MANUAL OF STANDARDS in obstetric - gynecologic practice THE AMERICAN COLLEGE OF OBSTETRICIANS AND GYNECOLOGISTS First Edition — March, 1959 he He whi J 4 oy MANUAL OF STANDARDS IN OBSTETRIC-GYNECOLOGIC PRACTICE First Printing March, 1959 Second Printing September, 1959 Third Printing January, 1960 THE AMERICAN COLLEGE OF tH OBSTETRICIANS AND GYNECOLOGISTS 79 WEST MONROE STREET CHicaco 3, ILLINOIS PUBLIC EEALTH LIB. Introduction Section | Section li Section lil Section IV Section V Section VI Section VII Section VIII Section IX Section X Section Xl Section XII Physical Facilities and Equipment Personnel and Adjunct Services Departmental Organization Standards of Prenatal Care Nursing Care of the Obstetric Inpatient Intrapartal Care — the Obstetrician Postpartal Care Consultation and Referral Standards of Obstetric-Gynecologic Care Radiation Hazards Definitions Recommended Publications 248 16 18 24 3 33 39 44 51 32 ol - = “h hg INTRODUCTION HYSICIANS, nurses, public health officials, hospital administrators, and lay members of hospital boards have often expressed a need for a reference book of standards to guide them in providing facilities and care for gynecologic and obstetric patients. In its most inclusive sense, gynecology refers to the total life cycle of the individual woman. Obstetrics is that part of gynecology which pertains to the reproduc- tive periods in a woman’s life. The hospital care of maternity patients also carries with it the responsibility of providing proper facilities and care for the newborn. An attempt to meet this need is herewith presented. This manual is not a set of iron-clad rules, but rather an organized group of recommendations which are, of necessity, subject to modification to fit the local situation. They will be revised from time to time as the standards of practice in the care of obstetric and gynecologic patients undergo changes that are inevitable in any alert, forward-looking specialty. In order to avoid any misunderstanding rel- ative to the purpose of the MANUAL OF STANDARDS, this is to advise that the Manual is not intended to, nor does it in any manner attempt to set forth any type of restrictions on the practice of medicine. The Manual offers suggestions to the Obstet- rical and Gynecological Committees and Execu- tive Committees of Hospitals to assist them in the formulation of local hospital rules accord- ing to the facilities, equipment, and resident and non-resident staff available in the community. The practice of medicine requires the exercise of discretion and judgement by the attending physician. Therefore, this Manual must be in- terpreted to allow for variations in the standards of practice as conducted by well trained, quali- fied, and reputable physicians. The first edition represents the efforts of many Fellows of The American College of Ob- stetricians and Gynecologists by the liberal sub- mission of material, by many pertinent sug- gestions, and by active participation in the preparation of the text. The present Chairman wishes to acknowledge the accomplishments of those who contributed to the development of the manual as committee members. He also wishes to express his gratitude to Drs. C. J. Lunp and J. R. WiLLsoN as the final ad hoc advisory committee. Finally, his thanks and the thanks of the Executive Board of The American College of Obstetricians and Gyne- cologists are extended to Dr. Ralph A. Reis for the final chore of editing the manuscript. F.L.P. COMMITTEES ON PROFESSIONAL STANDARDS 1954 NorMAN F. MILLER, Chairman Conrap G. COLLINS Freo H. FALLs HerserT F. TRAUT Pap F. WILLIAMS 1955 ConraDp G. CoLLiNs, Chairman ALLAN C. BARNES R. Goroon DoucrLAs Frep H. FaLLs J. P. GREENHILL FRANKLIN L. PAYNE GEORGE V. SMITH W. NorMAN THORNTON, JR. 1956-1958 FrankLIN L. PAYNE, Chairman Roy J. HEFFERNAN W. C. KEETTEL DanNiEL G. MORTON Joun L. PARKS Tromas C. PEIGHTAL Joun C. ULLERY PaiLip F. WILLIAMS Burorp WORD SECTION | PHYSICAL FACILITIES AND EQUIPMENT MATERNITY and newborn service should provide itself with the means for the best possible care of the obstetric patient and her infant. Today the vast majority of women are delivered in hospitals. They are not ill in the ordinary sense of the word but they enter the hospital because the facilities for their care are better than at home and because the hospital is the safest place in which to have a baby. Hos- pitals provide additional safeguards against the accidents of pregnancy and labor which the home cannot offer. While many factors have added to the increased safety of childbirth, the accepted custom of hospital confinement is probably the most important factor in the lowered maternal and infant mortality rate. However, one of the shortcomings of the modern hospital, so far as facilities for obstetric care are concerned, lies in the failure to recognize that most obstetric patients are healthy individuals who, except for the more critical period during the hours of parturition and immediately there- after, neither require nor desire many other features that characterize customary hospital care. The maternity service must be equipped with a variety of facilities for the purpose of providing every safeguard for the pregnant, parturient, and postpartum woman and her in- fant. It should also provide facilities for the comfort and relaxation of the mother. The serv- ice should arrange facilities for two areas of activity, outpatient and inpatient. OUTPATIENT ACTIVITY Ideally, the outpatient facilities should con- sist of a prenatal clinic and an emergency out- patient examining room. In hospitals that do not offer prenatal services, the outpatient facility may be confined to a small unit adjacent to the receiving or accident ward. This arrangement for the examination of obstetric patients as out- patients is highly desirable in order to permit the physician to evaluate minor emergencies and to execute prompt admission if necessary. When admission is unnecessary, the setting up of a hospital record and the use of an inpatient bed is avoided. The outpatient facility may con- sist of only a single examining room, or greater facilities may be required depending upon the hospital and community needs. Each examining room should be of adequate size, equipped with good lighting, including spot lighting, an exam- ining table, dressing space, the ordinary drugs, and such special equipment as sterile rubber gloves, linen, antiseptics, a biopsy forceps, pelvi- meters, specimen bottles for urine and tissue, record sheets, stethoscopes, blood pressure ap- paratus, a beam weighing scale, and such other equipment as a physician serving the hospital may deem necessary. PRENATAL CLINIC Obstetric units offering prenatal clinic facili- ties should provide for adequate privacy and a sufficient number of examining rooms to meet the demand. Deluxe facilities do not assure the best quality of patient care, but inadequate means contribute to hasty processing and pre- dispose to inadequate care. While the physical layout of the outpatient clinic depends upon local conditions, it requires: 1. A readily available information desk. 2. Records conveniently located and quickly accessible. 