
nal binder may add to her comfort. A brassiere should be chosen that
supports the breasts but does not bind them tightly. The breasts should
be allowed plenty of room to develop. Shoes with low, broad heels are
Elim ination.— If the pregnant mother is drinking enough fluid she
should void from 1 to 2 quarts of urine—pass from 1 to 2 quarts of water—
every day. Voiding too little urine, dark in color, is one of the danger
signals of pregnancy. (See lesson I, p. 26.)
The bowels should move regularly. Constipation is usually caused
by lack of exercise, incorrect diet, too little or too concentrated food, in­
sufficient fluids, or irregular toilet habits.
T o correct constipation the mother should drink one or two glasses
of hot or cold water before breakfast; go to the toilet at the same time
every day, preferably after breakfast; eat whole-grain (dark) bread, green
vegetables, raw or cooked fruit, especially prunes and figs; and drink
water between meals.
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Preparation for nursing.— The ideal food for the baby is his
mother’s milk. It is the easiest and cheapest baby food to be had. Flies
cannot spoil it and it will not sour. The mother’s general health, her
food, and her rest affect the quality and the quantity of her supply of millr
for the baby.
Supporting the breasts.— Show the midwives how to teach the
mother to support her breasts. Breasts should not be compressed by a
tight binder nor allowed to sag of their own weight.
A well-fitted brassiere with broad straps over the shoulders will sup­
port the breasts correctly. This type of brassiere should be worn every
day after the breasts begin to enlarge. The brassiere should be made of
thin, porous material that washes easily and allows good ventilation.
Brassieres should be washed every day. (Fig. 25.)


Care of the birth canal.— Be sure that the midwife knows
about telling the mother why she should not take a douche during preg­
nancy unless a doctor has said she needs one; why she should not permit
any one except a doctor to examine her internally at any time during preg­
nancy or labor; why she should have no sexual intercourse after the seventh
month of pregnancy until 6 weeks after delivery.

Be sure the midwife knows that it is important to tell the mother how
she will know when labor begins, why she must notify the midwife at
once, and what she is to do while waiting for the midwife. If the midwife
is notified at once, she can get there in time to make all the necessary
preparations for the clean delivery technique that protects the mother and
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baby from infection. The woman who has had several children and think«
she should wait to notify the midwife until pains become regular and close
together runs an unnecessary risk for herself and her baby. The midwife
should have a fair chance to prepare the mother, herself, and her equip­
ment and to be on hand to conserve the mother's strength during labor.
Labor usually begins with pain that starts in the lower part of the
back and works around to the abdomen or starts in the abdomen and works
around to the back. During the pain the uterus becomes hard and
contracted but softens or relaxes as the pain passes off. Labor pains
recur at shortening intervals and last longer and become stronger.
A discharge of mucus slightly stained with blood is called the “ show”
and should also be considered a sign of beginning labor. The midwife
should be called as soon as the show appears or pains begin.
After the midwife has been called, two large covered kettles of water
should be put on the stove to boil, and one may be set aside to cool after
it has boiled for 10 minutes. The mother's bed should be prepared for
labor. (See lesson V I , p. 55.) The mother should take a warm sponge
bath and comb her hair; and if it is long, she should fasten it in braids so
that it cannot come undone. The mother's supplies should be set out
where they are easy to reach. The baby's bed should be put out with a
set of baby clothes, blankets, and receiving blanket in it, as well as a hot
brick, iron, or water bottle to warm the bed and everything in it. The
mother should then “ take it easy” until the midwife arrives.
Sometimes the membranes may rupture— the bag of waters break—
before the mother has felt any labor pains, though usually this happens
after the mother has been in labor for some time. Whenever the
membranes rupture the mother should go to bed, and, if she has not already
done so, she should send for her midwife.
Be sure that the midwife understands that she should tell every
mother she registers about going to bed and calling' a doctor at once
if there is any bleeding, because bleeding is a serious danger signal
and not one moment should be lost in getting a doctor.
Premature Labor

Explain to the midwife how she can tell the mother about premature
labor—labor that begins any time after the mother has felt life and more
than 2 weeks before the date the baby is expected. If the mother has any
cramplike pain, she should go to bed and send for her midwife. If the
midwife is “ suspicious” that the mother is in labor she should notify a
doctor immediately. Premature birth can often be prevented by keeping
the mother quiet in bed and getting a doctor at once. The midwife must
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not deliver such a mother because a premature delivery is not normal* the
mother and baby need the best of medical care.
If the mother is not in labor but is having persistent abdominal pain
the midwife should notify the doctor so that he can find the cause of the
pam and give the mother the care she needs.

The good midwife who knows the day-to-day needs of the pregnant
mother will Use her influence to encourage her to eat the food that is good
for her— plenty of milk, vegetables, and fruit and small amounts of meat
and cereals or breads every day; to drink the eight glasses of fluid a d a y
to get enough sleep, rest, and exercise; to be careful about her bathing'
clothing, and elimination every day; to do all that she should to be ready
to give birth to her baby and to nurse him.
The midwife will be very sure the mother knows when to call her and
what to do when labor begins, when there is bleeding, or when the membranes rupture before the midwife arrives.

2 4 9 1 3 7 °— 41

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Lesson IV.

M aking the Supplies

T o show the midwife about making the supplies that will serve well
when the mother cannot buy everything she needs. When nothing else
is available newspapers can be used to protect beds and to make pans
and bags that will take the place of basins and buckets.

A table; iron on the stove; iron holder; several pieces of fresh, clean
wrapping paper; a generous supply of clean newspapers; grade-A and
grade-B absorbent cotton; 24 pieces of unbleached muslin (46 inches long
and 36 inches wide) and a bag of clean white rags of various sizes for
making sanitary pads, lining for newspaper pans, wipes, and so forth;
hand basin; bucket of water; dipper; soap in dish; and paper towels.

Show the midwife how to make the various articles and explain their
many uses. Wash your hands before beginning and explain why washing
is necessary.
Newspaper bag.— Spread on the table before you two full-size
double sheets of newspaper folded to the size of a newspaper page, one
sheet inside the other with the edges even, so that there are four thick­
nesses of paper. Fold the two upper thicknesses in half lengthwise of
the columns of printing (fig. 26, step 1). Turn the paper over, fold it
in thirds crosswise of the columns of printing (step 2), and tuck E and F
between A and B (step 3) to complete the bag. The pocket that is to
be used as a bag is now on the under side, and therefore the paper should
be turned over. C becomes the flap that slips under the edge of
the tray, or it can help to reinforce the side so that the bag can be opened
up wide and stand on a table. Explain that three of these newspaper
bags will be needed (see p. 56).
Newspaper pan.— Lay newspapers opened wide at angles one with
the other and roll in the edges (fig. 27, three views). Six thicknesses of
paper will make a thin pan that can be used to catch soiled cotton, rags,
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Step 3



and so forth. Explain that three of these thin newspaper pans will be
A thick pan can be made of 16 to 20 thicknesses of newspaper. Explain
that three of these thick newspaper pans will be needed. One of these
thick newspaper pans should be lined with a clean rag (see pp. 56, 98).
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A thick newspaper pan can be used as a bedpan if it is not possible
to get a regular bedpan or to improvise one from a bakepan and a smooth
board covered with a newspaper and placed across one end of the pan.
The three thick newspaper pans will be needed in addition to the bedpan.
Newspaper pad.— Spread on the table one of the large pieces of
unbleached muslin. Explain that the midwife can teach the mother to
use freshly laundered old white rags instead of the unbleached muslin
you are using. On this lay one sheet of newspaper opened to full size to
serve as a pattern for making the pad cover the right size. Fold the
muslin over the edge of the newspaper on all four sides, remove the news­
paper, and tack the comers of the muslin securely to make the pad cover.
Explain that the mother should make six of these covers.

Open 12 sheets of newspaper wide and stack them with the edges
even and insert them in the cover. Turn the cloth side up. Wash your
hands. With a very hot iron, press the cloth from side to side until the
whole surface has been ironed. D o not touch the cloth side with the
hands after ironing it. Fold the pad with the cloth side in and explain
that the mother’s six pads, each one ironed and folded this same way,
should be wrapped in paper or two thicknesses of newspaper and the
package put away with the mother’s supplies (fig. 28, three views).
At delivery or during the postpartum period, as the pads are used
and become soiled, the newspapers can be taken out and burned and the
mushn covers washed and boiled to use again.
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Sanitary pads.— If sanitary pads can be bought, show the mid­
wives how they should be kept covered and not handled before they are
Sanitary pads can be made of freshly laundered old muslin about 18
to 24 inches square. Fold, and iron each fold as shown in fig. 29. These
home-made sanitary pads should be wrapped individually in clean wrap-

Fig. 29.— M A KIN G SA N ITA R Y PADS.


ping paper and put away in a convenient drawer until it is time to
sterilize them. (For directions for sterilizing the pads see p. 21.)
Cotton balls.— Demonstrate how to make large and small cotton
balls for the baby’s tray, using the grade-A absorbent cotton, and explain
their use (fig. 30, three views). Explain that when the midwife prepares

Fold edenes "together



the baby’s tray she should make enough large balls to fill one jar and
enough small balls to fill another jar. (See pp. 50, 53.)
Cotton swabs.— Demonstrate also how to make cotton swabs of the
grade-B cotton and explain that rag wipes can be used if the mother
cannot get cotton for making these swabs.
Have the midwives practice making each item, first in groups, then
under individual supervision until they can make everything correctly.
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Lesson V.

The M other’s Preparation for D elivery

W hat type of mother does a midwife care for? How can a m id­
wife best serve an ailing mother?
W hy is a complete physical examination by a doctor important
to the expectant mother?
Nam e some of the danger signals of pregnancy.
W hat do we m ean by the prenatal period?
W hat should a pregnant wom an who is well eat, and why?
How m uch liquid should she drink?
How m any hours should she sleep? W hy is rest important?
W hat kind of exercise should she take?
W hat kind of bath should she take the month the baby is ex­
W hat kind of clothing should she wear?
W hat should be done for constipation?
W hat are the signs of beginning labor?
W hen should the mother call the midwife?
W hat should a mother do when labor begins?
W hen T o Prepare

Explain why it is important to have things ready early. As we do
not know what brings about the onset of labor and cannot predict the
exact day on which it will occur, it is important that everything be pre­
pared well in advance of the day the baby is expected.
The expectant mother should begin her preparations early in preg­
nancy so that she will not be forced to hurry at the end. Rush and hurry
are very tiring. Explain that everything should be in readiness by the
beginning of the eighth month— 8 weeks before the baby is expected.
Go over each item on the list of supplies, explaining possible sub­
stitutes and the use which will be made of each article. The midwife
should help the mother with a plan for getting the supplies early. The
mother should first get two boxes or clean out two bureau drawers, one for
her supplies and one for the baby’s, in which to put the things when she
prepares them so that they will be clean and in order.
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Supplies for the M other (fig. 31)

These she m ust have:
A. Four basins or pans (two of them the same size).
B. Two large covered kettles for boiling water (teakettle and large stew
pan or boiler with cover).

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2 clean wash cloths.
4 clean towels.
4 clean sheets.
4 clean pillowcases.
2 clean nightgowns.
Clean quilts or blankets.
2 pairs of stockings (1 pair white).
1 tooth brush.
1 comb.
1 kimono.
1 pair of house slippers.
4 dozen sanitary pads.
1 pitcher.
1 pound of grade-B absorbent

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One long-handled dipper.
Two stew pans with lids such as are used for cooking vegetables.
One quart pitcher or mason jar.
One cup, four saucers, two teaspoons, and two plates.
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G. One toilet bucket with a cover and three uncovered buckets (one for


clean water and two for dirty water).
Laundry tub ready— empty and clean.
Two cakes of white soap. Saucers can be used as soap dishes.
Two clean washcloths.
Four clean towels.
Four clean sheets.
Four clean pillowcases.
Clean quilts or blankets.
Two clean nightgowns.
One kimono or smock.
Two pairs of clean stockings (white preferred).
One pair of house slippers.
One toothbrush.
One comb.
One pair of ordinary household scissors.
Six newspaper pads. (See lesson IV , p. 44.)
Four dozen machine-made sanitary pads bought packed in boxes, or
12 home-made pads of clean old muslin. (See lesson IV , p. 45.)
One bag of clean white rags of various sizes for making wipes, sanitary
pads, covers for the newspaper pads, and so forth.
A large bundle of newspapers, about 200 sheets.

These she should have:
A. One roll of toilet paper (kept wrapped).
B. One pound of grade-B absorbent cotton to use instead of rags for making

C. One bedpan (tin, zinc, or enamel) or a bakepan and a smooth board
covered with a newspaper and placed across one end of the pan for
a bedpan.

The midwife should make it her business to know that every mother
whom she registers for delivery has her supplies ready in good time. She
can help the mother who cannot buy things to make the best use of those
she has in the house.
Supplies for the Baby (fig. 32)

Explain to the midwife all about the supplies which the mother
should have to make it easier to give good care to the baby.
These she must have:
A. Three shirts, size 2, open down the front.
B. Three bands— made of outing flannel. Half a yard tom into three
equal strips will make three bands 6 inches wide and 27 inches long.

C. Two dozen diapers 27 inches square.
D. Three baby blankets 36 inches square.
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Two flannelette squares 36 inches on each side.
Two small, soft washcloths.
Two towels— old, soft, clean ones are best.
One bed for the baby— a paper carton, a wooden box, a basket, or a
home-made crib. It should be at least 30 inches long, 18 inches
wide, and 12 inches deep.

2 old, soft towels.
2 small, soft washcloths.
2 flannelette squares 36 by 36
1 folded clean quilt or cotton
blanket for mattress in baby's
1 mosquito net 54 by 54 inches.
1 pound of grade-A absorbent
Oilcloth or rubber pad to cover
1 pillowcase to cover the mattress
and oilcloth or rubber pad.

I. One crib mattress. A hair pillow is best, but a folded, clean cotton
blanket or quilt makes a good substitute.

J. One rubber pad or piece of oilcloth to cover the mattress.
K. One pillowcase for covering the mattress and the mattress pad.
L. One mosquito net to cover the baby’s bed. A piece o f mosquito
netting 54 inches square, rounded at the comers, hemmed all around
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the edge with elastic run in the hem. This size will fit the ordinary
baby bed of the size given above.
Baby tray 12 inches by 15 inches or larger.
Five covered glass jars for—
1. Oil.
2. M other’s boiled water.
3. Nipples and rubber bottle caps.
4. Large cotton balls.
5. Small cotton balls.
One pint bottle or jar with top, for baby’s boiled water.
Two nursing bottles—4-ounce size.
Four nipples.
Two rubber caps for nursing bottles.
One dozen large safety pins.
One dozen small safety pins.
Two cakes of white unscented soap.
One pint of mineral or cottonseed oil.
One soap dish. A saucer with a cup turned upside down over the
soap will serve.
One pound of grade-A absorbent cotton.

These she should have:
Three dresses— made with kimono sleeves and open all the way down
the back. (But blankets are more important.)
Choosing the Room for the Delivery

Teach the midwife what to look for in advising the mother which
room to use for the confinement room. If a choice of rooms is possible,
choose the room that best meets the requirements of cleanliness, comfort,
and convenience. These are things to consider in the selection of the
A. Size. It should be large enough to allow for free working space.
B. Nearness to bathroom or kitchen to make easier the preparation for
delivery and care in the postpartum period.

C. Ventilation. It should be easily aired without draft.
D. Sunshine. It should be cheerful for convalescence.
E. Quietness and privacy. It is helpful if the room can be shut off from
the rest of the house

F. G ood fight, day and night.
Advance Preparation o f the Room

Teach the midwife how to give the mother detailed directions about
preparing the room for confinement and the family's responsibility for
getting this done.
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About 1 month before the expected date of confinement all the furni­
ture, ornaments, and clothing which are not needed in that room should
be put somewhere else in the house in order to give more space for quick
action and to do away with the danger of spoiling things. Then the
husband or other strong person should help to give the room a thorough
cleaning. Go over with the midwife the directions for cleaning a room
thoroughly. The mother should not do any of the lifting or heavy work.
To “ house clean” a room .— Clean the dresser drawers, dust
and wash all the furniture, and move each piece except the bed into an
adjoining room. Strip the bed and put the soiled linen to soak and the
clean comfortables or blankets to air in the sun.
Examine the mattress carefully for vermin, looking well into the
seams and folds; brush it thoroughly around the buttons and bindings,
sweeping from the center toward the edge. Turn the mattress over and
repeat the process. Stand the mattress on its side at the head of the bed
on newspapers. Put a clean newspaper on the spring or slats, and brush
the pillows on both sides.
Carry the mattress and pillows into the open air, hang them on a
clothesline or fence or lay them on clean chairs or on the grass, and leave
them exposed to the sunshine, if possible, all day. Bring them in before
night to keep them from getting damp from dew.
If the weather or the housing situation prevents taking the bedding
into the open, air it all as long as possible in front of an open window
in another room.
Take down all the curtains and have them washed or cleaned.
Remove any rugs or carpets, have them cleaned if possible, or sweep
both sides, shake, beat, and air them. If they must be swept in the house,
put wet paper on them first to keep the dust from rising.
If there is much dust under the rugs, sprinkle the floor lightly to
lay the dust before sweeping.
Examine the bed for vermin. Dust the springs, wash the slats and
bed frame.
Wash the windows, inside and outside. Wash the woodwork and
door knobs, giving particular attention to any accumulation of dust in
cracks or ledges of the moldings.
After everything else is throughly cleaned, scrub the floor. When
it is dry, lay the rugs and rearrange the furniture as it will be most con­
venient for the delivery.
To rearrange the room after house cleaning.— Make sure that
the bed and mattress are free from vermin and that the bed is put to
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gether securely. Place the bed so that it is out from the wall with both
sides easily accessible and the right side toward the center of the room.
The best light should fall across the foot of the bed.
If the spring or mattress has sagged and there is a hollow in the bed,
a table leaf or a strong, wide board should be used to reinforce it at the
time of delivery (fig. 33 and pp. 4, 55).


There should be a good bright light that can be used day or night.
Such a light should be adjustable and portable.

Arranging the Supplies

When the room has been cleaned, the mother’s and baby’s supplies
should be arranged so that there will be no unnecessary delay in the
preparations when labor begins. The midwife should tell the mother to
put the cotton or the bag of clean rags to be used as wipes and the four
basins away last, as they will be used first.
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A t this time the packages of sanitary pads should be sterilized.
(See pp. 21, 45.
The midwife should show the mother how, from the box or drawer
of baby’s supplies, to make up the baby’s bed and a bundle for the baby’s
first oil bath containing—

Flannelette square.
Dress or nightgown.
Six diapers.
Two soft, old, clean towels.
Two small, soft cloths.

To prepare the baby's tray— This can be done a day or so after
the room is house cleaned.” The midwife should show the mother how
A. Wash the tray, all the jars and bottles, the caps, and the new nipples




in warm, soapy water. Rinse them thoroughly in clean water.
Put the jars, bottles, caps, and lids in a kettle of cool water on the
stove so that they are covered with the water. After the water is
boiling, drop in the nipples and the rubber caps for the nursing bottles.
Allow them to boil for 5 minutes.
Remove the kettle from the fire, drain off the water, and allow the
jars to cool.
Make a supply of large and of small cotton balls.
Remove the boiled jars from the kettle with a clean teaspoon without
touching the inside of the jars. Turn them upside down on a clean
dish towel. Put the boiled nipples and the rubber bottle caps into
one sterilized jar and put on the cover. Put the large cotton balls
in one jar and put on that cover. Put the small cotton balls into
another jar and put on the cover. Cover and leave to be filled later
the pint bottle or jar for the day’s supply of boiled water, one jar
for oil, and one for boiled water for washing the mother’s nipples
before and after she nurses the baby.
Take one cake of white soap and stick the safety pins— six large and
six small ones— into it ready for use. Put the other cake of white
soap in the soap dish and cover it. Arrange the jars, nursing bottles,
pint bottle for baby’s boiled water, soap dish, and soap pincushion
on the baby’s tray.
Cover the whole tray with the clean towel and put it in the confinement
room out of reach of small children.

After the room and supplies are so organized, there is pleasure and
security in knowing that things are ready for use at a moment’s notice.
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The good midwife will help the mother make a plan for getting early
all the supplies she needs for her delivery and the care of the baby. She
will explain how each article is used so that the mother will understand
why it must be “ just s o /’ She will check up with her from time to time
to see that the mother is following the plan and will be ready in plenty
of time. She will help her to have the best possible arrangement for the
confinement room. She will make sure that it is “ house cleaned” and that
the supplies are conveniently sorted and easy to get at when labor begins.
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Lesson V I.

M aking a D elivery Bed


To teach the midwife how to prepare a clean delivery bed and how to
protect the mattress.

One table, dresser, three chairs, one bed—made up as if slept in but
with clean quilts or blankets a table leaf or board, three clean sheets,
one clean pillowcase, one clean blanket, newspaper pads with cloth
covers, a generous supply of fresh newspapers, some large pieces of clean
old muslin, hand basin, bucket of water, dipper, soap m dish, and paper

Wash your hands. Carry the clean sheets and pillowcase, one clean
blanket, and a generous supply of newspapers to the bedside and put them
over the head board or a chair back or on a table.
Strip the bed. Take off the upper clean quilt or bedspread and lay
it over a chair to air. Take off the blankets likewise.
Strip the pillowcase from the pillow, put the pillow on the chair,
and put the case on top of the soiled sheets that are still on the bed.
Loosen the sheets from under the mattress and fold the ends toward the
center. Roll up the soiled linen in a newspaper. Fix the mattress
straight and firm on the bed. Put the table leaf or board under the mat­
tress crosswise about where the mother’s hips will rest.
Wash your hands.
Protect the mattress well with newspapers. Begin at the head of the
bed on the far side and cover that side from the head to the foot. Use
three thicknesses of papers at a time and place each three so they overlap
the last three about 4 inches. Have the papers extend well over the
mattress at the top and at the edge. After the far side has been pro­
tected begin at the head of the bed on the near side and cover that side
with five thicknesses of paper overlapping the paper on the other side.
Have each five thicknesses of paper overlap the last papers put in place.
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This overlapping is important to insure good protection for the mattress
(fig. 35).
Unfold a clean sheet and spread it on the papers. Tuck it well under
the mattress at the top, sides, and foot. Show the midwife how she can
favor the right side of the bed where the mother will lie if the sheet is a
bit narrow.
Spread on the bed the top sheet and blanket or quilt. Turn them
down at the top as you would in making any bed, and turn them up at
the bottom instead of tucking them in. Tuck them in on the far side

and then fold this bedding to the far side of the bed so that it will be out
of the way. Put the clean pillowcase on the pillow and adjust it on the
Place a folded blanket and draping sheet over the foot of the bed.
Make three thick and three thin newspaper pans at this time on the
bed so that the midwife can see what to do if there is no large table on
which to work. Line one of the thick newspaper pans with a clean white
rag tucked into the rolled edges and put it on the bedside table for the
moment. Put the others on the dresser.
Place the first bed pad across the bed about where the mother's
buttocks will be at delivery but extending over the mattress edge. Place *
the second bed pad lengthwise of the bed (fig. 36).
Then put the lined newspaper pan in place.
Make three large newspaper bags. Place one near the pillow on the
bed to be used by the mother if she needs to spit. Place the second
paper bag on the foot of the bed out of the way, to be used for soiled
wipes. Place the third paper bag on the kitchen table to use for soiled
wipes as you cleanse the baby.
T idy the room and carry out the newspaper bundle of soiled linen.
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Be sure to emphasize the care that is necessary—
A.. N ot to stir up dust while preparing the bed during labor.
JB. T o make sure the mattress is well protected.
O. T o see to it that the bed can be made ready for the delivery quickly, if
labor should be short.

D. T o keep the mother com fortably warm if it is at all possible. Use a
hot stone or brick if the mother’s feet should get cold.

After your demonstration watch each midwife strip the bed and
make it.

2 4 9 1 3 7 °— 41

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Lesson V II.

The M idw ife’s Preparation o f H erself

W hen should all preparation of the supplies for delivery he
W hat items of the baby’s layette are most important?
W hat could you get for 10 cents which could be m ade to serve as
a bed pan by adding a board?
W hy should the room be prepared for delivery before labor
If white rags are scarce, what might the mother prepare instead
for the delivery?
W hy should the midwife be notified as soon as labor begins?
W hat dangers m ay come to mother and baby if the midwife is
Give three signs of beginning labor.
If labor begins with painless bleeding, what should the mother
W hat m ay painless bleeding m ean?
The M aternity Situation

Explain the dangers of maternity. In the United States in 1939
about 9,000 mothers died from causes assigned to pregnancy and child­
birth. Childbirth is a greater risk of death to women between 15 and 45
years old than is any disease or class of diseases except tuberculosis and
diseases of the heart. Of the 9,000 women who died in childbirth in
1939, probably 4,500 could have been saved by proper care.
Forty-five hundred mothers’ lives are not the only price we pay for
poor maternity care. M any mothers are made invalids. M any babies
are born dead and many others die after birth as the result of improper
or insufficient care. In 1939 about 73,000 babies were born dead in this
country and 66,000 babies that were born alive died before they were a
month old.
The midwife can help to save the lives and health of mothers and
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A. If she prepares herself for her work—
a. B y getting as much public-school education as she can.
b. B y getting as much experience under supervision as she can
to help her to develop good technique and skill.

c. B y attending the classes for midwives that are given in her
county or State.

B. If she keeps herself in good condition—
a. B y being examined by a competent doctor to make sure she
has no disease and carries no germs in her nose or throat
that might be carried to the mother or the baby. She
should not attend a birth if she has a head cold, sore throat,
cough, or infection of the skin, particularly of the hands.
b. B y keeping herself, her fam ily, and her house clean and neat.
Cleanliness helps to prevent disease. It will help her to
keep well and to keep her mothers well. It will also set a
good example for the mothers.
c. B y calling a doctor if she or any of her fam ily should become
ill, to learn how to care for the ill person and to prevent the
spread of disease from her house to any one else in the com ­
munity. She should not attend a birth if there is illness in
her own home.
C. If she keeps her standard equipment in perfect order, clean, and ready
to use at a moment’s notice.
D. If she uses her influence in the community to persuade every expectant
mother to have a medical examination early in pregnancy
and then registers only those mothers whom the doctor says
it is safe for her to deliver.
E. If she practices good midwifery—
a. B y keeping in touch during their pregnancy with the mothers
she registers and reporting immediately to a doctor if all is
not going well.
b. B y helping the mother to conserve her strength during preg­
nancy and labor so that she will protect her baby, and to
prepare the supplies that she will need to care for him.
c. B y protecting the mother and baby from infection during and
after labor (a) by being clean and using good technique,
(b) by seeing that the mother prepares early the supplies
she needs, (c) by seeing that the mother knows that she must
call the midwife as soon as labor begins so that the midwife
will have time to do everything in the best way, and (d) by
not attending a birth if she has just attended a woman with
an infection or with fever or if she herself or any member of
her fam ily is not well.
d. B y following every rule and regulation of the town, county, or
State department of health for the practice of midwifery and
every detail of the teachings and advice of her supervisor.
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t e a c h in g

m id w iv e s

Go over each of these points, explaining its importance. The mid­
wife who promises to care for a mother in labor and at delivery is responsi­
ble for the life and health of two human beings. Good intentions alone
will not save those lives. If the midwife is to deliver mothers safely, she
must add to the best intentions in the world the good technique, wise
judgment, and skill that come only when good teaching is followed by
continuous effort to improve every detail of her work. When a real
desire to be helpful leads to such careful preparation we can expect some
reduction in the hazards to mothers and babies.
Midwifery is hard work. It takes a well, strong, intelligent woman
to be a good midwife.
If the midwife delivers more than four mothers a year, she should
have two sets of the standard equipment, so that she can be sure there will
always be a clean one ready to use. A good midwife should have her bag
ready for inspection at all times, and it should be absolutely clean with
each article in good repair and in its proper place. The midwife should
consider all the equipment soiled if the bag has been opened at all.
Nothing but the standard equipment should ever be put into the bag.
Nothing that belongs to the standard equipment should ever be used for
any other purpose.
To clean the equipm ent.— Tell the midwife how to clean her
A. Take everything out of the bag.



Wash, boil, and dry outdoors in the
sun, well out of reach of children and of animals, the lining, cap,
midwife apron, wrapping for the apron, mask, towel, four muslin
cases, hand scrub brush, and nail stick.
Wash off the inside and the outside of the bag, using a clean cloth, soap,
and water. Let the bag dry, out of reach o f children and animals.
Wash the hands just before touching the clean, dry goods, which
should be ironed with a “ spitting” hot iron on a clean ironing board.
Wash, boil, and dry the scissors and safety pin.
Inspect the silver nitrate (eye drops) for freshness and wash the outside
of the box with a clean soapy cloth, rinse and dry it with a clean
cloth. Replace the box if it is empty. Make sure a needle is in
the box.
Put glass connecting-tube into cold water and heat. When water is
boiling drop into it the rectal tube, funnel, and rubber tubing and
boil for 3 minutes.
W ith careful use the pencil, birth-record book, and other stationery will
not become soiled. They should be aired in the sun.
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H. When everything is thoroughly dry, repack and close the bag tight.
(See figs. 3, 4, and p. 21.) Before putting it away out o f the reach
o f children or animals, wrap it carefully in wrapping paper to pro­
tect it from dust.
W hen the Call Conies

The good, midwife is always ready to answer a labor call. She keeps a
freshly laundered dress and a set of clean underclothes wrapped in a
drawer or a box where she can get them on a minute's notice. She keeps
her nails short and smooth. She washes her hair every week and she
bathes every day. # She keeps her mouth clean by scrubbing her teeth and
rinsing her mouth with salt water or some other mouth wash.
Explain that every call should be answered at once, as there is no
way of knowing until the midwife sees the mother whether she is in labor
and how much time there will be for the preparation for delivery.
Without losing one minute the midwife should bathe quickly, put on
the clean clothes, take the clean bag that is always ready, and go to the
mother by the quickest route.
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Lesson V III *

The H and Scrub


To teach the midwife how and why she should scrub her hands and
arms—to get rid of germs that might give the mother childbed fever and
the baby blood poisoning or lockjaw.

A clean basin, a soap dish or saucer containing a new cake of soap,
a wooden nail stick, and a hand scrub brush on a chair protected with
newspaper; a teakettle of hot boiled water on newspapers on the floor,
and beside them on a newspaper on the floor the toilet bucket with a cuff
of folded newspaper (fig. 37).

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Explain the reasons for scrubbing the hands and arms thoroughly.
Explain why the basin should be clean. Stress the importance of using
only clean soap and a brush and a nail stick that have been boiled. A
brush that has been used and not boiled is dangerous because it may have
germs on it from some other mother.
Roll the sleeves above the elbow so that they cannot come down.
Point out that you are not wearing rings or bracelets and tell why. Point
out that your nails are cut short and rounded. Explain the danger of
long nails picking up dirt and scratching the mother and baby or tearing
the tender membranes of the baby’s mouth if it should be necessary to
wipe out mucus.
Pour warm boiled water from the teakettle into the basin. Explain
why the water should be as warm as can be borne. Dip the brush in the
water and rub the soap well into the brush. Using this brush and begin­
ning at the elbow, systematically scrub each forearm and hand with quick
vigorous action for 2 minutes. In scrubbing go all around the arm from
the elbow to the wrists, then scrub the back of the hand and between and
around each finger, and finish with the palm and the fingernails, on
which the most time is spent. Rinse the suds off the hands and arms.
Clean the nails with the nail stick and scrub the hands again with the
brush, dipping the brush frequently into the water during the process.
Empty the basin into the bucket, rinse the soap dish and the basin
thoroughly, and fill the basin again with warm water from the teakettle
so that it will be ready for the next midwife to use.
Have each midwife practice scrubbing until she can do it perfectly.
Watch her closely so as not to miss any errors of technique that might
develop into habits.
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Lesson IX .