3. A children’s play room and a supervisor for the care of children who come with their mothers. 4. Office space and privacy for doctors, social workers, dietitians and others who may be called upon to serve patients. 5. Individual history rooms where the pa- tients may answer questions of importance freely in establishing a reasonable record. 6. A beam scale and sphygmomanometers. 7. Convenient and adequate toilet facilities for obtaining specimens. 8. Adequate dressing space or dressing rooms provided with mirrors, clothes hangers and shelf space adjacent to the examining room. 9. Examining rooms or examining areas so constructed as to provide privacy. INPATIENT ACTIVITY The maternity and newborn unit should be separate from other departments in the hospital and should maintain separate facilities from any service not intimately concerned with preg- nancy, delivery, puerperal care, and the care of the newborn. Only maternity patients or new- born infants shall be hospitalized in this area. It is both medically and psychologically inad- visable to share these facilities with other serv- ices. The facilities for a large inpatient service must consist of three major areas. As to the units of each area, for smaller institutions cer- tain units may be combined so long as the spe- cified services are provided. It is far safer to combine obstetric units physically than to mix these units with those of other hospital services, because of the necessity that the types of illness of the applicants for admission be screened by the Director of the Department of Obstetrics and Gynecology or by his delegate. 1. A labor and delivery area divided into: . An admitting and observation unit A labor unit A delivery unit . A recovery unit Staff locker and rest room Nurses’ locker room MEARE 2. A maternity housing area should contain: A. An isolation unit B. A study unit C. A convalescent unit for service patients D. A unit for private and semiprivate ac- commodations. 3. The newborn area should consist of the following nurseries: A. Infant recovery unit B. Full-time (mature) unit C. Premature unit D. Suspect unit E. Isolation unit 4. Numerous ancillary areas and facilities, to be detailed later. ADMITTING, OBSERVATION, AND EARLY LABOR UNIT The inpatient area should be equipped with an admitting unit containing facilities for com- plete examination and adequate preparation of the patient. This unit should contain a shower or bathing facility and toilet. Patients admitted to this unit will, after a period of observation, divide into two groups: those not actually in labor, to return to the floor or to their homes; and those to be transferred to the labor rooms. Transportation from the admitting to the labor rooms must be individualized; under certain circumstances it should be by litter or bed. The location of this unit may be adjoining the hos- pital receiving or admitting ward, or it may be adjacent to the labor floor area. The latter lo- cation seems to be more desirable provided that it is close to, but not an intimate part of, the labor-delivery unit. LABOR AND DELIVERY UNITS Labor Rooms The standard requirement is that of one labor room to every 5 to 10 maternity beds, depend- ing upon the length of puerperal hospitalization and upon the percentage of emergency admis- sions. This ratio may also be inadequate when labor rooms are used as recovery rooms or when they are used for the purpose of observation and preparation. The minimum floor area for each bed in the labor room should be 70 square feet. The labor rooms should be immediately acces- sible to the delivery rooms and to an operating room. Soundproofing is highly desirable. In all new construction or renovation single labor rooms should be provided. Temporarily, 2-bed labor rooms may be used to meet the emer gency. The following equipment should be sup. plied for each labor room: 1. Toilet facilities with hand bowls 2. A utility room located preferably between two labor rooms 3. Lighting arrangement to permit darkening and to permit adequate lighting for exam- ination 4. Call bell, signal light, or intercommuni- cation system 5. Ample door space for the passage of beds without damage to either the bed or the door facing 6. Air conditioning when climatic conditions warrant it 7. Piped-in music; reading matter The following furniture is required: 1. Bed of plastic or metal with side rails 2. Footstool for each bed 3. A comfortable chair for the husband or attendant 4. An ample straight chair for the patient, preferably of plastic or metal Bedside cabinet for storage Equipment: wash basin, bedpan, fetoscope A small desk or writing shelf for records PHS An adequate supply of drugs and supplies commonly used such as the following is necessary: Labor Floor Supplies: Oxygen, ether, N20, cyclopropane Morphine Demerol Dilaudid Scopolamine Atropine Barbiturates Sodium Amytal for intravenous admin- istration Sodium Secobarbital for intravenous or intramuscular administration Secobarbital capsules Digitalis Intravenous preparation (Gitalagin) Intramuscular preparation (Digitoxin) Quinidine Pronestyl Aminophylline Calcium lactate 50% Glucose Insulin Magnesium sulfate 10% and 50% solution Vasoxyl Methedrine Neosynephrine Levophen Caffeine sodium benzoate Nalline or Lorfan Amyl nitrite Calcium lactate Progesterone Curare Heparin Pitocin Ergotrate Antibiotics Hydrocortisone Vitamin K Benadryl Adrenalin, ephedrine In addition, all drugs commonly available in every hospital unit Immediate blood transfusion therapy must be available at all times, with properly matched or group O Rh-negative blood in extreme emer- gency. When the possibility of transfusion is an- ticipated the patient’s blood should be typed and cross-matched instead of depending upon the short supply of group O Rh-negative blood. An adequate supply of plasma, plasma expand- ers, and fibrinogen must be available for im- mediate use. These supplies and facilities must be replaced immediately when used and are to be checked every 24 hours. The Delivery Unit The number of delivery rooms shall be in the ratio of 1:2 or 1:214 labor rooms. The delivery rooms shall be used only for the parturient pa- tient and/or her infant. A delivery room is simi- lar to an operating room in design and ancillary equipment, such as protection against explosion hazards, special clocks, call lights, suction, oxy- gen, emergency lighting system, air condition- ing, etc. Each delivery room should be large enough and so equipped as to permit its prompt use for major operative procedures, or the de- livery rooms should be in close proximity to a readily available operating room. Each delivery room should be maintained as a separate unit. The equipment and supplies for each room should include: 1. A bassinet, incubator, or crib that can be heated. 2. A suction apparatus with equipment for aspiration of mucus. 