W hat is the m idwife’s responsibility in helping to prevent deaths
in childbirth?
How can the midwife help to prevent early infant deaths?
Where does the midwife get her permit to practice midwifery?
W hy should the m idw ife’s bag be clean?
W hat do we m ean by “ clean” ?
W hy is it important that her equipment be complete?
The Birth Canal

Tell the midwives briefly about the birth canal.
During the prenatal period the baby is in the uterus (womb) inside the
mother’s abdomen (belly). The uterus is a muscular bag with an opening
at the bottom that is closed tight during pregnancy by two rings of mus­
cles and a plug of mucus. Before the baby can be born these rings of
muscles must be stretched open so that he can be pushed out of the uterus.
On the way out of the uterus and through the vagina (the last part of
the birth canal) the baby must pass through the bony broad funnel that
is formed by the hipbones, the lower part of the backbone, and the pubic
bones in front. The normal passageway inside these bones is something
like that in a curved stovepipe elbow (fig. 38, two views).
Any deformity of the bones might spoil the shape of the inside pas­
sageway so that there would not be room for a 9-month baby to pass
through. That is why the doctor’s examination early in pregnancy
includes the measurement or X -ray picture of this bony passageway.
(See p. 24.)
Definition o f Labor

The midwife must understand what happens in the mother’s body
during labor if she is to be intelligent in her care of the mother. Explain
to her just what the processes of labor are. Labor is the name given to
the process of nature by which the waters, the baby, and the afterbirth
are expelled, or pushed out, from the mother’s body by way of the birth
canal. It is divided into three stages.
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\n \


Front view of pelvic bones.

Side view of birth canal (cross section).
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The first stage— the stage of opening the mouth of the u teru slasts from the beginning of labor pains until the mouth of the uterus is
stretched wide open. It may last from 12 to 18 hours when the mother
is giving birth to her first baby and from 4 to 12 hours or even less when
she has already had one or more babies.
The second stage— the stage of expelling, or pushing out, the
baby—begins as soon as the mouth of the womb is completely open and
ends when the baby is born. It may last from 15 minutes to 2 hours or
The third stage—the afterbirth stage— begins as soon as the baby
is bom and ends when the afterbirth is pushed out. It may last from 15
minutes to an hour or more.
Point out that normally it is always a force from behind the baby and
afterbirth that pushes them out. The midwife should never pull or try to
twist or turn the baby or the afterbirth. If they do not come naturally,
she must call a doctor, for she is supposed to attend only normal, term
The M uscles Used in Labor

It is the muscles of the uterus and the abdomen that work during
labor. When a muscle works it contracts (shortens) and pulls on what­
ever it is attached to. Sometimes a muscled contraction moves some
part of the body; sometimes it holds the part steady. Sometimes it
stretches another muscle that is attached to it. A powerful workingman
boasting of his strength will show how big and hard the muscle is in his
arm. He lifts a heavy weight to his shoulder. The muscle on the upper
arm bulges under the skin, and if it is felt with the fingers, it will be hard
and firm. That is a contracted muscle— a working muscle. If a muscle
gets overtired, it may stop working. If it becomes irritated, it may
contract so tight that it cannot work normally for some time.
When labor begins the mother can feel the contractions of the muscles
of the uterus. The midwife can feel them, too, by laying her hand on
the mother’s abdomen, just above the navel. During labor the muscles
of the uterus work and then rest and then work again. While they work
the mother has a labor contraction; while they rest she has no contraction.
These contractions of the uterus usually cause the mother to feel pain.
A t first the contractions are short and the rests are long. Gradually the
contractions last longer and are stronger as the muscles work harder,
and the rests between contractions grow shorter and shorter.
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Neither the mother nor the midwife can control the contractions of
the uterus, but when the midwife understands what muscles are working
during each stage of labor she can help the mother to help herself. B y
wise and careful management, enabling the mother to rest during each
stage of labor, the midwife may keep the muscles from becoming overtired
or irritated and so keep the labor progressing normally.
During the first stage of labor the muscle at work is solely that of
the uterus. The contractions of the upper part of the uterus slowly but
gradually stretch wide the muscular rings on the inner surface, then the
ring on the outer surface.
Demonstrating the first stage of labor with a bag and a
doll.—T o show the midwife how the muscles of the uterus work to stretch
the cervix (mouth of the uterus) so that the baby can be pushed through
the opening, use a muslin bag having a double drawstring and contain­
ing a baldheaded doll whose legs and arms wdll fold up like those of
an unborn baby. The folded doll must just fit the bag so that with the
drawstrings pulled tight the bag will close over the doll’s head.
Hold the closed bag containing the doll in both hands with the doll’s
head down, and the back of the doll’s head forward. Explain that when
labor begins the uterus is closed tight just as the bag is. Place both
hands tightly against the bag and draw the hands closed, as the uterine
muscle shortens during a labor pain. Explain how the uterine contrac­
tions pull on the muscular ring at the cervix until it is stretched open
just as the bag is opened by the pull of your closing hands. Show how the
opening is gradually stretched a little more and a little more with each
pain (fig. 39, two views).
Explain how the bag of waters, when it does not break too soon,
makes a smooth bumper in front of the baby’s head that protects the
soft lips of the uterus against bruising and also acts as a wedge inside the
muscle ring to help stretch it open.
Point out that the stretching must be completed before the baby can
be pushed out of the uterus into the vagina— the last section of the birth
canal. Explain that during all this slow stretching the muscle work of
the uterus is using the mother’s strength and energy. The midwife who
knows how to “ manage” during labor wdll see that the mother’s strength
is kept up by having her rest between pains and by giving her some light
nourishment wdth plenty of liquids every 2 hours.
The mother may have an idea that she should keep up and about
and should try to help push out her baby as soon as labor begins. That
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idea is all wrong. The midwife should know how to explain at the begin­
ning of labor the following:
That nature must stretch the opening of the womb before the mother can
push out the baby.
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That the mother must not begin to “ push,” or “ bear down,” until the
midwife tells her to.
That she can help herself most by walking about the room a little, by rest­
ing often, by taking light nourishment, and by drinking water.
That she will be more comfortable and that labor will progress faster if her
bowels are empty and she passes water often.

Then with the bag partly open show the midwife what happens when
the doll is pushed down by pressing on its buttocks (fig. 40).


Explain how that is like the push on a baby when the mother
“ bears down” before the mouth of the uterus is stretched. Show that
bearing down at this time does not stretch the opening because that can
only be done normally by the even pull of the contracting muscles of the
uterus all the way around the ring of muscles at its mouth. Explain how
the waters are pushed to the side by each pressure on the baby's buttocks
and how the baby’s head forced against the soft lips of the uterus will
bruise them. If repeated, this will irritate the ring of muscle and might
cause it to contract so tight that it could not be stretched open until a
doctor could give the mother an anesthetic. Explain that this is why
the mother should not be allowed to bear down during the first stage of
labor. Bearing down at this time does not shorten labor. It may even
lengthen it and cause unnecessary injury and use the mother’s strength
for nothing.
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There should be no real bleeding during this first stage of labor.
There may be some blood-stained mucus discharge. Tiny glands at the
mouth of the uterus throw out a slippery watery secretion (mucus) which
keeps the passage moist. Sometimes this discharge is blood-streaked
because of the stretching of the mouth of the uterus and the separation of
the membranes, but real bleeding is abnormal. If it occurs, a doctor
should be called at once.
The waters should break when the stretching is complete. When
they break earlier the mother has a “ dry birth.” When this happens the
first stage of labor may be longer and the pains may be sharper because
there is no bag of waters to act as a bumper or a wedge.
The tim e to “ bear dow n.” — Explain to the midwife the import­
ance of watching the mother constantly for signs which will suggest that
the stretching (the first stage of labor) is over and that the time to bear
down has arrived.
Signs of the second stage of labor:
A. Pains become more regular, more frequent, are harder, and they last

B. M other may complain of nausea— sick stomach— may feel she must
vom it; she may vom it.

C. M other feels her bowels should m ove or complains of a pain in the
rectum. (The baby’s head pressing on the rectum gives the mother
a false idea that she is about to have a stool.)
D. A small amount of mucus mixed with blood, the so-called “ bloody
show,” comes from the birth canal.
E. If the bag of waters has not broken earlier, it may do so now.

This is the time for the mother to begin to push out the baby. If she
takes a deep breath as soon as she feels a pain coming, then holds her
breath and “ pushes” as long as the pain lasts, just as if she were trying to
move her bowels, she can add a great deal to the force behind the baby, and
every pain will bring the baby a little farther on his way out. She should
rest between pains so that she can “ use every pain.” This is the way she
can help herself most and really shorten labor. With each contraction
the vulva will bulge and open, and the baby’s scalp can be seen.
When the baby begins to move down through the birth canal the
mother may have pain in her back and legs. It will be a relief for her to
straighten her legs and stretch her toes as far down as she can between
pains. It will also help for the midwife to rub her back if it aches.
If her rectum is not empty, the mother may move her bowels as she
bears down and the stool will soil everything that has been so carefully
cleansed to prevent infection. That is why an enema is given early in
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labor (see p. 76), so that there will be no material left in the rectum to be
pushed out during the second stage.
The time to “ pant.” —The baby’s head can be born more easily
if the mother does not bear down with the pains just as it is coming out.
T oo much force behind the head at that time would push it out too fast and
might tear the edges of the birth canal. When the head is coming out it is
better for her to “ pant like a dog.” The midwife should teach her how to
do this when she teaches her how to “ hold Jier breath and push.” The
midwife should be sure that the mother understands and then have her
promise to stop pushing and begin to pant the minute the midwife says,
“ Pant.”
Then, when the contraction is over, the midwife can let the mother
push again but she should push just a little, so that the head and shoulders
will come through slowly and not tear the edges of the birth canal. If the
edges should be tom , the midwife must call a doctor to mend the tear to
prevent the mother from having “ body trouble” later.
The afterbirth.—After the baby is bom , the mother will have a
few minutes’ re£t. Then there will be a few more contractions so that
she can push out the afterbirth. As soon as the uterus is empty its muscles
contract in still another way to lessen the bleeding from the area on its
inner surface where the afterbirth was attached. If more than one cup of
blood comes with the afterbirth, the uterus is not contracting properly and
the midwife should send for a doctor at once, in the meantime massaging
the wall of the abdomen to make the uterus contract.
Duration o f Labor

Usually the labor at the birth of a first baby is the longest, for the first
stretching of the mouth of the uterus is a long, slow process. The succeed­
ing labors may be much shorter. The mother who has had many babies or
who is overtired or poorly nourished may have longer labors because her
muscles do not work so well. The mother whose abdomen is very large
during pregnancy may have a long labor because her muscles have been
stretched till they have lost some of their power to contract. The mother
with the very large abdomen should be watched with great care for bleeding
after the baby is bom , because her stretched muscles may not contract as
much as they should when the afterbirth has separated from the wall of the
utems. The midwife who understands the mother’s need of care during
the first stage of labor can so manage the mother’s “ work” (bearing down),
rest, nutrition, and elimination as to help prevent many complications in
the second and third stages of labor.
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Preventing Infection

Point out to the midwife why the whole birth canal must be protected
from infection. The large area where the afterbirth was attached to the
inside of the uterus is just like an open wound—warm, moist, dark— a
place for disease germs to grow and cause childbed fever, milk leg, a whole
train of other ills, or even death.
In the uterus there will be a raw surface and in the birth canal tiny
tears that would allow germs to get in and grow. If disease germs get into
the birth canal it is almost impossible to keep them from growing and
spreading up into the uterus. So disease germs must be kept away from
the birth canal before, during, and after labor and delivery.
W hat the mother should d o :

A. Keep her body, clothes, and house clean all during pregnancy so that
there will be fewer germs around.

B. Take sponge baths instead o f tub baths during the latter part of preg­
nancy so that germs from the bath water cannot get into the vagina.

C. Take no douches during pregnancy, keep her fingers away from the
vulva, allow no one except a doctor to examine her internally with
instruments or fingers, and have no sexual intercourse after the
seventh month of pregnancy until 6 weeks after delivery.
D. Have the room , bed, bedclothes, and supplies that the midwife will
need clean and ready in time, and call the midwife as soon as labor
begins so that she will have the time and the things she needs to do
everything in the right way.
W hat the midwife should d o :

A. Teach and help the mother to do her part and be sure the husband
understands, too.

B. Keep her own house, her clothes, and her body clean at all times so that
there will be fewer germs around.

C. Come to the mother’s house with her equipment clean and herself
bathed and dressed in freshly laundered clothes so that she cannot
transfer germs from another mother.
D. Wash her hands and put on her cap and mask before she does anything
for a mother in labor; prepare the supplies and scrub her hands and
put on the midwife apron before the delivery.
E. Prepare the mother in every detail according to instructions-—without
fail, every time— to remove any germs that may be near the birth
F. See that nothing— water, oil, fingers, or instruments— is put into the
birth canal during or after labor.

Be sure the midwife understands that it is childbed fever that kills
many mothers every year and that most of them die because someone—
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the mother, the father, the midwife, or the doctor—was not clean and
The Baby

Many babies die a few hours or days after they are bom because they
are not cared for properly at birth. The care of the baby comes in
another lesson, but his immediate needs must be mentioned here, too,
because the midwife must understand why he needs special care as soon
as he is bom . He must be separated from the afterbirth, watched to be
sure he can breathe properly, and protected from infection, injury, and
chilling. If he does not have good color, if he does not cry and breathe
naturally, or if anything else is wrong, a doctor must be called at once.
As the baby’s eyes may be infected by discharges from the birth
canal, his face should be wiped clean and his hands kept away from his
eyes until thé drops can be put in them. (See p. 85.)
The cord should be tied securely in two places with sterile tape
because blood vessels that go into the baby’s belly are cut and they must
be kept from bleeding. The cord should be cut with sharp, sterile scissors
because germs must be kept away from the cord stump so that they do
not get into the open blood vessels. (See p. 105.)
The baby has come from a warm place, and special care must be
taken to keep him warm until he can get used to the cooler air outside his
mother’s body. He should be wrapped in the warmed blanket which has
been placed ready to receive him and which is fastened snugly to keep his
hands and arms inside. He should be laid in his bed with his head lower
than his feet so that mucus can drain out of his mouth and nose. The
bed should be so placed that the baby can be watched to see that he does
not choke, that his color is good, that he does not bleed from the cord,
and that he does not get uncovered.
The M idw ife’s Responsibility

When the processes of labor have been thoroughly discussed so that
the midwife really knows what the muscles are doing and how labor should
progress in each stage, emphasize her great responsibility for protecting
the mother and the baby from fatigue, chilling, injury, and infection.
Emphasize that when everything is normal nature, working through the
mother, delivers the baby. The good midwife manages the whole situa­
tion so that nature will not be interfered with when everything is normal,
and calls a doctor at once if labor is not progressing or if anything goes
2 4 9 1 3 7 °— 41-
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M anaging means:
Answering a labor call immediately so as to make the necessary prepara­
tions in the best way to prevent infection.
Seeing that the mother has rest, nourishment, and fluid and keeps her
bowels and bladder empty.
Encouraging her as labor progresses.
Helping her to “ push” and to “ pant” at the proper times during the
second stage of labor.
W atching her every minute all during labor so as to be sure to get a doctor
in time if all is not going well.
Giving the baby proper care as soon as he is bom .

The midwife who manages well is a great power in the community.
Every time she attends a woman in labor she stands guard over the life
of a mother and a baby and works with God and nature to keep alive the
precious spark of life from generation to generation. It is no wonder the
people “ rise up and call her blessed.”
The midwife who tries to hurry nature, who does not call a doctor in
time, who is careless about protecting the mother from infection, who
neglects a baby, is a menace not only to that mother and baby but to the
whole community.
It might be a good idea to close this lesson or the whole institute
with an impressive ceremony when each midwife would be asked to sign
a solemn pledge promising to guard the life of every mother she attends
during pregnancy, at delivery, and after delivery and to cherish every
baby as if it were her own, by being clean and careful all day and every
day, by following to the least detail the instructions for the care of mother
and baby, by urging all pregnant mothers to go to good doctors for ex­
amination early in pregnancy, by helping them to follow the doctor’s
advice, and by calling a doctor whenever she is not sure that everything
is going well.