3. A resuscitation apparatus equipped with oxygen and infant-sized mask. 4. A device and materials for identifying the infant. 5. One or more anesthesia machines and anesthesia equipment with supplies. In the installation and utilization of all such equipment observance of the state and local rules and regulations against explosion and fire hazards must be maintained. The following facilities should be provided in a delivery unit: 1. Instruments and equipment for use in nor- mal and forceps delivery, for exposing the cervix, for repairing lacerations, and for proper management of obstetric emergen- cies. 2. Solutions and equipment for administer- ing intravenous fluids. A room shall be available in the delivery unit for immediate cesarean section and shall con- tain such additional instruments and supplies as may be needed for this purpose. One delivery room should be used for the care of infected patients. This room must not of necessity be set aside for this purpose alone, but the room used for this purpose cannot be used again until it has undergone acceptable rehabilitation, to con- sist of thorough washing down and complete ventilation for 24 hours after its use for an in- fected case. A desirable alternative would be the delivery of all infected women elsewhere in the hospital. Auxiliary rooms and facilities: 1. Scrub- up facilities. There shall be scrub-up facilities in close proximity to the delivery rooms, ar- ranged so that the physician may see the inte- rior of the delivery room while scrubbing. Fa- cilities shall consist of scrub sinks with hot and cold running water operated by arm, leg, or foot controls. 2. Utility rooms. There shall be at least one utility room physically separated from the labor and delivery room. 3. Sterilizing room. There shall be steriliz- ing facilities readily available to the delivery unit to be used for obstetric equipment. Pres- sure steam sterilizers shall be provided and sup- plies of hot and cold sterile water shall be avail- able at all times. 4. Supply room. A room equipped with shelves and cabinets with adequate storage space for supplies and equipment used in the delivery unit shall be provided. 5. Warm room. A warm room shall be equipped with facilities for keeping blankets and solutions at the proper temperature. This may be a portion of the supply room. 6. Work room. There shall be a clean-up and work room in close proximity to the steri- lizing room. The Recovery Unit Modern obstetric care entails close observa- tion of the recently delivered patient. Provision of this care during the crucial few hours follow- ing delivery is necessary. This is best done by establishing a recovery unit for large obstetric services. The unit should be equipped with standard facilities required for any surgical re- covery unit. In smaller services the labor or the delivery rooms may be used for this purpose. Whether or not a separate unit is set aside as a recovery area, definite provision must be made for this type of obstetric care on every delivery floor. Locker and Rest Rooms 1. Nurses’ dressing room. This room should be located in the labor floor unit. It should con- tain adequate handbowl, toilet, locker, and re- laxation facilities for the comfort and conven- ience of the labor floor nursing personnel. 2. Staff locker and rest rooms. The conduct of labor in the modern manner entails constant proximity to the patient and frequent personal evaluation of the progress of labor. No matter what caliber the obstetrician, he does better work when he is rested than when he is fa- tigued. Obstetricians rest when given the oppor- tunity to do so. A necessary facility of a labor floor is a sleeping room equipped with an ade- quate number of comfortable beds with ventila- tion or air conditioning to provide rest for the man in charge of the patient in labor. An ad- ditional rest room should be provided with comfortable chairs and reading matter, both professional and lay. Such provision encourages close proximity, frequent checking of the pa- tient, decisions of an alert mind, and capable implementation of these decisions. Because the labor and delivery units are separate from the surgical units of the hospital, the locker room, bath, toilet facilities, and reading room of the obstetrician will naturally fall in the labor and delivery area. THE MATERNITY HOUSING UNIT The term “housing unit” is used to cover the ordinary ward, semiprivate, and private bed areas. The number of beds must be sufficient to meet the previous commitments of the hospital for obstetric inpatient care. Because of the in- evitable wide fluctuation in the urgent need for these facilities, the annual rate of bed occu- pancy should not exceed 70 to 75 per cent. The economics of modern hospital care make it es- sential that provision be made to meet the pub- lic demand for semiprivate space. With the marked fluctuation in obstetric bed occupancy, the unit should be flexible as to semiprivate or service occupancy, whenever it is feasible to adopt this policy. It is desirable not to house parturient patients in th e postnatal area who have lost their babies. The minimum floor area for patient units should be 80 square feet in single-bed rooms and 70 square feet in multiple-bed rooms. In multi- ple-bed rooms there should be a minimum of 3 feet between beds and a method of screening patients to insure privacy. For each patient unit there should be provided individual equipment and supplies including: 1. A signal system . Bedside stand Drinking water container and glass Wash basin Thermometer 2 3 4. Bedpan 5 6 7 Soap, washcloths and towels Auxiliary facilities: Each housing unit shall have the following facilities: 1. An equipped nurses’ station 2. Nurses’ washroom facilities 3. Storage closets 4 . Facilities for sterilization of instruments and utensils 5. Containers for waste disposal and tempor- ary linen disposal as well as waste storage 6. A pantry and closet for household articles and supplies Patients’ washrooms should have hot and cold running water with ample shower facilities. Each toilet room shall contain at least one lava- tory. For each two water closets an additional lavatory should be provided. Water closets shall be provided in the ratio of 1 to every 8 beds in the maternity areas not equipped with pri- vate water closets. When the number of beds in any one mater- nity nursing unit exceeds 30, additional auxili- ary facilities beyond those specified shall be provided commensurate with the number of ad- ditional beds. Isolation Facilities Separate accommodations for isolation of the maternity patient shall be provided and main- tained ready for use, unless such a patient is to be transferred to isolation quarters elsewhere. Such an accommodation shall consist of a room provided with a lavatory and such other facili- ties as may be needed for the isolation. While the physical separation for the isolation patients in a separate wing of the maternity hospital may be no longer necessary, it is necessary to segregate