The midwife who would give intelligent care to a mother must manage
the whole situation during each stage of labor with three things in mind:
The birth canal or passage through which the baby comes into the
world, the “ powers” that push him out of the mother’s body, and
the passenger, the baby himself.
The passage, if the mother is to have a normal delivery, must be
large enough for a full-term baby to come through and must be free from
deformities so that there will be nothing sticking out to catch the baby’s
chin or shoulder. It is important for the midwife to know about this
early in the pregnancy—one more reason why the doctor’s examination
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of the mother should be made before the midwife promises to care for her.
The doctor will take measurements of the pelvis. If there is any doubt
that the passage is normal the doctor may want X -ray pictures. If
the passage is not normal, he will want the mother to be in a hospital
for the labor.
When the midwife is caring for a mother with a doctor’s assurance
that the passage is normal, she should never forget for one second that
she must keep disease germs from getting in or near the passage. She
should remember that if the mother is tom during delivery, the tear
must be repaired by a doctor.
The “ powers” — the muscle contractions—must be strong enough
to push out the baby or the mother cannot have a normal delivery even
when the passage is normal. The strength of these powers cannot be
tested during pregnancy. No one can tell how a muscle will work at a
given time. No one can be sure that a big, strong woman will have
strong powers during labor or that a little, frail woman will not have.
The woman who has lived wisely during pregnancy (see lesson III, p. 36)
will be more likely to have enough power to deliver her baby normally
than the mother who has been overtired and underfed. The mother
who has had many babies or has had the muscles of her uterus stretched
b y much fluid or by big babies may not have muscles strong enough to
push out the baby normally.
The midwife must be on her guard every minute to save the mother’s
strength by seeing that she rests between pains, that she takes some
nourishing fluid evety 2 hours, that she does not waste her strength
and slow up the progress of labor by “ bearing down” before the signs
appear that the stretching of the mouth of the uterus has been com­
pleted, by teaching her when and how to “ push” and “ pant,” and by
keeping her encouraged as labor progresses. If the mother seems to
be tired, if the pains grow weak or stop, or if the baby does not seem to be
coming along normally after the mother has had an hour of second-stage
pains, the midwife should call a doctor.
The passenger—the baby—must be kept in mind during labor.
Everything must be put in readiness for him. His clothing, his bed,
the receiving blanket must be warm to receive him so that he will not
be chilled. The sterile cord scissors, ties, and dressing and the eyedrops
must be at hand, and the toilet tray ready in a warm place for his first
oiling and drink. He must be watched so that a doctor can be called
at once if all is not as it should be.
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L e sso n X .

The Soapsuds Enema


To teach the midwife why, how, and when to give an enema to a
woman in labor. T o warn her when she should not give an enema.

As the enema is usually given during the first stage of labor, the room
should be arranged as described in lesson X II (p. 88), the bed made for
delivery, the midwife’s hand-scrub equipment ready to use, and her other
things and the mother’s supplies conveniently arranged in the mother’s
room and the kitchen. There will be newspapers, toilet paper, grade-B
absorbent cotton or clean dry rags for wipes, a bedpan, thick newspaper
pans, newspaper bags, and a toilet bucket in the mother’s room. The
mother’s soap in a saucer and the basin she uses for a sponge bath and a
clean pitcher or jar will be at hand. The mother will be up and about
wearing a nightgown, kimono, stockings, and slippers. The midwife
will be dressed in a wash dress and wearing her cap and mask. The doll
and the supervisor who is demonstrating to the class should be dressed

Tell the midwives that an enema for a woman in labor means warm,
soapy water poured into the rectum (back passage) through a rubber tube
to stimulate the lower bowel to empty itself so that the rectum will be
empty during labor and delivery. The heat and pressure on the uterus
from the rectum filled with the warm soapy water usually will also stimu­
late the uterus to contract and the bladder to empty itself.
Explain that an empty lower bowel and bladder leave more room for
the lower birth canal to stretch as the baby passes along it. Their being
empty also helps to prevent injury to the bowel and bladder walls from
the pressure of the baby (fig. 41, two views).
If the rectum is not emptied early in labor, the bowels may move
during delivery, and some of the feces may get into the birth canal and
cause infection. So an enema not only helps delivery by emptying the
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rectum and bladder and stimulating the uterus to contract but prevents
soiling and possible infection.
Tell the midwife of the importance of learning before giving an enema
when the mother passed water last and how much fluid she had had
to drink in the last few hours. If she had had little to drink and had not
passed water recently, she should have two glasses of hot water, weak tea,
or coffee to drink while the midwife is preparing the enema, so that she
can pass water easily when she expels the enema.
Warn the midwife not to give an enema without advice from a doctor
if the bag of waters has broken, if the pains are coming hard and close
together, if the baby's scalp is in sight, if the baby's cord, his hand, foot,
or buttocks can be seen coming down in the birth canal, if there is bleeding,
or if there is any other danger signal. Emphasize why danger signals
mean sending for a doctor at once.
When you are sure the midwife understands when and why to give
an enema and when and why not to give one, show her just how to prepare
and give one to a mother in labor.
Preparing the enem a.—Into a pitcher or a jar pour a little hot
water on the white soap in the mother's supplies. While it stands for a
few minutes see that the rim of the toilet bucket is protected with folded
newspaper. Then shake the soap and water well and add enough warm
water to fill the pitcher or jar. Take out the soap and skim off the soap
bubbles. The soapy water should feel warm to your hand. Place the
pitcher of soapy water in a hand basin. Connect the funnel, rubber
tubing, glass connecting nozzle, and rectal tube and put them in the basin
beside the pitcher. Fit a piece of toilet paper or clean wipe over your
index finger and put some unsalted lard on it and wrap it around the end
of the rectal tube. Carry the basin and its contents to the bedside.
Preparation at the bedside.—Explain the purpose of the enema
to the mother (demonstrate with the doll) and tell her just what you are
going to do. Urge her to help by breathing through her mouth if she has
a labor pain while you are giving the enema and to let you run in as much
soapy water as she can hold to allow the enema to help her as much as it
Arrange the equipment on a bedside chair well protected with newspapers. See that the toilet bucket is on newspapers on the floor beside
the bed, and the roll of toilet paper within reach.
Preparation of the mother.—Ask the mother to take off her
kimono and lie on the bed. Cover her with the draping sheet. Place the
small blanket from the foot of the bed over her upper body to prevent
shilling and exposure. See that a thick newspaper pan is under her
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hips and turn her on her left side with her hips even with the edge of the
bed and with the right knee well drawn up. Turn her nightgown up out of
the way.
Giving the enem a.— Place the basin and its contents on the bed
beside the mother’s knees (fig. 42). Hold the funnel in your left hand and

form a loop in the tubing by pinching it in two places with the same hand
(fig. 43). Then pour some of the soapy water into the funnel. Put the
pitcher down in the basin and let go of the tubing. Let the soapy water
run through the rectal tube into the bucket to warm the tube and expel
the air. Pinch off the flow again before the funnel is empty.
Look carefully to see if there are varicose veins or hemorrhoids (piles)
around the mother’s anus. Take great care to avoid hurting the mother
as you insert the tube into the rectum. A well-greased tube will go in
easily. If it has a tendency to slip out, ask the mother to hold it in place
(fig. 44).
Pour some more soapy water into the funnel and set the pitcher in
the basin again. Allow some of the water to run slowly into the bowel
and put the rectal tube in gradually as far as 6 to 8 inches. Hold the
funnel just high enough above the anus to keep the water flowing slowly.
Six to twelve inches is usually high enough. The rectum will be emptied
more completely if the soapy water runs in very slowly.
Refill the funnel each time just before it becomes empty so that no
air can get into the rectum.
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Explain about lowering the funnel a little to slow down the flow if
the mother has a pain or complains of cramps and about pinching the
tube to stop the flow for a few seconds. Show how when the mother is
sure she can hold no more you would pinch the tube while there is water
in the funnel and withdraw it slowly, with one hand pressing a wad of
toilet paper or wipes against the anus. This will help to prevent the
escape of fluid when or immediately after the tube is withdrawn.


Hold the funnel up and let the water from the funnel run through
the tube into the bucket. This will rinse the inside of the tube. Wipe
the end of the rectal tube with toilet paper. Disconnect the rectal tube
from the glass connecting nozzle and wrap the rectal tube in newspaper.
Then put it and the pitcher, funnel, rubber tubing, and glass connecting
nozzle in the basin and set them aside to be cleansed later when the
mother can be left.
Dry the mother with toilet paper and help her to turn on her back.
Describe how when she thinks she can hold the water no longer you would
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help her to get up to expel the enema in the toilet bucket. While the
mother is on the bucket the bed should be straightened, any moist or
soiled articles should be replaced by clean dry ones, and the draping sheet
and small blanket should be folded at the foot of the bed if she does not
need either around her shoulders.
Explain why the mother should never be allowed to go any distance
away or to an outside privy but should be watched carefully because the

enema may be followed immediately by severe second-stage pains. She
should not be left alone in the room. If, while the mother is using the
bucket, the pains should suddenly become very severe or if she should
complain of a desire to bear down or if there should be any bright red
show, she should be helped at once into bed, where she can be watched
and controlled more easily, and should finish the expulsion of the enema
on a bedpan.
Explain that after the mother has finished emptying her bowels and
has passed water if that is possible, you would look at the contents of the
toilet bucket to judge whether the enema had all been returned and to
see if the mother had had a good bowel movement: use toilet paper to
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wipe the surface from the birth canal back over the anus; help her into
bed when she is clean; cover her; cover the bucket with a lid or with news­
papers; ask a member of the family to empty the toilet bucket, wash and
scald it, and bring it back to the delivery room.
While the mother is resting a few minutes lay the enema equipment on
a fresh newspaper out of the way so that you can wash the pitcher, the
basin, and your hands thoroughly. Fill the basin with warm water for
washing the mother. Explain that when there is time and a basin that will
not be needed, the rectal tube will be washed in soapy water and rinsed;
the funnel and nozzle will be put in the basin with some warm water and
put on the stove to boil. As soon as the water boils hard the rectal tube
and connecting tube will be dropped into the boiling water and boiled for 3
minutes. When the equipment is dried it is ready to be put in its
muslin case.
Bring the basin of warm water and the mother’s soap in a saucer to
the bedside. See that you have 18 or 20 clean dry wipes ready. Have the
mother lying on her back. Put a thick newspaper pan under her hips.
Turn back the covers and put the draping sheet over her. Put the
blanket from the foot of the bed across her upper body. With one of the
clean wipes moistened and well soaped wash her abdomen thoroughly
from the ribs to the vulval-hair margin. D o not let any water run or
drip on the vulva. Throw this wipe away in the newspaper bag, moisten
a clean one, and rinse the abdomen. Throw this wipe away and dry
with another clean wipe. Wash, rinse, and dry first one thigh and then
the other from the knee to the groin, throwing away each wipe as before.
Turn the mother on her left side and, using more wipes, wash, rinse, and
dry the buttocks and the anus. Be careful to keep water from running
or dripping on the vulva. With a clean wipe and plenty of soap wash
thoroughly about the vulva, explaining why you do not open the lips nor
allow any soapy water to enter the birth canal. Throw away the soapy
wipe in the paper bag. Rinse off the soap with a second wipe and dry
carefully with another one.
Straighten the bed and leave the mother to rest a few minutes while
you wash the soap, soap dish, and basin and scrub your hands.
Explain that if second-stage pains had begun you would have washed
the mother with boiled water and wipes as shown in lesson X III (p. 101)
and would have kept her in bed. If there are no second-stage pains and
no leaking, it is well for the mother to walk about a bit again after a
few minutes’ rest.
Have the midwives practice (with the doll) how to handle the enema
equipment—hold the funnel, pinch the tubing, fill the funnel, and so
forth—and wash the vulva and buttocks.
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L e sso n X I .

The Care o f the Baby’s Eyes


T o show the midwife how and to help her understand why she should
protect the eyes of the newborn baby against infection.

A table in a good light with a clean wrapping-paper cover. On it or
on a chair near it a newspaper bag; paper wrapper of the sterile cord dress­
ing containing two cotton balls; a box containing two new wax ampules of
silver-nitrate solution and a needle; a baby doll with a binder on, wrapped
in a receiving blanket and lying in the baby bed well covered; hand basin;
bucket of water; dipper; soap in dish; and hand scrub brush (fig. 45).
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Explain that every baby’s eyes need special care because germs
from the birth canal may get into them as he is being bom . After the baby
is born there is still danger of infecting his eyes if the discharges from the
birth canal are carried to his eyes by his own hands or by the fingers of the
doctor, nurse, or midwife, or, later, of the mother. Because germs which
cause the mother no symptoms or discomfort may irritate the baby’s eyes
enough to cause blindness, the eyes of the baby whose mother has had no
discharge from the vagina during pregnancy need just as much care as the
eyes of the baby whose mother has had such a discharge.
In most States there is a law which requires the doctor, midwife,
nurse, or other person in attendance on a confinement case to put two drops
of a silver-nitrate solution in each of the baby’s eyes soon after birth. And
most State departments of health will supply the silver-nitrate solution in
wax ampules free to doctors and midwives. Even if there is no State law
about using the eyedrops, the conscientious midwife is morally responsible
for using them to protect the eyes of the babies she delivers.
Be sure that the midwife knows where to get the eyedrops. Be sure
that she can explain what she must do to comply with the law or with the
practice approved by the department of health in her own State. She
should also be able to explain to the family why the eyedrops are used.
Some parents object to them because they think “ babies’ sore eyes” are
caused only by the gonorrhea germ and that the drops are not necessary
when the mother has had no discharge during pregnancy.
Both ideas are wrong. The gonorrhea germ causes only about half
the eye infections at birth. The other germs from the birth canal that
may infect babies’ eyes during or after birth may or may not cause the
mother to have discharges from the vagina during pregnancy.
The midwife’s responsibility for the care of the baby’s eyes does not
end when she has put the drops in them. In the daily care of the baby she
must make sure that nothing (her hands or the mother’s hands, bedclothes,
or nightgown) which is soiled with the discharge from the vagina after a
baby is bom touches the baby’s clothes, hands, or eyes. Everyone who
touches the baby should wash the hands first, and no one should touch
the baby’s eyes except the person who wipes his eyelids gently with a clean
washcloth and towel when giving him his bath. The mother’s hands,
bedclothes, and nightgown must be kept clean, and the clothes must be
boiled every time they are washed.
For at least 2 weeks after birth the baby’s eyes should be watched
daily for any signs of irritation. If there is a discharge or a collection of
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“ matter” in the comer of one eye or on the lid or eyelashes, the town,
county, or State department of health must be notified at once. This, too,
is usually required by law. In most States the presence of any discharge
from the eye of the newborn must be reported immediately to the board
of health, and every effort possible be made to get a doctor at once. “ At
once” means without losing one minute.
While waiting for the doctor the midwife should keep the baby from
touching his eyes with his hands, and she should not touch anything but
the baby until she has scrubbed her hands. Otherwise she might transfer
the germs from the baby’s eyes to her own or to another’s eyes. She
might send someone for the town or county nurse to help in making the
plans for caring for the mother and the baby so as to protect the rest of
the family.
Because good doctors and midwives give all this careful attention to
babies’ eyes, fewer children now are blind because they had “ babies’ sore
After the midwives have had a chance to ask questions about this
general explanation, show them exactly how to care for the baby’s eyes,
as follows:
A. Arrange the things on the table so that they are convenient to use.
B. Put the baby bed with the head toward the light so that the doll is




looking away from the light. This will give the midwife light to see
what she is doing and at the same time keep the baby from screwing
his eyes tight shut as he would if he were looking toward the light.
Turn the doll on its back.
Scrub the hands thoroughly. Emphasize the importance of clean
hands, which can carry no infection to the baby’s eyes.
Warm one ampule of silver-nitrate solution by holding it in the hand
for a few moments.
Open the ampule by sticking the needle in the top.
With the ampule held between the thumb and the first two fingers of
the right hand, squeeze out one drop of the solution over the news­
paper bag.
Then, standing so that you face the doll, go through the motions of
opening the doll’s right eye by laying the thumb of the left hand on
the cheekbone and the first finger on the eyebrow and separating
the thumb and the finger. This will open the eyelids of a baby
without pressing on the eyeball and without digging the fingers into
the flesh or letting them slip on the skin (fig. 46).
With the ampule in the right hand, squeeze two drops of solution into
the eye.
Remove the finger and thumb to let the baby’s eye close and then
catch the overflow with a clean cotton ball so that it will not run
onto the blanket and stain it.
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K. W ait a few minutes and shade the doll’s eyes.

You would wait for the
baby to open his eyes of his own accord. If you did not do this,
he might keep his left eye shut so tight that it would be difficult to
open it.
L. In the same way put two drops in the left eye.


Let each midwife practice doing this, using the doll so that she can
learn to use her hands correctly. Try the opening of the eyelids on the
midwife herself to let her see how it is done gently and without pressure.
Scrub your hands after demonstration to each midwife in order to em­
phasize how important it is to protect every eye from the possibility of
transferring a germ to another even when there is no inflammation. Have
the midwife scrub her hands and open your eye to be sure she has learned
to do it gently. Be on the watch for the midwife who “ digs in” with her
fingertips instead of just laying them on the surface and separating the
fingers without letting them slip on the skin. Be sure that every midwife
before she leaves learns to put the drops in the baby's eyes properly.
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Lesson X II.

The M idw ife’s M anagem ent During the First Stage o f Labor

W hat happens during the first stage of labor?
W hat happens during the second stage of labor?
W hat happens during the third stage of labor?
W hat three things must we keep especially in m ind during labor?
W hat are the “ powers11 during the first stage of labor?
W hy is it harm ful to bear down during the first stage of labor?
Give two reasons.
How can we keep up the mother’s power and strength to assist in
her delivery? Give two ways.
W hat do we m ean by “ the passage11?
W hy do we need a doctor to determine its size and shape?
W hat is a germ?
W ho are responsible for keeping disease germs away from the
birth canal?
W hat must each one do?
W hy is it dangerous for a midwife to put fingers or anything else
into the birth canal?
How does she prepare her hands for the delivery of the baby?
W hy does the midwife wear a m ask?
How long can we expect the first stage of labor to last?
How long can we expect the second stage of labor to last?
How long can we expect the third stage of labor to last?

When the midwife understands the processes of labor, the most
practical way to teach her the m anagem ent of labor is to present it as a
3-act play or demonstration. The supervisor takes the part of a midwife
and makes the whole performance as realistic as possible with dolls to
represent the mother and the baby. She describes in detail any proce­
dures that cannot be acted.
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T o show the midwife how she should manage during the first stage of
A. To prepare for a safe and clean delivery in order to protect the mother
and the baby from injury or infection.

B. To watch for signs of danger in order to get medical assistance if there is
the slightest sign that all is not going well.

C. T o guide the mother’s activity in order to conserve her strength.
D. To keep up the mother’s nutrition and fluid intake in order to provide
energy, keep up morale, and make for ready elimination.

A bedroom and a kitchen arranged as for a delivery with the following
furniture and supplies:
In the kitchen (fig. 47, p. 94):

Stove or makeshift to represent a stove with a large teakettle with a lid,
two cooking kettles with handles and lids, a long-handled dipper in the
larger kettle, and irons, bricks, or bags of sand for warming the beds.
Three chairs.
Large kitchen table with four basins (two of them the same size), a 1-quart
water pitcher, one cup, four saucers, two teaspoons, two plates, a can of
milk, a jar of sugar, a can of cocoa, a pair of ordinary household scissors,
a jar of lard. Nearby is a bucket of clean water.
Baby tray with five covered glass jars, one pint bottle (with top) for
baby’s boiled water, one nursing bottle, two nipples, one cap for the
nursing bottle, six large and six small safety pins, two cakes of soap,
1 pint of mineral oil, one soap dish (a saucer with a cup turned upside
down), one new box of grade-A absorbent cotton. (See pp. 50, 53, 94
and fig. 32, p. 49.)
On the floor under the table a laundry tub clean and empty and an un­
covered bucket for dirty water.
In the bedroom (fig. 48, p. 95):

One bedstead with springs, mattress, and a table leaf or board (see p. 4)
to use for reinforcing the mattress. The bed should be made up for
sleeping with a clean blanket and a quilt on it.
Two bedside tables.
Three bedroom chairs.
Toilet bucket or slop jar with cover.
In one dresser drawer a bag of clean white rags of various sizes, two cakes
of soap, two clean washcloths, four clean towels, four clean sheets, four
clean pillowcases, two clean nightgowns, two pairs of clean stockings,
one blanket, one toothbrush, one comb, a large bundle of newspapers,
six newspaper pads, four sanitary pads, one new roll of toilet paper, a
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bedpan or a bakepan and a smooth board covered with a newspaper and
placed across one end of the pan.
In another dresser drawer, one baby shirt, one band with three small safety
pins attached, six diapers, one dress, one flannelette square, two wash­
cloths, two towels, and one baby doll with string to serve as a cord attached
to its abdomen with adhesive.
Baby bed with mattress and mattress pad, pillowcase, three baby blankets,
and mosquito netting.
Adult-size doll dressed in nightgown, kimono, stockings, and house slippers
and sitting on a chair.
Midwife's standard equipment in perfect condition with the apron and cap
to fit the nurse who is demonstrating.

Explain that you are going to act the part of a midwife attending a
woman in labor. Leave the room and enter with your hat and coat on
and carrying your bag and a newspaper.
Greet the mother cheerfully, put your hat and coat on the back of a
nearby chair and your bag on the newspaper spread on the seat of the
chair. Wash your hands, using the family soap and basin. Watch the
mother’s expression, feel her abdomen during two or three pains, and
inquire about her condition wdth some such questions as these:
When did your pains begin?
Have you had any rest?
Where are the pains, in your back or in your abdomen?
How often do they come?
How long do they last?
Have you any pain or soreness in your abdomen between the labor pains?
Is there any watery or bloody discharge from the birth canal?
Is there any bleeding?
Has the bag of waters broken?
D o you feel like bearing down?
D o you feel the baby moving?
When did your bowels move?
Are you constipated?
When did you pass water?
When did you eat last?
What did you eat?
Have you vomited?
Have you a cold, sore throat, bad headache, cough, chills, fever, shortness
of breath, any swelling, fits, or any other discomfort or misery?

Explain that the answers to these questions and the mother’s expres­
sion and behavior during a pain or two if she has any would give the
midwife an idea whether or not the mother is in labor and whether she
2 4 9 1 3 7 °— 41-------7
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has had any of the danger signals. If there is the slightest suggestion of
a danger signal or if the baby is not yet due and the mother is having real
pains, the midwife should call a doctor.
Suppose that there are no signals of danger and that there are labor
contractions which you can feel when you put your hand on the mother’s
abdomen, so that there is no time to lose in getting ready.
First things to d o :

A. See that the fire in the kitchen stove is burning well.



Put plenty of
water on to boil in the large teakettle and the large covered cook
kettle with a dipper in it. Put irons on stove. Explain to the family
the need of a fire for warmth, for a good supply of hot boiled water,
and for keeping the irons hot.
Cover the kitchen table with clean newspapers.
Wash your hands again.
Open your bag and take out the equipment.
Put on the cap, tucking your hair well inside.
Put on the mask, making certain that it covers your mouth and your
Wash your hands again.
Arrange the rest of the equipment on the table so that you can get it
Close your bag and put it out of the way.
Put in one of the basins 30 to 35 wipes (large swabs of grade-B absorb­
ent cotton or pieces of clean white rags about 4 inches square),
cover them with boiling water, invert a second basin over it to use
as a cover, and put them on to boil. Let them boil for 10 minutes
after the water begins to bubble.
Place the cord scissors in the sterilizing pan from your bag, cover them
with boiling water, put on the lid, and let them boil for 10 minutes.
Place the mother’s household scissors in a stewpan, cover them with
boiling water, put on the lid, and let them boil for 10 minutes.

The mother’s bath.—Assume that the mother has not bathed and
prepare a basin of warm water, a cake of soap on a saucer, a clean towel,
a washcloth, stockings, and a nightdress. Explain that the mother can
take an all-over sponge bath, put on the clean clothes, and comb her hair
(fastening the braids if her hair is long) while the midwife is making the
delivery bed. Show how the midwife can help the mother wash her
feet and her back because they are hard for her to reach, and can put
newspapers on the floor for her to step on if she has no bedroom slippers.
Empty, wash, rinse, and scald the basin. Rinse the soap and soap dish
and put them away with the mother’s washcloth and towelfor her use later.
M aking the delivery bed.— Make a delivery bed and the news­
paper pans and bags as directed in lessons IV and V I (pp. 42 and 55).
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Arranging the supplies at the bedside.

A. Cover two chairs, one table, and the dresser top with several thicknesses



of newspaper and arrange those things from the dresser drawer that
you will need during labor and delivery where they can be easily
reached as you need them.
Place on newspapers on the floor ne^r the bed the toilet bucket with the
rim protected with folded newspapers and the lid or a newspaper
cover near it.
After the water has boiled for 10 minutes, set everything off the stove '
to cool except the big kettle of boiling water.
Drain the water off the cord scissors, taking care not to remove the lid nor
drop the scissors. If anything should touch the scissors, boil them
again. Place on the bedside table the covered pan with the boiled
untouched scissors in it. Explain why the scissors must be kept
Drain the water off the household scissors and let them dry.
Place the basin of boiled wipes, still covered, on the bedside table and
a clean cake of soap in a saucer beside it.
Place nearby the packages of cord dressing and clean apron, all un­
Prepare a receiving blanket for the baby by putting one large piece of
the clean old muslin inside a clean baby blanket and wrapping them
around a warm flatiron. Put it within easy reach on the bedside table.
Beside it in the following order put a large piece of the clean old muslin,
a baby binder with three safety pins attached, and two sanitary pads
in their covers.

M aking a hand-scrub table to use for the final hand scrub just
before the baby is bom .— Use a chair covered with newspapers for a table
and place it where you can watch the mother while scrubbing. Place on it a
clean empty basin and a saucer with your soap, hand brush, and nail stick
on it. Nearby on the floor put several newspapers and on them the tea­
kettle of boiled water.
Preparing the vulva for the delivery.—Explain that the vulva
should always be prepared before an enema is given because if the enema
should stimulate hard pains there might not be enough time to do it
thoroughly afterward. Wash your hands thoroughly so that you will not
run any risk of transferring germs to the mother. While you are arrang­
ing, on a newspaper-covered chair near the bed, a clean basin of warm
water, the mother’s soap in a dish, the family scissors, boiled and dried,
and 18 or 20 clean dry wipes, explain that you would have the mother
pass water and empty the bowels if possible before lying down on the bed.
If she is unable to pass water easily, she should drink two glasses of water
or of some sweet sugary drink.
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The mother (the doll) is lying on her back with the newspaper pan
under her buttocks and is covered with the draping sheet and blankets.
Show how to clip the vulval hair as close as possible, using the familyscissors and throwing away the waste in the newspaper bag. Then wash,
rinse, and dry the abdomen, thighs, vulva, buttocks, and the anus as de­
scribed in lesson X (p. 82) after the enema. Explain that while you are
preparing the vulva you have an excellent opportunity to watch the
mother during pains and decide how fast the labor is progressing.
The enem a.— This is the time to decide about the enema. Go
over the reasons for deciding whether or not to give an enema. Give an
enema as described in lesson X (p. 79). Explain why the washing must be
repeated after the enema and again if the bowels move again before the
fiufl.1 washing with the boiled wipes that is demonstrated in lesson X III.
After that the area is kept clean with the boiled wipes. Explain that after
the mother has rested a few minutes she could put on shoes or house
slippers and walk about a while in her bedroom unless the second stage
seems to have begun or the bag of waters has broken and there is some
W atching the progress of labor.—Explain that all this time and
during the whole of labor you keep careful watch of the mother, note the
frequency of the pains, their duration, their character, do not let the
mother bear down during the first stage of labor, look for bulging during a
pain every few pains so that you will know as soon as the second stage of
labor begins. Watch for bleeding, discharge, odor, sores about the vulva.
Explain how each of these is dangerous for the midwife, the mother, and
the baby.
If the midwife notices anything abnormal, if the mother cannot obtain
relief although she complains of a full bladder, or if she passes water only
infrequently although she has taken plenty of fluid, the midwife should
send for a doctor at once. If the mother has had six glasses of fluid
since she passed water last, she should have no more until the doctor
prescribes for her.
Explain to the mother about “ bearing down” and later “ panting like
a dog.” Tell her why she cannot help herself by bearing down in the first
stage of labor. Tell her how much she can help when you give her the sig­
nal if she will do it just as you show her how to and stop when you say
“ Pant.”
Nourishment.— Explain that mothers often refuse nourishment
during labor because of nausea—feeling sick at the stomach—but
that the mother in labor will surely find her spirits sinking when her stom­
ach is empty. Prepare a cup of cocoa so that the midwife can see it as
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part of her care of the mother and urge the mother to keep up her strength
by drinking nourishing fluids. Explain that the midwife might substitute
for the cocoa, lemonade, orangeade, fruit juice, hot milk- or coffee. Ex­
plain that the midwife should see that the mother takes some nourishing
fluid every 2 hours. Loss of blood at the time o f delivery and after­
ward is more serious and harder to control if the mother is weakened by lack
of nourishment.
Rest. Explain why periods of rest are necessary, especially if the
mother is haying a long first stage of labor with little or no sleep.
Alternate periods of rest and activity divert the mother’s attention from
herself, help the time to pass more quickly, and allow a freedom that is
satisfying. Mothers are more content when allowed to walk about the
room if there is nothing in their condition to make this a risk.
Describe the mother who complains of pains in the small of her back
and rub her back with each pain. While the mother is resting or walking
about, the midwife can see that everything is ready for the second stage
of labor, looking and listening constantly in order to notice anything
abnormal about the mother’s condition and to know just when the second
stage o f labor begins.
Encouraging the mother.—Tell how encouragement, reassurance,
and a quiet attitude on the part of the midwife and the family help
to relieve the mother’s mind of fear and anxiety and how that is an impor­
tant factor in her care. Labor progresses better if the mother keeps up her
courage and her spirits. A pat of the hand and a bit of praise after a hard
pain will help. Telling the mother about the progress she is making will
also help, and keeping up her strength with nourishing drink will do a
great deal for her courage, too.
The baby s things. Make the baby’s bed between times, pro­
tecting the mattress with an oilcloth or rubber pad and slipping the
mattress and pad into a pillowcase. Raise the foot by putting a roll of
newspapers under that end o f the mattress. Put a folded newspaper
covered with one o f the clean white rags at the head of the baby’s bed
for his head to rest against. Wrap the baby blankets about a warm
flatiron and place them in the baby’s bed to warm it. Tie together with
a strong rope the two chairs in the bedroom and put the baby bed on
these chairs near the delivery bed. Explain everything you do as you
Assume that there is time, before the second stage begins, to prepare
the baby tray and that the mother has not already done this. (See
lesson V, p. 53.) Put the box of silver nitrate on the tray.
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Get everything ready to put the drops in the baby’s eyes where the
light is good (see lesson X I, p. 83) and to oil the baby near the kitchen


A. Arrange the kitchen table (see p. 88), leaving a place on the table for
the baby bed.

B. Set the baby tray where you can reach it, but leave the covers on the
jars until you are ready to oil the baby.

O. Put nearby the baby clothes, washcloth, and towel rolled in a flannelette
square with a warm iron.

J). Measure out about half a cup of the oil and set the cup in the pan of hot


water on the back of the stove to keep warm. Assume that the sup­
ply of oil is not in a new unopened bottle, and put all the oil in a clean
saucepan and boil it in order to kill any germs that might be in it.
Be sure to warn the midwives about using it too warm. It must be
cooled to blood heat before it can be used. Explain that the oil
should be neither hot nor cold but warm enough not to chill the baby.
From the teakettle fill the jar on the baby’s tray for the boiled water
for washing the mother’s nipples and the pint bottle or jar for the
day’s supply of boiled water for the baby.

Sym ptom s of approaching second stage of labor.—After
everything is ready, watch and wait for the signs of the second stage
of labor:
A. The pains will become more regular and more frequent, will be


harder, and will last longer.
The mother will complain more of discomfort; her voice will become
high pitched.
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5. Boiled absorbent-cotton
rag wipes in basin.
6. Cord dressing.
7. Saucer and soap.
8. Newspaper bag.
9. Midwife's apron.
10. Baby's bed.


1. Baby binder and 3 safetypins.
2. Clean
wrapped around a warm
flatiron, and large piece of
clean, old muslin.
3. Covered sterilizing pan (has
boiled cord scissors in it).
4. Sanitary pads.


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C. The mother will vomit or feel as if she were going to.
D. The mother will involuntarily push or bear down or grunt when she
has a pain, and say she can’t help it.

E. The mother will feel that her bowels are about to move or will complain
of pain in her rectum.

F. The anus will open with each pain.
G. A small amount of bright red “ show” will appear at the vulva— a
trickle of blood.

H. The bag of waters may break.
I. The vulva will bulge and open with each contraction.

Explain that the mother should go to bed when these signs appear if
it is a first baby. If she has had a baby before, she should go to bed when
the pains are hard and coining every 2 or 3 minutes. The midwife sees
that the bed is dry and clean and that a dry clean newspaper pad and the
lined thick newspaper pan are in place. Help the mother to take off her
kimono, house slippers, and stockings, and put on the clean stockings.
Help her into bed, see that the paper pan and pad are under her buttocks,
and cover her with the draping sheet and blanket (fig. 48). Then the
midwife must hasten to scrub her hands and arms and get ready for the
baby’s birth. Another lesson will go on from here through the second
stage of labor.