infected patients including both new admissions and those who develop infections while they are inpatients. The Study Unit Since obstetrics is a specialty of internal medi- cine plus the presence of pregnancy, the need to admit pregnant patients to the hospital for ob- servation and study is frequent. Modern obstet- ric areas should afford facilities for the obser- vation of toxemic patients, those with antenatal bleeding, and those with medical or surgical complications of pregnancy. In small services this facility may fit into the convalescent area, unless the complication is infectious, in which case it fits into the isolation facility. Generally speaking, however, for both the psychologic and physical welfare of the patient it is better not to house antepartum and puerperal patients in the same geographic area. Examination Rooms An examination room with full equipment for complete pelvic examination should be placed in each housing unit. Private and Semiprivate Accommodations Some private rooms should be available, but the trend is toward the use of semiprivate ac- commodations. Flexibility in the utilization of the rooms by placing either one bed or two beds as needed in a large room will make for more satisfactory accommodations. Isolation Facilities. The same rules regard- ing isolation apply to private and semiprivate patients as to those in the ward facilities. It is considered unwise to attempt complete isolation of private patients in private rooms not geo- graphically removed from the private room unit. THE NEWBORN AREA * The newborn unit shall include the following patient accommodations, which should be main- tained in order for immediate use: 1. Newborn unit for normal infants born at term. 2. A premature newborn unit in those ma- ternity departments having 20 or more ma- ternity beds. 3. A suspect or observation newborn unit. An isolation newborn unit, except when the procedure is to transfer infants with communicable disease to another depart ment or another hospital. Each newborn unit containing 5 or more bas sinets shall include a chart space, examining space, and work space. The chart space shall contain a desk, chair, chart rack, telephone, and lavatory. Caps, masks, and gowns shall be read- ily available. The examining space shall be pro- vided with instruments for examining the infant, and such instruments shall not be transferred to other nursing units. The work space shall be separate from the chart space and will contain a sink, bottle warmer, table or shelf, and cup- boards. Special needles, tubing, glassware, and * For further details and references see Hospital Care of Newborn Infants, American Academy of Pediatrics, Chicago, 1954. other equipment suitable for the use of newborn infants, and special sets for particular tech- niques such as infusions, transfusions, and lum- bar punctures, shall be available in sterile pack- ages ready for emergency use. The nursery in each newborn unit shall be equipped with viewing windows. Partitions used to form cubicles shall not exceed 414 feet in height. Bassinets shall not be placed against any wall or partition. There shall be at least 2 feet of space between bassinets and an aisle space at least 3 feet wide. The equipment of each nursery shall be lim- ited to that necessary for care of the infants and shall include the following: 1. Bassinet and bassinet stand. A separate bassinet and bassinet stand for each infant is desirable. Where bassinet frames are used they shall be covered with remov- able, washable linen. 2. Storage stand. Where any bassinet stand is not equipped with storage space, pro- vision shall be made at the side of such stand for the storage of supplies. 3. Wall thermometer. 4. Lavatory with hot and cold running water operated by arm, leg, or foot controls and supplied with soap or detergent and indi- vidual towels. 5. Diaper receptacle, metal. Such receptacle shall have a cover opened by foot control and shall have removable cloth or paper liners. 6. A hamper for soiled linen other than dia- pers. Such hamper shall consist of wash- able frames equipped with removable cloth bags provided with drawstring. 7. Balance scales for weighing infants. 8. Individual rectal thermometer and lubri- cant for each infant. 9. Clothing. A separate supply of diapers, clothing, and linen for each infant to be kept at each occupied bassinet. The following special equipment shall be readily available for each newborn unit: 1. A suction device with suitable equipment for use in aspirating infants. 2. A resuscitation apparatus equipped with oxygen and infant-sized mask. 3. A supply of oxygen, equipped with a de- vice for regulating and controlling the flow of gas. Term newborn units shall house not more than 12 bassinets per nursery. In existing hos- pitals there shall be no less than 20 square feet of floor area for each bassinet. Premature Care Facilities for the care of premature infants should be provided even in the smallest hos- pitals. Whether this be in a central nursery or as a separate unit is determined by the size of the service. Modern newborn incubators have partially replaced the former need for a com- plete separate premature nursery. The prema- ture infants in their incubators can be conven- iently housed and properly cared for in a segre- gated area of the nursery unit. It is not the housing so much as the pediatric and nursing philosophy that will increase survival rates in the premature population. The premature nursery should have sufficient incubators to accommodate approximately 10 percent of the infants that are born in the obstetric service. Premature newborn units shall be furnished with incubators carrying the seal of approval of the Underwriter’s Laboratories, Inc., or approved by the Chief of Pediatrics. Such units shall contain a suction apparatus, a resuscitation apparatus, and a supply of oxygen. The Isolation Newborn Unit or Facility This shall be provided with facilities and equipment to maintain complete isolation. This nursery shall provide not less than 30 square feet of floor space per bassinet and shall be divided into separate cubicles for each bassinet. The Suspect Nursery or Facility A unit shall be provided to accommodate babies who are suspect of infections from the other nurseries. This shall contain no more than 4 bassinets per nursery, shall provide not less than 30 square feet of floor space per bassinet, and shall be divided into separate cubicles for each bassinet. Ritual Circumcision In maternity departments permitting ritual circumcision a separate room outside of the new- born unit shall be provided for the procedures. Facilities for proper scrub-up and the sterili- zation of instruments are required. Further- more, the area shall have space for the infant’s family, arranged to permit observation but pre- vent contact with the infant. The Rooming-in Plan Not all mothers care to utilize the rooming-in plan and, furthermore, newborn infants present- ing gross malformations and those presenting survival problems will probably best be cared for in a central nursery. The term “rooming-in” means the placing of the baby in a crib beside the mother’s bed. Two modern trends open the door to rooming-in: * decentralization of nurseries and early ambu- lation of mothers. Several architectural plans have been suggested. One is that of a peripheral nursery to accommodate six to eight babies in mobile bassinets. Three to four bed rooms ad- join the nursery on either side, each equipped with a hand bowl. A central nursery is still use- ful for supplies, formula storage, records, nurs- ery training, and the care of babies who require skilled supervision or special treatment. Where the rooming-in type of program is adopted fully or in part, it is probable that nurseries with more than eight bassinets or less than four will be impractical. The Formula Room The responsibility for the formula room may be that of the nursing, the dietetic, the pedi- atric, of the obstetric service. It is especially important that its planning be agreed upon by all interested groups. A separate room should be provided and used exclusively for prepara- tion of infant formulas. Such rooms shall be situated where there is the least possibility of contamination. ADDITIONAL FACILITIES Patients’ dining room. Following the imme- diate effects of delivery the average obstetric patient is a healthy individual who enjoys both physical activity and social contacts. Establish- ment of a dining area to which ambulatory pa- tients may go for meals bears consideration. It would prove a highly acceptable variation to the patient and furthermore might well contribute toward reduced hospital costs through the re- duction of food waste and the decreased number of required food handlers. Not all patients can participate in this program and, consequently, some floor service is necessary. Relaxation unit. Because the modern trend in medical care encourages a reasonable amount of physical activity, some area other than the hospital corridor should be provided for the congregation of patients. This is particularly true in obstetrics. The nature of the relaxation unit will depend much upon climate and geo- graphic location of the institution. This area might well provide space for a small central beauty parlor, a quiet reading room or music room on one side and a combination card room or television room on the other side. Provision for pay-telephone booths in this area is also desirable. SERVICE FACILITIES 1. Elevators. Every hospital having a ma- ternity-newborn service with more than one floor should provide elevator service for patients only, when this service is needed. Such elevator should be of suffi- cient size to accommodate a hospital bed. Newborn babies should be transported in an elevator that contains only the opera. tor and the baby’s attendant. 2. Food for patients. All food served to patients in maternity-newborn service shall be selected and prepared under the supervision of qualified nutritionists or a qualified dietitian or nurse with special training in dietetics. 3. Laundry. It is recommended that all washable linens from the maternity de- partment, including the newborn unit, be marked and washed separately. 4. Heating. All rooms shall be maintained at a minimum temperature of between 60° and 70° F. The temperature in the nurs- eries and in the delivery suites shall be maintained at not less than 75° F. Hot water shall be available at all times. 5. Lighting. Rooms for patients and the newborn shall be outside rooms, well ven- tilated and provided with window area not less than 1/10 of the floor area. Every room including service rooms and work centers shall have artificial lighting facil- ities including electric outlets so that all areas will be clearly visible. It is espe- cially important that hallways, inclines, ramps, exits, and entrances be well lighted in order to prevent accidents. The various other necessary facilities are de- tailed in many other publications on hospital administration. They include storage and re- frigeration of foods, washing and disinfection of dishes and utensils, the prevention of water- supply contamination, sweeping technic, recep- tacles for soiled linen, disposal of infected ma- terials, and facilities for garbage and refuse disposal. * “Rooming-In Is Here To Stay,” Thaddeus L. Mont. gomery, The Modern Hospital, March, 1951. 1 For details and references see Hospital Care of New- born Infants, American Academy of Pediatrics, Chi- cago, 1954. SECTION II PERSONNEL AND ADJUNCT SERVICES DEFINITIONS The following terms are defined as they are used in this manual. 1. Registered Professional Nurse: A nurse who has been graduated from a professional school of nursing and who holds a license issued by the Department of Education of the state to practice as a registered professional nurse and who has registered with such department in accordance with the provisions of the educa- tional law. 2. Professional Nurse: A person whose reg- istration is currently pending before the Nurses Examining Board. 3. Nonprofessional Nurse: A person who is ineligible for registration by the Professional Nurses Examining Board but who is engaged in giving a limited type of nursing care. Such person may be a student nurse, a practical nurse, a nursing aid, or an attendant. 4. Private-Practice Nurse: A nurse (either of the above) who is engaged directly by the patient or her representative for the purpose of rendering nursing care to that patient. 5. Qualified Nutritionist: Any person who has been graduated with a Bachelor’s degree in home economics from an approved institution of learning and has had at least 2 years experi- ence as a nutritionist. A person who has received a Master’s degree in nutrition from such an in- stitution and has had at least one year experi- ence as a nutritionist. 6. Qualified Dietitian: Any person who has been graduated with a Bachelor’s degree in home economics from an approved institution of learning and has had an internship as a dieti- tian in a hospital approved by the American Dietetic Association or who has had the equiv- alent of such training in experience. 7. Medical Personnel: Obstetrician, pedia- trician, anesthesiologist, pathologist, and roent- genologist mean physicians engaged in these re- spective branches of medicine who are certified or eligible for certification by the appropriate national medical board or who have the equiv- alent in training and experience in that branch of medicine. 8. Qualified Obstetrician and/or Gynecolo- gist: A physician who a. is a diplomate of the American Board of Obstetrics and Gynecology or one whose training and experience would qualify him for the Board examina- tion, or b. is a Fellow of the American College of Surgeons (in the specialty of Ob- stetrics and Gynecology) or of the American . College of Obstetricians and Gynecologists, or c. has served for a minimum of 5 years on the Attending Staff in the Depart- ment of Obstetrics and Gynecology in a hospital that is approved for resi- dency training in this field by the Council of Medical Education in Hos- pitals of the American Medical Asso- ciation. 