Remember that a properly managed first stage of labor usually
means less trouble and less complication in the second and third stages.
D o the first things first: learn the mother’s condition, make sure about
having a good fire, plenty of hot and cool boiled water, your things
where you can get them, the sterile wipes and scissors in the mother’s
room, the mother, her room, her bed, and the supplies clean and ready,
and the baby’s things ready to keep him warm and to protect him from
infection. Make it your constant care to watch the mother, encourage
her, keep her warm, clean, protected from infection, fed, and rested. Do
not let the baby arrive before you are ready for him because you failed
to recognize the signs of the second stage of labor in time. And, above
all, keep your eyes and ears open for danger signals and get a doctor if
you have the slightest reason to think all is not as it should be.
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L e sso n X I I I .

The M idw ife’s M anagem ent During the Second Stage o f

W hat happens during the first stage of labor?
W hat three things m ust we keep in m ind as we prepare for the
W hat should we ask about, as soon as we arrive in a hom e where
a mother is in labor?
W hat will you do to protect the mother from infection?
W hat danger signals should we look for in the first stage of labor?
W hat would you do if you found bleeding, fits, exhaustion?
W hat would you do if the mother had strong labor pains for 12
hours and you could see no signs of the second stage of labor?
How will you know when the second stage of labor is about to

T o show the midwife how to manage during the second stage of labor
so that—
A. She can help the mother—



1. T o use each pain to advantage.
2. T o rest between pains.
She can protect the mother—
1. From infection.
2. From injury.
3. From chilling.
4. From unnecessary fatigue.
She can call a doctor if there are signals of danger.
She can care for the baby when he is being bom and immediately
1. T o make sure he is coming norm ally; or, if not, to call a doctor.
2. T o protect the cord and eyes from infection.
3. T o tie and cut the cord properly.
4. T o keep him warm.
5. T o watch his color and his breathing.
6. T o watch the binder for any sign o f bleeding from the cord.
She can watch the mother while she cares for the baby.
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Everything is as it was at the close of lesson X I (p. 86), the super­
visor wearing a mask and a cap.

Explain that we left the mother in bed lying on her back, covered
with a clean sheet and a blanket. Turn down this sheet to slightly
below the waist. Fold the blanket in two crosswise and place it on the
mother’s chest and turn it up to about the hip line. See that the news­
paper pads and a thick newspaper pan lined with a piece of clean old
muslin are under the buttocks and that the pads extend well down toward
the feet. The bag of waters may break at any time now if it has not
done so before.
“ Pushing” and “ panting.” —Explain to the mother that the time
has now come when she must use her abdominal muscles to help push out

the baby. Describe how when the pain begins you would have her take a
good breath, close her lips tight, and bear down as she might when she
is having a bowel movement. Show her how she can draw up her legs
against her abdomen with her knees bent and grasp the tops of her
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V,, ;Ci (3.i-UliC


ing more effective (fig. 49). She should push only when the uterus is
contracting during a pain. Pushing between contractions will waste her
strength and wear her out. Show how she can be helped to stretch her
legs and relax between the pains.
Explain to the mother that later when you tell her to “ pant” she
must open her mouth and “ pant like a dog” even though she has a strong
urge to bear down. This cooperation on the part of the mother will
make it possible for the midwife to delay the delivery of the head during
the greatest force of the contraction, so as to avoid tearing the mother
as the head comes through the vulva.
Staying with the mother.—Explain why the midwife should not
leave the bedside of the mother again. If possible, a member of the family
should stay in or near the room in case the midwife should need any help.
Show how you would look at the vulva with every pain to see if there is
any bleeding or if any part of the baby is in sight. Explain that if a hand
or foot or cord should appear, you would send for a doctor at once. In
such an emergency the midwife should not touch the baby or the birth
canal. If the mother should become exhausted, pale, or cold, if the pains

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1 1 J

I I I /V

ioo .vx0 ,


stop, if she bleeds, if she has a sharp abdominal pain or any other symptom
of trouble, the midwife should send for a doctor at once.
A ll the supplies within reach.— See that the supplies can be
reached from the bedside. Then break the seal of the package of sterile
cord ties and dressing and open it half way, leaving the upper flap still
covering the sterile supplies (fig. 50, four views). Open the package con­
taining the clean midwife apron without touching the apron (fig. 51).

boiled cord scissors in it).

The m idwife’s final scrub up.— This is the time for the midwife
to scrub her hands thoroughly in preparation for the baby’s birth. Re­
view the technique of lesson V III (p. 62) as you scrub your hands. Keep
one eye on the mother as you scrub. Rinse the basin, scald it, put your
soap in it, and fill it with warm boiled water for your later use.
Assuming that the baby is coming soon, put on the clean midwife
Draping with the sheet.— Drape the mother with the large sheet
that is over her legs. This draping is done by pulling the sheet comerwise. The upper comer is folded under itself and the sheet is tucked under
the mother’s back near the waist. The outer comers are used to cover
each leg. N o effort is made to cover the feet as the mother has on clean
stockings. This sheet should be so arranged that it will not get in the
way during the birth of the baby.
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W ashing the vulva with the boiled wipes.— Remove the basin
which has been covering the boiled cotton or rag wipes and place it on the
far comer of the mother’s bed for use later. Wash your hands, digging
your nails into the soap. D o not dry them. Pick off the top wipe.
Wring it as dry as you can over the hand-scrub basin. Soap it well,
using the clean soap in the dish beside the basin, and wash the mother
thoroughly, using one wipe for the abdomen, one for each thigh, another
for the vulva, and another to wash about the buttocks and the anus.
Drop the soiled wipes into the paper bag. Use fresh wipes to rinse the
parts and discard each one in the same way. Leave the basin of boiled
wipes where you can reach it easily. Show how you would use them to
wipe away feces if the mother’s bowels should move with the pains,
wiping from the birth canal, never toward it, and using a fresh wipe for
each down stroke.
Keep the bed dry.— Explain how if the lined newspaper pan
under the mother should become wet you would replace it with a clean,
dry one, pushing the wet one under the bed or into the toilet bucket.
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Or, if the bag of waters has broken, you would leave the mother on a clean,
dry pad without a pan. The baby can be born on the clean, muslincovered newspaper pad.
W hen the baby’s hair is in sight.— Describe how the birth canal
begins to open up and the baby’s hair can be seen, then spread the large
piece of clean old muslin (that you left near the receiving blanket— see
p. 91) between the mother’s flexed legs, so as to have a clean, dry place
to lay the baby, after he is breathing well, while you tie and cut the cord.
Wash your hands again quickly, keeping an eye on the vulva.
Stand ready, watch, and wait. Describe the mother’s face as cov­
ered with sweat and ask a member of the family to sponge her face,
wrists, and hands and dry them with a clean towel. Open wide the sterile
package (fig. 52).
W hen the head is being born.— Describe the descent of the head
with each contraction and speak of the difference one would expect when
a mother is having her first baby and when she is having later ones.

FIs. 53.— BIRTH O F THE H EA D .
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Point out how the midwife would have the mother push. Show the
position of the mother—legs flexed on the abdomen, hands grasping
stockings just below the knees. The mother can remain in this position
until the baby’s head “ crowns” at the vulva. Then she should lower
her feet to the bed with her knees flexed and “ pant” so that she will stop
pushing during the expulsive pain. Then describe the pain as passed
and tell her to “ bear down” gently so that the baby’s head will be born.
As if the baby’s head were being bom , show how to support it with the
left hand while with the right hand you wipe away the mucus from the
eyelids, nose, and mouth, using the clean cotton balls from the sterile
package (fig. 53, four views).
Explain that about one baby in four has one or more loops of cord
around his neck. The midwife should feel for the cord around the baby’s
neck as soon as the head is born and push the cord down over his shoulders
or slip it over his head, whichever is easier.
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“ Catching” the baby.— D o not hurry. Speak calmly and quietly
and describe how you continue the support while the baby turns his head.
Describe how his shoulders turn perpendicular to the bed and emphasize
that you do not interfere with his movement. The midwife must not
attempt to turn the baby’s head for him. After a brief rest another pain
will come and the shoulders and body will be bom . Emphasize again
that the baby is pushed out from above and the midwife should never do
any pulling but should just support and “ catch” the baby as he is pushed
Helping the baby to get his breath.— Grasp the baby by the
heels with the left hand, support his head with the right hand, and hold
him up to drain. Avoid any pulling on the cord and hold him with his
head so near the mother’s inner thigh that there is no danger of injury
from falling (fig. 54).
Strip his nose as if there were mucus and wipe out his mouth with
the little finger as if he had phlegm. Rub the fingers up and down his
back to stimulate breathing. Explain that if he does not breathe at
once, tapping gently on the buttocks or snapping your finger against the

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soles of the baby’s feet will usually make him cry lustily. If he does not
cry within 2 or 3 minutes, if he is pale all over or a bluish-purple color,
send for a doctor at once. Explain that too vigorous efforts to make
the baby breathe must be avoided.
When the baby has cried well and is a good warm-pink color, lay
him on the clean, dry cloth between the mother’s flexed legs (fig. 55).
See to it that there is no pull on the cord and explain how important this is.
Wash your hands again quickly as you explain that after the baby is
bom there will usually be a few minutes before the pains begin again when
the afterbirth is being pushed out. The mother can rest in these few
minutes. The midwife can tie, cut, and dress the baby’s cord while she
watches the mother so that she will be sure to know as soon as the pains
begin again.
Tying, cutting, and dressing the cord.—Explain that the baby
gets about one-third of a cup more blood if we wait to tie the cord until
the baby’s lungs fill with air and the blood is withdrawn from the after­
birth. When the throbbing in the cord stops, this withdrawal has taken
place. Explain the importance of the baby’s getting that extra blood.
Using the index and third fingers feel the cord for throbbing (fig. 56).

When the throbbing stops, tie, cut, and dress the cord as follows:
Make a single knot in one end of the tape (fig. 57).
H old the knotted end in the right hand and slip the other end under the
baby’s cord (fig. 58).
2 4 9 1 3 7 °— 41-
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In making the first loop, place the knotted end of the tape, which is still
in the right hand, in front of and over the other end of the tape, trans­
ferring the knotted end to the left hand as you pull it down through
the loop (fig. 59, two views).
Draw the loop to within 1 inch of the point where the cord joins the baby’s
skin at the navel. Draw the loop close to the cord at this point (fig. 60).

12 inches






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Place the hands under the tapes (fig. 61).



Pinch the tape against the index fingers with the thumb (fig. 62).



Roll the fists together, pulling the cord tape evenly by forcing the little
fingers farther and farther apart.

Do not lift up as you do this. Avoid any pulling on the cord because of
possible injury to the baby. A firm, steady pull on the tapes will tie
the first loop securely and will not cut through the cord (fig. 63).
In making the second loop, place the knotted end of the tape, now in your
left hand, in front of and over the other end of the tape, transferring
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the knotted end to the right hand as you pull it down through the loop
(fig. 64, two views).
Draw this loop close against the first loop (fig. 65). Slip the hands under
the tapes (as was shown in figs. 61 and 62).






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Pinch the tape against the index fingers with the thumbs (fig. 66).
Roll the fists together, giving a steady, strong pull, which will be felt most
on the outside of the little fingers as they are forced apart.
Put a second tie on the cord about 1 inch from the first one— that is, about
2 inches from the baby’s skin—repeating each procedure as described
for putting on the first tie (fig. 67).


The tie nearer to the mother serves to avoid soiling the bed with
blood from the afterbirth, and in case of a twin pregnancy it may prevent
bleeding of the unborn twin. The tie nearer to the baby keeps him from
losing blood through the cord. It is very important that the cord ties
should he so tight that they cannot slip. Many babies have bled
to death because the cord tie slipped.


Remove the lid from the sterilizing basin containing the cord scissors and
with the right hand pick up the scissors by the handles. D o not allow
the blades of the scissors to touch anything (fig. 68).
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Pick up the strings of the second cord tie in the left hand and cut the
cord between the ties about half an inch from the tie nearer to the baby
(fig. 69). Replace the scissors in the sterilizing basin.

Emphasize how the baby can be infected through the cord and get
lockjaw or blood poison if the hands, cord ties, scissors, and cord dressing
are not perfectly clean.
Pick up the ends of the tie on the baby’s cord stump, one in either hand,
and look carefully to see if there is any blood oozing from the end of
the stump (fig. 70).

Show how if there is any oozing of blood the midwife should tie another
square knot on the opposite side of the cord from the first one and watch
the stump to make sure the oozing has been stopped (fig. 71).
Show how when there is no oozing of blood you would pick up the upper
gauze dressing in your left hand and with your right hand holding up
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the stump by the tape ties, place the gauze about the stump. See to it
that the side of the gauze untouched by the hand is next to the cut
stump (fig. 72).

Pick up the scissors again and cut the cord ties about 2 inches from the
knot (fig. 73).
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Pick up the second gauze dressing, taking care not to carry cotton balls as
well. Place it on top of the cord stump with the untouched surface
down on the cut stump (fig. 74).

Quickly apply the baby binder so that it is snug, smooth, and not too
tight, to keep the dressing in place (fig. 75). Pin it carefully.

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Emphasize again that the baby’s cord must be tied, cut, and dressed
so that it cannot bleed, will be protected from infection, and will be kept
clean until it drops off when the navel is healed. Every detail is very
important and the midwife is responsible for doing it exactly right.
Putting the baby in his bed.— Now reach for the receiving
blanket. Take the warm iron from the blanket and wrap the baby
securely in the warm blanket, making sure that the arms and hands are
well covered (fig. 76).

Ask the family to remove the iron from the baby’s bed. Place the
baby in his bed with the feet slightly higher than the head (fig. 77).
Have the family cover him snugly with the warmed blankets. The bed
must be where the midwife can take a quick look at the baby’s binder
and watch his face constantly while she stays with the mother. He
might choke with mucus and suffocate if not watched so that the mucus
could be drained if it should collect in his throat. Describe the sound of
a mucus rattle and of a moaning breath when there is mucus in a baby’s
throat and show how to pick him up again so that the mucus can drain
out. If the condition does not clear up quickly, or if his color is not a
warm pink, or if the cord stump bleeds after the midwife has tied it
securely, the midwife should send for a doctor at once.
W hen there is not time to complete the cord dressing.—
Watch the mother constantly while you are working with the baby.
Explain that the afterbirth may separate at any moment and the mother
need the midwife’s attention. After the first cord tie is tied the rest of
the baby’s care could wait if the mother should need the midwife. Show
how the midwife can cover the baby’s body (not his head) with his blanket
without stopping to cut the cord and put on the dressing, and can keep
him between his mother’s legs, where he cannot fall and where there will
be no pull on the cord, until the midwife can, with safety to the mother,
finish his care.
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The management of the second stage of labor means:
A. Showing the mother how to use and not waste her power— the con­
tractions of the muscles of the uterus and abdomen.

B. Watching her every moment to make sure that a doctor will be sent
for in time if the labor does not progress normally.

Protecting the passage from infection or injury.

D. Cherishing the passenger by receiving him gently and safeguarding
him from falling, suffocating, hemorrhaging, being infected, or being
E. Watching the mother for third-stage pains.
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Lesson X IV .

Som e M idw ife Procedures During the Second Stage o f Labor


T o give the midwife an opportunity to practice some of the procedures
o f lesson X III.

The same as for lesson X III and, in addition, 15 “ demonstration”
packages of cord ties and dressing, and enough strong, thick string for
each midwife to practice tying square knots and for each midwife to have a
fresh piece to attach to the baby doll so that she may practice tying the

Explain that each midwife will have a chance to practice doing some
of the things that you did at the last lesson. Have each midwife, in wash
dress, cap, and mask, in turn take her position at the mother’s bed. Begin
by seeing that the table of supplies is in order and that she can reach
everything before she breaks the seal of the sterile package and opens it
half way and opens the package containing the midwife apron without
touching the apron.
Ask her to tell you how she would scrub her hands. Then have her
put on the apron, using the one from her bag so that it will fit her. Then
she should drape the mother and wash the mother’s vulva with the steri­
lized wipes.
Telling her that the baby’s hair is now in sight, have her open up wide
the sterile package and wash her hands. Show her how she would help
the mother to stretch and relax between pains and to “ pant” when the head
is about to be delivered. Have her support the head with one hand and
wipe the mucus from the baby’s eyes with the cotton ball, feel for the cord
around the baby’s neck and release it if necessary, but avoid interfering
with the turning of the baby’s head.
Then tell her the baby is just born and ask her to show you how she
would pick him up by his feet to let the mucus drain and how she would
wipe his nose and mouth and make him breathe well. Have her soap
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her hands and rinse them well. Then have her tie the cord, following
each step as shown in the drawings. She should look at the pictures in
her copy of the manual so that she can practice between classes. If she
makes a mistake, be sure to tell her at once and have her do over again
and do correctly anything she first did incorrectly.
Have her put on the cord dressing and binder and wrap the baby
securely in his blanket, then put him into his bed with his head slightly
lower than his feet. Have each midwife go through all the procedures if
possible and arrange for her to practice if she has trouble learning to do
correctly any part of any procedure.
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Lesson X V .