9. Qualified Anesthesiologist: A physician who is a diplomate of the American Board of Anesthesiology or one whose training and ex- perience would qualify him for admission to examination by such a board. 10. Certified Registered Nurse Anesthetist: A graduate registered nurse who has had 12-18 months of recognized training in anesthesia and who has passed the qualifying examination of the American Association of Nurse Anesthetists. 11. Resident Physician: A physician who has finished at least one year of internship and is serving in the capacity of house physician for the purpose of specialized training. The require- ments, as to previous training, of the Council on Medical Education of the A.M.A., should be observed in the acceptance of physicians for resident training. 12. Intern: A person who was graduated from a recognized medical school and is serving as a house physician for the purpose of general training. NURSING STAFF The nursing service of the maternity depart- ment shall be under the supervision of a pro- fessional nurse who has had special preparation in maternity nursing or who has had significant experience in maternity nursing in the place of such preparation. Head nurses in charge of the various units of the maternity building shall be professional nurses with special preparation or experience in the corresponding branch or branches of nursing. Additional professional nurses or nonpro- fessional nursing personnel shall be employed to aid in the nursing for all patients. There shall be at least one professional nurse on duty at all times to supervise maternity and newborn nursing care. At least one nurse shall be provided at all times for each 12 newborn infants. Nonprofessional nursing personnel shall be under the supervision of a professional nurse who shall be on duty at all times. Their duties shall be clearly defined and they shall be in- structed in all duties assigned to them. Private-practice nurses shall at all times be under the supervision and direction of the su- pervising nurse of the maternity or newborn units, and shall be required to follow the nurs- ing technic prescribed for such units. An adequate complement of nursing person- nel shall be assigned regularly for exclusive use in the maternity department. Under emergency circumstances, additional nursing personnel shall be drawn from other clean areas. Nursing personnel assigned temporarily elsewhere may not return to the maternity department during a specific tour of duty. Professional nurses, dietitians, or other per- sonnel assigned to the formula room shall have special instruction or experience in the prepa- ration of infant formulas and shall be prohib- ited from doing any other type of duty at this time which may bring them in contact with in- fected patients in any part of the hospital. THE MEDICAL STAFF The obstetric-gynecologic staff of the hospital shall be organized under the directorship of a qualified obstetrician-gynecologist who shall be responsible for the policies, procedures, and supervision of obstetric work in the department. The medical staff of the newborn unit shall be organized under the directorship of a pedi- atrician who shall be responsible for the super- vision of the professional work in the newborn units. The Pediatrician in charge of the new- born units, in cooperation with the director of the obstetric-gynecologic department, shall es- tablish policies and procedures for the care of the newborn, full-term and premature. There shall be at least one staff or house physician assigned to the newborn units who will be on call at all times and who will visit the newborn units at regular intervals. ADJUNCT FACILITIES AND SERVICES Facilities and personnel for competent anes- 10 thesia, clinical and pathologic laboratories, and x-ray facilities shall be provided for emergency as well as for routine duties, and shall be readily accessible to the maternity department. The following equipment and supplies shall be readily available: 1. Equipment and supplies for laboratory examination including blood counts, hemoglo- bin determinations, cross matching in Rh and other typing of blood, and urinalysis. 2. Equipment and supplies for blood trans- fusions and other intravenous therapy. 3. X-ray equipment and supplies including special devices for obstetric roentgenography. 4. A blood bank should be available to every maternity department, and the obstetric service should take an active part in establishing and maintaining this facility. All maternity hospital services should have prepared irradiated blood plasma, plasma expanders, and fibrinogen. 5. Anesthesia. A general policy regarding anesthesia should be determined by the chair- men of the two departments. In hospitals with no physician anesthetist, the policy should be determined by the chief of the obstetric-gyne- cologic service. This applies also to those hos- pitals with no anesthetists except the attending physicians. The types of anesthesia to be per- mitted, the personnel for administration, and necessary safeguards should be known to all members of the staff. In the absence of trained anesthetists a wider use of local anesthetic agents by the obstetrician is to be encouraged. Spinal, caudal, inhalation, and intravenous anes- thesia should be given only by one who is ex- perienced in anesthesia. Recommendations made in an effort to assure better anesthesia for de- livery will soon be provided by the Joint Com- mittee on Obstetric Anesthesia and Analgesia of The American Society of Anesthesiologists and The American College of Obstetricians and Gynecologists. The rules and regulations of the Insurance Underwriters as to explosion hazards of anesthetic gases must be observed constantly. CHILD-PLACEMENT REGULATIONS The release of infants for adoption shall con- form to the state and local laws regarding adop- tion procedures. The administrative offices of the hospital shall report to the proper agency within 48 hours the name and address of any person other than a parent or relative by blood or marriage, or any organization or institution into whose custody the child is given upon dis- charge from the hospital. A duplicate of this report shall be filed with the mother’s hospital record. PHYSICAL EXAMINATIONS OF PERSONNEL All personnel working in the maternity unit shall have a pre-employment physical exam- ination and thereafter an annual physical exam- ination and such interim examinations as may be required by the hospital. The pre-employ- ment examinations shall include a chest film and tests for syphilis and gonorrhea; interim ex- aminations will be as required by the hospital health officer. No one shall be assigned to the care of maternity patients unless approval has been given by the hospital’s employment health service or, in the absence of such a service, by a physician authorized by the hospital to ap- prove such