The M idw ife’s M anagem ent During the Third Stage o f Labor

W hat happens during the second stage of labor?
W hat are the dangers to the baby?
W hat are the dangers to the mother?
W hy is it important to warm the baby's bed and blankets before
he is born?
W hy should the midwife wait until the cord stops throbbing
before she ties it?
W hy should the midwife tie the mother's end of the cord?
W hat would you do if you dropped the scissors on the floor just
as you were about to cut the cord?

T o show the midwife how to manage during the third stage of labor
so that she can—

Receive the placenta.
Watch the mother while she cares for the baby.
Watch the baby while she cares for the mother.
Leave the mother and the baby clean and comfortable.
Show the family what to do until she comes again.

Same as at the close of lesson X III.

The supervisor who is demonstrating should have on a gown, cap,
and mask when she explains that this lesson continues with the care of
the mother and baby until they can be left clean and comfortable in their
clean dry beds.
At the close of the last lesson the mother was in bed draped and
covered to prevent chilling while she rested and waited for the afterbirth.
The midwife had just put the baby, securely wrapped in a receiving blan117
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ket, in his bed, where she could watch his color, listen to his breathing,
and look at the binder every few minutes.
W aiting for the afterbirth.— While waiting with the mother for
the pains to come again look at the baby every few minutes. Place the
left hand, palm down, on the mother’s abdomen just below the navel so
that you can feel the womb and explain that the midwife should keep her
hand quietly in this same position as long as the mother’s uterus stays
firm and does not grow larger. She should not rub or knead the mother’s
abdomen. Using the right hand, wipe off the secretion from about the
vulva with well-wrung boiled wipes, one stroke down with each wipe.
Get the empty basin that you used as a cover for the boiled wipes from
the foot of the bed where you put it (lesson X III, p. 101) and place it against
the buttocks so that you can drop the end of the cord into it.
If the mother bleeds.— Explain that sometimes the uterus does
not contract as it should after the baby is born and the mother may bleed
either before or after the afterbirth is expelled. A glance at the vulva
every minute or two will show the midwife if there is any bleeding on the
outside. But sometimes mothers bleed on the inside without much blood
coming to the vulva. A pale face, sweating, cold hands and feet, excite­
ment, exhaustion, a great thirst, a soft, doughy womb are the signs of
internal bleeding. If any of these signs of internal bleeding or any ex­
ternal bleeding of more than one cup appears either before or after the
afterbirth comes, the midwife should send for a doctor at once, telling
him the trouble so that he will come without delay.
While waiting for the doctor, the midwife can gently rub the mother’s
abdomen around the navel until she feels the uterus hardening under her
hand, or if she does not feel it in a few seconds, she can have someone
help her raise the foot of the bed and rest it on the seats of two strong
chairs, one under each comer. Show her how to do it. Emphasize the
importance of keeping the mother quiet and warm by using hot drinks,
warm blankets, a warm flatiron at her feet. Show her how to put the
baby to the breast because suckling may help to stimulate the uterus to
contract as it should.
Be sure the midwife understands that it is quick work without
excitement that is needed if the mother bleeds too much. Watching the
mother constantly and knowing what to do while waiting for the doctor
are the best ways for the midwife to help in case of bleeding.
The pains begin again.—Explain that usually there is a brief
resting period after the baby is born. Then the uterus will begin to
contract with pains to push out the afterbirth. The signs to watch for
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A. The pains the mother will feel and the contractions the midwife can
feel with her left hand.

B. A little gush of blood at the vulva. The blood was expelled from the
uterus when the afterbirth was being pushed out.

C. The cord slips down and slides farther out of the birth canal as soon as
the afterbirth is pushed from the uterus into the birth canal.

D. The uterus feels rounder, smaller, and harder and rises up above the
navel as soon as it has expelled the afterbirth.

“ Catching” the afterbirth.—Explain that the contractions which
caused the pains will usually expel the afterbirth from the uterus, but the
mother must bear down strongly at the time that she has the pain to
push the afterbirth out of the birth canal into the basin. Explain why the
midwife should notice whether the membranes seem to tear as the after­
birth slides out of the birth canal into the basin. The midwife must not
attempt to hurry the delivery of the afterbirth. She should never pull on
the cord and never put her hand or finger inside the birth canal to get it
away. Make it clear that the midwife should call a doctor if the after­
birth does not come away in an hour. When the afterbirth is in the basin
she can put it out of the way, but she must look it over carefully later and
observe the points referred to on page 120.
M aking the mother comfortable.— Show how to wipe away all
the blood from the vulva, using one of the boiled wipes for each downward
stroke while you look to see if the parts are torn. A tear will look like a
lip with a fresh cut in it. Explain that if the midwife finds a tear she should
send for a doctor to repair it. It is a simple thing to do at the time, but
not doing it then means trouble for the mother and an operation later.
Turn the mother on her side. Wash and dry her back. Put on a
clean sanitary pad without touching the part that goes next to the mother.
Explain that the old-fashioned T-binder is no longer advised when the
mother is in bed because it is so quickly soiled and because it holds the
sanitary pad too close to the vulva. Take out the soiled under bedding and
remove the stockings. Straighten the bed, cover the mother, and tuck the
covers in at the foot and sides, making the mother cozy and warm.
Explain that the mother should lie on her back with her knees together
for the first few hours.
Ask someone in the family to prepare hot coffee, cocoa, tea, or soup
and some toast for the mother. Explain why she needs nourishment.
Explain why the midwife should lay her hand gently on the mother’s
abdomen to feel the uterus and should look at the sanitary pad every few
minutes to see how much the mother is bleeding. Except for this nothing
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needs to be done for the mother while the baby is cared for and the place
made tidy, and she should be allowed to rest.
The afterbirth.— Show how you would look carefully at the after­
birth (fig. 78, two views). Perhaps you can get one for the demonstration.
Hold the placenta up by the cord (baby side out). Note the size, where
the cord is attached, any big blood vessels that lead to the edge and appear

to be broken off, or any apparently missing part of the sac, especially near
the slit that the baby comes through. Note the color. Does it look like
fresh meat or does it look dark and old or slightly decayed? Note the
odor. Has it a fresh-meat odor or has it a spoiled offensive smell? Turn
the afterbirth so that the fleshy side can be seen. Hold it in your cupped
hands. Is the surface smooth, like biscuits baked close together in a pan,
or is it rough—as if the top of the biscuit had been removed? D o the
biscuits fit together when the hands are cupped or do some of the biscuits
appear to be missing? D o the biscuits look soft and smooth or are some
of them rough and lumpy? Explain why, if any part of the membranes or
afterbirth is missing or if the afterbirth is unusual, the midwife should save
it and call a doctor. She should not attempt to find or remove any
missing part herself.
If the afterbirth is complete, the midwife can wrap it in the soiled
papers and have the family bum it at once.
Tidying up.— With the family’s help arrange the delivery room
so it will be easy to care for the mother. Take the package with the two
sterile cotton balls to the kitchen and put it beside the baby tray. The
midwife should see that all the soiled bed linen, towels, and so forth are
put to soak so that they can be washed, boiled, and dried in the sun as
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soon as possible. She should arrange to have the soiled papers and useless
rags burned and the usable ones put to soak. She can have some one
scrub, rinse, and dry the basins while she gets ready to care for the baby.
See that the light is not shining in the m others face. See that she has
drinking water where she can reach it and explain why she needs to drink
plenty of water. Then carry the baby in his bed out to the kitchen.
Caring for the baby.—First wash your hands, then see that every­
thing is ready in the kitchen as you left it in lesson X I (p. 84). Explain
that if the labor were short and the time for preparation limited, the
midwife might have to prepare the baby’s tray and supplies at this time.
See that the room is warm and the oil the right temperature to use. Half
fill the nursing bottle with boiled water from the pint bottle, put on a
nipple, and set it in a saucepan of warm water on the back of the stove
to warm.
Then move the table where the light is right so that you can put the
drops in the baby’s eyes just as you did in lesson X I (p. 85), explaining
the reason for each move as you work.
Then, when you have checked the mother’s condition and washed
your hands, move the table back close to the stove and take the covers off
the jars. When everything is ready open up the blanket. D o not
disturb the binder or cord dressing.
Using cotton balls, put the warm clean oil on the baby’s head, neck,
arms, chest, back, buttocks, and legs. This warm oil will dissolve the
white cheesy material on the baby’s body and keep his skin in good
condition. Gently remove the oil with a soft old towel. Apply more oil
in the skin creases and on the genitals. Explain that if this cheesy
material sticks fast to the baby’s skin, the midwife must be careful not to
rub too hard or the skin will get red. Wipe very lightly and apply more
oil, allowing it to soften until the next day, when it can be removed easily.
Avoid chilling the baby. Remind the midwife that she can help to
prevent infant deaths by keeping the new baby warm. If scales are
available, weigh the baby with the band on. The midwife can lift the
mattress and baby out on the table or can hold him on her lap to oil and
dress him.
While you are oiling the baby, notice the condition of the baby’s
skin, which should be pink and smooth. If it is rough, dry, and scaling,
with a rash, moist blobs or pustules, it is not normal and the doctor
should be called. Show how you would inspect the baby carefully back
and front to discover anything that is not normal. When the baby cries
look into his mouth for cleft palate or tongue-tie. Look to see that the
2 4 9 1 3 7 °— 41--------9
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anus is open. Count the fingers and toes. Explain that clubfeet and
other deformities or abnormalities should be reported to a doctor within
a few hours because the corrective treatment is usually more successful
when it is started soon after birth.
Slip out the receiving blanket and dress the baby quickly, handling
him as little as possible. He needs only a shirt, diaper, and dress. Then
wrap him in the flannelette square so that he looks his best and show him
to his mother. Give him a drink. Explain that if it is warm enough and
the mother is not too weary you would carry the baby and his bottle
into the mother’s room so that you could sit by her bed and she could
watch you give the baby his first drink of water. Be sure the midwife
knows how to hold the baby and the bottle. Explain that if possible the
midwife should have someone in the family watch her do everything she
does, for the baby and should show some grown person how to prepare
the bottle of boiled water and how to hold the baby.
Then put the baby securely wrapped in his blankets in his warm bed
with his head slightly lower than his heels so that the mucus can drain
from his nose and throat.
Feel to see if the mother's uterus is still well contracted and look
to see if there is any bleeding. Then help to straighten the kitchen and
get everything back in its place. Make out the birth certificate. Ex­
plain that the midwife should always do this before she leaves the house
so that she can take or send it to the local registrar without delay.
Caring for the vulva.— Describe an adult member of the family
as if she were at your side and then explain to her how important it is to
keep the mother clean and dry at all times and show her how to change
the pads and keep the vulva clean.
Explain that proper care of the vulva will help to prevent childbed
fever, to promote healing, to keep the mother clean and comfortable, and
to prevent offensive odors. Explain that it is so important to guard the
birth canal from germs that the person who cares for the mother’s vulva
should wear a mask and no one who has a cold should care for the mother
if anyone else can be found to do it. Three or four thicknesses of clean
muslin or close-woven gauze tied over the mouth and nose will make a
satisfactory mask. A clean one should be used each time.
Then collect from the mother’s supplies the things you will use:
A. Two basins of the same size.
B. Newspaper bag.
O. In a folded newspaper, a bedpan or a tin baking pan with a smooth
board covered with newspaper and placed across one end o f the pan.

D. A blanket.
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A clean folded newspaper pad.
An unopened, sterilized sanitary pad.
The mother’s soap dish and soap.
Twelve wipes— 4-inch squares o f clean rags or large swabs o f grade-B
absorbent cotton.
1. Several newspapers.
J. A mask. (Use the improvised one made from clean muslin to show how
it works.)

Put the wipes to boil in the basins. (See lesson X II, p. 90.) After
the water bubbles, let them boil for 10 minutes. Then set them off the
stove to cool with the cover still on. While they are cooling carry all
the other things to the bedside and arrange them conveniently on a
newspaper-covered bedside table or chair. Remember to talk to the
doll as if it were the mother, telling her what you are going to do and
asking her how she feels.
With the mother lying on her back turn up the nightgown to the
waistline. Turn down the top bedcovers to her waistline and place
the small blanket across her chest. Put the newspaper bag on the foot
of the bed. Ask the mother to bend her knees and raise herself with
her feet flat on the bed. With one hand supporting her hips slip the
bedpan under her with the other hand. Remove the soiled pad and
comment on the significance of the amount of discharge, the color, odor,
and presence or absence of clots. Drop the soiled pad in the paper bag
on the foot of the bed. Ask the mother to pass water if she can. Leave
her alone for a few minutes while you bring to the bedside the covered
basin of boiled wipes and wash your hands.
Take the cover off the basin of wipes and set the basin on the foot of
the bed. Pick off the top wipe; wring it nearly dry. Show how you wipe
off the secretion, using each wipe for one downward stroke, dropping
them in the newspaper bag, and using as many as are necessary to remove
all the secretion from the outside of the vulva. Emphasize why you do
not separate the parts or touch the inner surface of the vulva. Then go
oyer the vulva again, using soap on every other wipe and rinsing it off
with the next one and discarding each wipe after each downward stroke.
Then wash the inner surfaces of the thighs, remove the bedpan, and cover
it with newspapers. Turn the mother on her side so that you can wash
the buttocks and around the anus, using several wipes at once and
plenty of soap and rinsing off the soap thoroughly. Wring the last wipe
very dry. Put on a clean sanitary pad without touching the surface
that goes next to the mother. Roll up the soiled newspaper bedpad
and push it under the mother’s hips. Spread a clean one next to it and
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roll the mother over on the clean pad (fig. 79). Remove the soiled one,
straighten the fresh one, and cover the mother. Explain that she should
lie quietly with her knees together for the next few hours.

Show how to empty the bedpan and wash it with soapsuds, scald
it inside and out, and wrap it in a clean newspaper cover. Keep it in
the mother’s room. Explain that when a paper bedpan is used it should
be burned.
Tell how if rag wipes are used and there are plenty you would burn
them; if they are scarce, you would have them washed, boiled, and dried
in the sun to use again. If, instead of rag wipes, swabs of absorbent
cotton are used, they should be burned.
Wash your hands thoroughly and emphasize again the importance of
washing the hands before and after caring for the mother’s vulva, of
using each wipe for one downward stroke, and of not touching the inner
surface of the vulva.
Explain why it is necessary, as long as there is any discharge, to
change the sanitary pad every 4 hours and oftener when it is soiled.
Explain why the vulva should be washed with the boiled wipes every
4 hours and after each bowel movement as long as the mother stays in
Explain that when the mother’s bowels move, her buttocks should
be wiped with toilet paper and the bedpan emptied and washed or, if
made of paper, exchanged for a clean one.
The first nursing.—Explain to a responsible person that the baby
should be put to the breast from 6 to 12 hours after birth and show how
this is to be done, as the time for it may come before your second visit.
After washing your hands take the jar of large swabs and the
jar of boiled water for washing the mother’s breasts from the baby
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tray to the mother’s bedside. See that the mother is in a com­
fortable position and wash one breast with the swabs. Bring the
baby in and show how to put him to that breast in a comfortable
position (fig. 80). Explain that he should nurse for 5 minutes
and that his throat should be watched to make sure he is swallowing
and getting something as he nurses. After he finishes, the breast

should be washed again. Explain that at the next nursing he should
be put to the other breast for 5 minutes and that the breasts should
always be carefully washed before and after each nursing.
Explain that the nursing may help to contract the mother’s
womb and lessen bleeding. What the baby gets at the breast for the
first 3 or 4 days is not milk but a thick yellowish fluid called colostrum.
Having him nurse will stimulate the breasts to secrete milk. It will
also convince the family that he can nurse and swallow. Explain
that he should be brought to the mother for nursing, first at one
breast, then at the other, every 4 hours—at 6 and 10 o ’clock in the
morning, at 2 and 6 o ’clock in the afternoon, and at 10 o ’clock at
night. For the first 48 hours he should be nursed for only 5 minutes
each time so as not to make the nipples sore.
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Now put the baby back into bed, pack your bag, and leave after
again inspecting the mother and explaining to a responsible person
the need for continuing to observe the mother and the baby and for
calling you at once if there is any change in the condition of either
that is not understood. Tell the mother when to expect you, which
will be between 5 and 10 hours later, depending on the hour the baby
is bom .
Be sure to fill out the birth certificate before leaving the house.