assignments. Personnel with communicable disease or per- sons who have had contact with communicable disease shall be excluded from the maternity service until examined by a physician. The 11 examining physician shall certify that the em- ploye is free from infections before he or she may return to duty. Only well persons shall be in attendance on the maternity service. Personnel with evidence of upper respiratory infections or open skin lesions, diarrhea, or any other infectious disease shall be excluded. HOSPITAL ATTIRE Long clean coats or gowns should be worn by physicians who examine patients in the mater- nity unit. Uniforms worn by medical and nursing per- sonnel in any other service than maternity should be changed or covered by a clean gown or coat if this person is to examine patients. SECTION Ili DEPARTMENTAL ORGANIZATION The Board of Trustees of a hospital usually places administrative responsibility and author- ity in a lay or medical superintendent, director, or administrator. The medical responsibility is usually assigned to the medical staff through a medical executive committee consisting of the chiefs of the various hospital services. It is al- most impossible to establish sharp lines between “medical responsibility” and “administrative re- sponsibility.” The total responsibility is dual in nature and the maintenance of adequate care is a joint administrative-medical effort. OBSTETRIC-GYNECOLOGIC STAFF Obstetrics and gynecology is an established unified specialty. In the interest of patient care and professional training every general hospital should have a separate department of obstetrics and gynecology. The staff should be organized with a chairman appointed or elected for suffi- cient time (3-5 years) to give continuity to the medical program. He should be a qualified spe- cialist, as described in Section Il. In smaller institutions with no qualified specialists, an obstetric service should be organized with a chief to be chosen as the departmental staff re- presentative. This choice should be controlled by the attitude and competence of the man rather than by the size of his practice. Departmental staff membership should be characterized by: 1. Consistent and openly recognized require- ments together with the right of appeal by those who fail to meet such requirements. 2. Definite limited tenure (5 years is sug- gested) with regular review of each physi- cian’s status and activities. Life appoint- ments do not contribute to a strong staff. Yearly review and reappointment is re- commended by some. 3. The right to dismiss staff members when indicated (this right on occasion must be employed with adequately sustained legal opinion). ! The staff members in the department should be in sympathy with the policies of the chair- man as to administration, teaching, and the standards of professional medical practice. They should accept and fulfill satisfactorily any as- signments in these areas. Failure to do so may prevent reappointment. The right of appeal should be maintained, first to the chief, second to the Hospital Medical Exccutive Committee, and finally to the Board of Trustees, if the oc- casion arises. DUTIES OF THE CHIEF OF SERVICE The chairman of the Department should des- ignate the tour of duty of the various visitants, insure maintenance of the standards of practice, and establish the necessary committees.? He shall represent the Department on the Hospital Medical Executive Committee. The chief should be empowered to recom- mend to the proper authorities appointments and dismissal from the staff. He should be will- ing to accept the duties, responsibilities, and sacrifices involved and he should have the avail- able time and the ability to administer the de- partment competently. AREAS OF STAFF ACTIVITY The organization of the obstetric-gynecologic staff will vary decidedly with the size of the hos- pital and the degree of specialization. The fol- lowing activities are suggested for inclusion or exclusion, depending upon the size of the ser- vice. Committees or individuals may be assigned to conduct certain areas of activity. These areas should be under the constant scrutiny of the Department chairman. 1. EXECUTIVE AREA A. Applications for staff position. B. Problems of dismissal. C. Applications for internship and resi- dency. D. Coordination of policy matters with the hospital administration as to pri- ority and policy of admission, bed dis- tribution, assignment of house officers, senior nursing personnel, and others. 2. OUTPATIENT AREA A. Adequate outpatient facilities for com- plete antepartum and postpartum care. * Hospital Organization and Management (ed. 2), M\. T. MacEacheren, Physician’s Record Co., Chicago, I11., 1946. *The Medical Staff in the Hospital, Thomas R. Ponton (Revised by M. T. MacEacheren), Physician’s Record Co., Chicago, Ill. B. Adequate outpatient facilities for gyne- cologic care. C. Adequate ancillary services. D. Direct medical supervision of all pa- tients. E. Adequate medical supervision for the training of professional personnel. 3. HOSPITAL TUMOR CLINIC A. Representation from the Department of Obstetrics and Gynecology. (Committee should include a pathol- ogist, a radiologist, an internist, and a representative from each of the sur- gical specialties.) Assistance in conducting follow-up clinics. C. Consultations as to diagnosis and pre- ferred management of patients. D. Aid in conducting clinicopathologic meetings for the review of patient care and for teaching in postgraduate areas. 4. HOSPITAL TISSUE COMMITTEE OR OPERATIVE REVIEW COMMITTEE “Tissue Committee” is a misnomer. This committee should be a reviewing body that serves for the purpose of scanning the surgical procedures that are conducted on all services of the hospital. In the obstetric-gynecologic field many op- erations require the removal of normal tissue. In other instances operations may be ill-advised even though pathologic tissue is removed. On other occasions the choice of the surgical pro- cedure may have been incorrect for a given con- dition. There is great need for an operative re- view committee to consider the question “Was this operation both indicated and performed properly”? Such a committee might consist of senior representatives from the Departments of Obstetrics and Gynecology, Surgery, Medicine, and Pathology, to be appointed every two years by the president of the hospital staff. The chair- men of the respective surgical services should serve as ex officio members of the committee. The committee should meet regularly to con- sider all surgical procedures that have been conducted in the hospital. If question arises concerning the wisdom of the procedure or choice of an operation, the surgeon should be asked to appear before the committee to explain the undertaking. Should the explanation be in- adequate, the error must be reported to the 13 Chairman of the Department; if he feels that further action is indicated, he will report to the Hospital Medical Executive Committee for ac- tion. Cases should be reviewed by number only, never by name. The findings of the committee should not be made a part of the patient’s re- cord. Certain categories of cases should receive par- ticular attention, such as: 1. Those in which no tissues were removed, including vaginal plastic repairs. 