During the last stage of labor the midwife must remember to watch
the mother and the baby. Neglect of either for even a minute might be
fatal. The doctor must be called if the afterbirth does not come within
an hour; if the mother loses more than a cup of blood before or after the
afterbirth; if the uterus is soft and doughy; if the edges of the birth canal
are tom ; if the mother is cold, pale, sweats all over, has clammy feet and
hands, grows excited or feels exhausted and faint; if there is anything
unusual about the afterbirth; if the baby’s skin is not soft and pink; if his
cord stump bleeds; if he has any deformities or abnormalities; if he does
not breathe easily and quietly.
The midwife must remember she “ catches” the afterbirth; she does
not pull it out or use her hands or fingers in any way to hurry or help it out.
It is important for the midwife to leave the mother and baby clean
and warm and to be sure there is someone in the house who knows how
to care for them until she comes again. She must be sure the baby has
had water and can nurse before she leaves. She should leave direc­
tions on how to nurse the baby and how often he should be fed. She
should not leave the house, even when everything seems all right, for at
least 2 hours after the afterbirth is born, to be sure it is safe to leave the
mother and baby.
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Lesson X V I.

A Practice Period
For this lesson the supervisor should arrange extra practice in those
procedures which the midwives have had difficulty in learning—probably
tying, cutting, and dressing the cord and putting the drops into the baby’s
eyes. The equipment should be complete and correct, just as it has been
described, for the procedures that will be practiced.
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Lesson X V II.

Aftercare o f the M other and Baby

W hat can the midwife do if the mother bleeds BEFORE the
afterbirth is expelled?
Can she do anything different if the bleeding comes AFTER
the afterbirth is expelled?
W hat are the sym ptom s of concealed or internal bleeding?
How can the midwife tell that the afterbirth has separated?
W hat can the midwife do if the afterbirth does not come away?
W hat does the midwife do for the baby before the afterbirth?
After that?
W hat M other and Baby N eed

Explain that the mother and baby need to be kept clean, warm, and
comfortable, to rest, to have the right food, to be watched for the begin­
ning of any complication, and to be protected from infection. If either
the mother or the baby is not well, the doctor will give special instructions.
The following lesson covers the care of the well mother and baby.
The M other

Keeping the mother clean, warm,
Explain that this means—



A. A warm soap and water bath every day. After the first 24 hours the
mother can bathe herself sitting up in bed. That much exercise is
good for her and the moving about is restful. She will need help in
washing her feet and her back. She will not touch nipples or vulva
because they are cared for as described in lesson X V (pp. 122 and 124).
Remind the midwife that brushing the teeth, using amouthwash, com b­
ing the hair, and cleaning the nails are all part o f the bath. Empha­
size the importance of not letting the mother get chilled during the
bath or at any other time.
B. Clean clothes that have been washed, rinsed, boiled, and dried in the
sun or ironed with a hot iron. A clean nightdress every day and when­
ever the one she is wearing becomes soiled.
C. A clean bed. The sheets and newspaper pads and other bedclothes
should be changed as often as they become soiled. The bedclothes
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should be washed and boiled and should be dried in the sun or ironed
with a hot iron.
D. A clean room that by the use of a damp broom and a damp dust cloth
is kept clean without raising a dust and that has fresh air without
drafts blowing on the mother or baby.

Seeing that she rests.— Explain to the family as well as to the
mother why the mother needs to sleep as much as she can for the first few
days after she has had a baby. Ask the family if they can and will help
make it possible for the mother to have all the sleep she needs and 10 days
in bed. The mother should lie quietly with her knees together for the
first few hours and not sit up in bed for the first day. After that she can
move about in bed as much as she likes. She should lie face down for 15
minutes twice a day to help the uterus return to its normal position. Hav­
ing her bath and moving about when her bed is changed, when she uses the
bedpan, when the vulva is washed, and when she nurses the baby will
probably be as much as she will feel like doing for 3 to 5 days.
Visitors before the fifth day will disturb her rest, so that everyone
but the family should stay away for the first week. She needs to stay in
bed at least 8 days— 10 days if possible. She should sit up in a chair for
a short time the first day she gets up, for a longer time twice the next day.
The next day she can begin to walk about the house. Then she can begin
little by little to do a few things about the house and for the baby. The
husband or some other member of the family or a friend should be there
to do the housework until the mother is able to do it. The midwife should
do everything she can in arranging to have the mother get the help she
needs so that she can rest.
The right food.—Explain why the mother needs eight glasses of
liquids every day. She needs food to keep up her strength and to make
milk for the baby. The first day after the baby comes she can have toast,
soft-cooked egg, cereal, cooked fruit, fruit juice, and ice cream. If her
bowels move the next day, she can have regular meals such as she ate
before the baby came. If her bowels do not move, she should stay on a
soft diet.
W atching for com plications.—Emphasize that the midwife
must be on the lookout for any of the following symptoms:
A. Free bleeding.
B. Exhaustion.
C. Inability to pass water.
D. Constipation.
E. Diarrhea.
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F. Childbed fever, the signs of which are—
a. H ot, dry shin with cold hands and feet, dry mouth, parched
lips, flushed face.
b. N o discharge from the birth canal, or discharge that is scant
or too profuse, or has a foul odor.
c. Abdominal pain or tenderness.
d. Severe headache.
e. Swelling and tenderness of leg, sometimes called milk leg.

Q. Breast difficulties:
a. N o milk.
b. Caked breast.
c. Redness or tenderness of the breasts.

d. Cracked nipples.
e. Breast abscess.
H. Convulsions.
If any one of these symptoms appears, the midwife must report it to
a doctor at once. The sooner any complication is treated the better are
the mother’s chances for recovery. The midwife should never wait a day
or even an hour “ to see if the trouble will clear up” before getting a doctor.
Protecting her from infection.— Explain that it is primarily the
birth canal and the nipples from which disease germs must be kept away.
Keeping everything around the mother clean helps to safeguard her from
disease germs. N ot touching the vulva with anything but the clean
boiled wipes used in the special care of the vulva as described in lesson X V
(p. 122) should keep anyone from transferring germs to the birth canal.
Emphasize why the mother should keep her hands away from the vulva
and should have no sexual intercourse until 6 weeks after delivery. The
midwife should be sure that the husband also understands about the risks
of intercourse too soon after the baby’s birth.
Explain that to keep disease germs away from the nipples we depend
on cleanliness— never touching the nipples except with a cotton swab
dipped in boiled water just after the hands have been washed thoroughly,
washing the nipples with swabs before and after each nursing, wearing

clean nightgowns.
. „
Explain that the mother needs protection too from any catching
diseases. No one, whether a member of the family or a visitor, should be
allowed in the mother’s room if he has boils or other “ sores” or if he is
sick or has a cold or fever or has come from contact with someone else
who is sick. The mother is more likely to catch diseases now than other
people are, and her life may be in danger if this rule is broken.
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The Baby

Keeping the baby clean, warm, and comfortable.—Explain
that the baby needs a warm-water sponge bath with a little soap every
day after he is 24 hours old until the navel is healed. Then he can have his
bath in a tub. The basin or tub that is used for the baby should be
scrubbed clean and covered each day after he is bathed. Rinse it out well
before he is bathed and fill with water that feels just warm to the elbow.
Tell why it is important to have everything ready in a warm place before
the baby is undressed and to handle him gently and quickly. His clothes
and bedclothes must be changed often enough to keep them clean and
dry. His room (the mother’s room usually) should be kept clean without
raising dust and warm but not hot and stuffy. Explain why he must not
get chilled but should not be kept too warm. His hands and feet should
always be warm, his skin pink and moist, and his breathing quiet and easy.
Seeing that the baby gets rest.—Explain why the new baby needs
to sleep, in his own bed or basket, except when he is being bathed, having
his clothes changed, or being fed. He should be handled as little as pos­
sible and always gently. His bed should be put where he will not be dis­
turbed. If the weather is warm and he is protected from the wind and
the bed is covered by a netting, he may be outdoors some of the time after
he is 2 weeks old. He should be wakened only for his feedings and his
bath. He needs exercise, too, and gets it from the handling when he is
being cared for. He should have a chance after the first month to he in
his bed in a warm place without any clothes on so that he can kick and
stretch for a few minutes every day.
Feeding the baby.—Explain again that until the milk comes
the baby should nurse for only 5 minutes at each breast every 4 hours—
at 6 and 10 o ’clock in the morning, at 2 and 6 o’clock in the afternoon,
and at 10 o ’clock at night, and also at 2 o ’clock at night if he wakes up.
After the milk comes he should nurse at the same times but for 10 to 20
minutes each time (fig. 81). Between feedings—at 8 o ’clock in the morning, at noon, and at 4 and 8 o ’clock after noon—the baby should be given
a drink of warm boiled water from a nursing bottle.
W atching for com plications.—Emphasize the importance of
noticing at once any of the following symptoms:

Bleeding from nose, mouth, or bowels.
Whining or moaning cry, hoarseness, cough, choking.
Bad color—gray, white, or bluish.
Baby does not breathe freely.
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E. Bleeding from the cord— blood stain on the front of the binder. Look
at the back, too, because if the baby is lying on his back the blood
may run around to the back.
F. Infection of the cord:
a. Cord stump becomes moist or has a bad odor.
b. Redness appears at the navel.
c. Swelling of the skin about the navel.
d. Jaundice which is severe or lasts beyond the first week.
G. Infection of the eyes:
a. Pus and sticky secretion on eyelids.
b. Swelling of eyelids.
c. Redness of eyes.
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27. Infection of the skin:
a. Rash.
b. M oist red patches on skin.
c. Scaling o f palms o f hands and soles o f feet.
d. Tiny cracks about the anus.
/ . Sore mouth:
a. Bleeding about lips or gums.
b. Rash in mouth— red or white pin dots.
J. Baby’s bowels do not move.
K. Baby does not pass water.
L. Baby does not nurse.
M. Baby does not gain weight.
N. Baby vomits.
O. Diarrhea.
P. Snuffles or discharge from the nose.
Q. Convulsions or fits.
R. Any abnormality discovered about the baby’s body.

Explain that any one of these symptoms means that the baby is not
well and should be seen by a doctor at once. Babies can become danger­
ously sick in a very short time. Time lost in getting a doctor may mean a
baby’s life lost needlessly.
Protecting the baby from infection.—Explain why anyone who
picks up the baby should wash the hands first. No one with a cold should
go near the baby. If the mother has a cold, she should wear a mask when
she does anything for the baby. Explain that kissing the baby should not
be permitted.
Explain that the baby’s eyes and cord are easily infected. They
should not be touched. The eyelids may be wiped when the face is
washed. The cord dressing should be changed only if it becomes very
soiled, and the change should be made without touching the stump. The
binder can be changed without disturbing the cord dressing. Nothing
but a sterilized dressing should touch the navel until it has healed. /
If it is necessary to change the cord dressing, the midwife should
roll up her sleeves, open a sterile cord-dressing package part way, have
a member of the family hold the baby with his clothes folded up over his
arms and chest and one hand holding down his legs while she takes off the
binder, scrubs her hands, and lifts off the soiled dressing without touching
the stump. Then the clean sterile dressing should be put on just as it was
done in lesson X III (pp. 110-112).
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Point out that the baby can put his hands to his eyes, so that his
hands and everything that they can touch should be kept clean all the time.
Recall that the discharges from the birth canal may have germs that would
irritate the baby’s eyes and cause blindness. Nothing that is soiled with
the discharge should touch the baby or his clothes. The mother’s hands,
clothes, and bedclothes should be kept clean so that the baby cannot get
any germs on his hands or in his eyes.

The midwife is responsible for seeing that the mother and her new
baby have the watchful care that will safeguard their lives, that they are
kept clean and comfortable, and that they have the rest and food they
need. Her own rest will be more comfortable as long as she lives when she
knows she has done everything—every least little thing—just as she has
been taught to do it for every mother and baby she has cared for.
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Lesson X V III.

The Birth Certificate

Mention the important items in the care of a new mother and
explain why each is important.
Mention each detail in the care of a new baby and explain why
each is important.

T o teach the midwife the importance of birth registration and how to
fill in a birth-certificate blank.

An enlarged copy of a birth-certificate blank on a sheet of white
paper 60 inches long and 40 inches high fastened on the wall.
Several birth-certificate blanks.

Explain the importance of birth registration to complete the country’s
count of its population and to furnish a permanent record from which
each citizen can secure the proof of his age and citizenship.
Every State in the Union has a law that requires any person who
attends a mother at childbirth to report the birth of the baby to the
local registrar within a period ranging in different States from 3 to 10
days. Failure to do this properly is a punishable offense against the
law. The proper blanks are furnished by the local registrar, and each
midwife should keep a supply on hand.
The midwife should understand that proof of age is needed in connec­
tion with—

Inheritance of property.
Claims of widows and orphans.
Settlement of insurance.
Establishment o f the right to pensions.
The right to serve on a jury.
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F. The right to enter school.
G. M ilitary service.
The right to vote.
The right to marry.
A license to drive an automobile.
Employment in industry.


Proof of citizenship is needed in connection with—

Getting a passport.
Being exempted from military service in foreign countries.
Holding certain offices.
Being admitted to certain professions.
Being eligible for old-age assistance and other benefits from the Govern­
ment (most States).

Explain that the birth certificate is a permanent record. It should
be made out completely, accurately, neatly, with carefully formed, printed
letters that can be read easily, and with unfading ink. Explain the meaning
of each item on the certificate and show exactly how it should be filled in.
Stress the reasons for each midwife's filling in the birth certificate before
she leaves the house after the birth of the baby so that the registrar can
have the record immediately. Send it immediately to the record office.
T o make the State records complete all births must be reported, even
those in which the baby is born dead.
Set up an imaginary situation and have each midwife who can read
and write fill in a certificate. If a midwife can neither read nor write, have
her tell how she would have the certificate made out for her.
Sample Situation
A son, John Henry, was bom to M r. and Mrs. Thomas Henry D oe at their home
on Caramel Hill, Bethlem, R . F. D . No. 1, Fairfield County, M iss., at 6:45 a. m.,
March 3, 1936.
Mrs. D oe was M ary Jane Smith before her marriage. Mrs. D oe was bom in
Jackson County, Miss., February 1909. She moved to Bethlem at the time of her
marriage, June 1929. Mrs. D oe formerly taught school, but since her marriage has
devoted all her talents to her home and children. Mrs. D oe has three living children:
George, bom in 1931; Harry, bom in 1934; and the new baby, John Henry, bom at
6 :45 a. m. on M arch 3, 1936. M ary Helen, born in 1933, died of whooping cough
at 3 months of age.
M r. Thomas Henry D oe for 9 years has been the delivery man at a chain
grocery store. M r. D oe was bom in Hale County, M iss., in 1904.
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Emphasize the midwife’s legal duty to send the certificate of every
birth to the local registrar promptly so that the baby can have proof of
his age and citizenship when he needs it. The law requires every doctor,
midwife, or parent to register births with the local registrar of vital
statistics within a period ranging in different States from 3 to 10 days
after the baby is bom . The law requires that stillbirths as well as live
births be reported.

2 4 9 1 3 7 °— 41-------10
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Lesson X I X .

A Review
Go over the questions reviewed in each lesson, the most important
points in each lesson, the summaries, and the list of antepartum and post­
partum complications. Give the midwives an opportunity to ask ques­
tions about anything they have not understood or would like to have
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Lesson X X .

A Practice Period
During this period the midwives can practice those procedures they
and the supervisor think need further work. The supervisor inspects each
midwife’s bag, commending her for the equipment that is in order or
telling her quietly and individually what she must do to make her bag
conform to the standard midwife equipment.

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