2. Those in which any of the female repro- ductive organs are removed in patients of less than 40 years. 3. Operations upon the uterus, such as sus- pension. 4. Appendectomies, neuronectomies, and herniotomies. 5. Cases in which there is great disparity be- tween the pre- and post-operative diagnosis. The Tissue Committee should not function as the Abortion-Sterilization Committee because of the difference in both the time of decision and the professional complement. 5. ABORTION-STERILIZATION COMMITTEE See Section VIII on Consultations. 6. CONSULTATIONS FOR WARD SERVICES For better functioning of the obstetric- gynecologic service, one or more attendings should be appointed for various specified periods to act as service consultants to the other hospital ward services. Preferably the consultants should be those on their tour of duty on the ward service. 7. FOLLOW-UP CLINIC In order to assess results of surgery or con- finement, a follow-up clinic should be es- tablished. If the service is sufficiently large, it should be conducted separately from the regular outpatient clinics, and divided into a “benign” clinic and a “malignant” fol- low-up clinic. The cost should not be as- sessed to the patient as long as therapy is not rendered to the patient. 8. NURSING PROCEDURE Problems concerning errors in nursing serv- ice, patients’ complaints, physicians’ com- plaints, and alterations in policy should be discussed at regularly scheduled meetings between representatives of the nursing service and of the obstetric-gynecologic service. 9. NURSING EDUCATION A representative of the Department of Ob. stetrics and Gynecology should collaborate with the School of Nursing to plan lectures and professional demonstrations. Staff members should volunteer or be assigned to conduct the necessary educational pro- gram. 10. NURSERY COMMITTEE Nursery procedures, forms, and technics 3 must be reviewed frequently with the De- partment of Pediatrics. This can be accom- plished by a committee or by discussions at staff meetings. 11. MEDICAL RECORDS These records are the direct and immediate responsibility of the Chief of Service. The definition of a completed record is a joint medical-administrative responsibility to be regulated by the recommendations of the Joint Commission on Accreditation. Sim- plification, within the confines of such sti- pulations, is urged. The operative note on each record should contain: I. An accurate description of the pel- vic and abdominal findings at the time of the laparotomy. 2. The surgical procedure as to the or- gans or portions thereof removed, those conserved, and the reconstruc- tive measures. 3. Any foreign bodies such as packs or drains to be removed subsequently. 4. Variation from the routine practice as to suture suture material or clo- sure. Record forms should be reviewed critically with an eye to avoiding duplication and un- necessary burdens on the nursing and the house staff. Diagnosis should follow the standard nom- enclature manual. * Definitions should follow those listed in Section XII. The certification that any individual record is completed is a medical responsibility. This is best achieved by careful inspection and signature by the Chief of Service or his delegated representative. This represent- ative should be a member of the Medical Re- cords Committee. The record room should have the records completed and available within a week of the termination of each month for re- view by the Staff Program Committee. It is desirable to have sufficient cross-indexing so that medical information is obtainable with ease and accuracy for review and study. 12. STAFF PROGRAM AREA A monthly business staff meeting for the review of the clinical activities of the de- partment during the preceding month should be conducted no matter how small the service. The following form is included for con- sideration and revision to fit the local con- ditions. Obstetric Report 1. Patients discharged during the pre- ceding month: (A) delivered; (B) undelivered. 2. Deliveries: (A) operative; (B) non- operative. 3. Deaths on maternity service: (A) di- rect obstetric; (B) indirect obstetric. 4. Deaths on maternity service, non- obstetric. 5. Live births: (A) mature; (B) pre- mature. 6. Miscarriages or abortions (1-16 weeks’ gestation). 7. Stillbirths (after 16 weeks’ gesta- tion) : (A) mature; (B) premature. 8. Neonatal deaths (after 16 weeks’ ges- tation) : (A) mature; (B) prema- ture. 9. Cesarean section: (A) Primary (per- centage) ; (B) Repeat (percentage) ; Total. 10. Sterilizations and therapeutic abor- tions. Details. 11. Operative deliveries: A. Cesarean section. B. Forceps (low, mid, high). C. Breech deliveries. D. Podalic versions. * Modern Hospital, September, 1953. ¢ Standard Nomenclature of Disease and Operations (ed. 4), Blakiston Co. (div. of McGraw-Hill, New York). 12. Maternal complications: A. Febrile morbidity. B. Hemorrhage. C. Miscellaneous, such as morbidity that impairs the convalescence of the patient or necessitates that she remain in the hospital longer than the usual postnatal period. Gynecologic Report 1. Total discharges: (A) private; (B) ward. 2. Nonoperative discharges. 3. Operations: A. Abdominal (1) Total hysterectomy (2) Supracervical hysterecto- m (3) Oophorectomy or salpin- go-oophorectomy (4) Miscellaneous B. Vaginal (1) Major (2) Minor (3) Hysterectomy (4) Miscellaneous 4. Irradiations. mn Sterilizations. Details. 6. Complications: A. Postoperative bleeding. B. Full postoperative febrile mor- bidity. C. Morbidity that prolongs conva- lescence. 7. Each death with pathologic reports and final diagnosis. Each death, fetal, neonatal, maternal, and gynecologic should be classified as to cause and preventability at the staff meeting. Monthly reports should be used as the basis for the annual report. HOUSE STAFF EDUCATION The future of this, or any specialty, is assured by continued postgraduate educa- tion. The administration as well as the medical staff must see that residency pro- grams are truly educational. Adequate time and facilities for reading, journal club meetings, scientific presentations at staff meetings, and bioclinical discussions of problem cases should be included in the program. No hospital is administratively so small or medically so busy that time cannot be devoted to an instructive pro- gram for the postgraduate staff. 5 14. 15. In hospitals with resident training, the program should be the responsibility of the Chairman of the Department. He will select his co-workers from the Department and assign to them various teaching duties. These men should have finished their clin- ical training to the point at which they no longer take over the pre-intra-, or post- operative care of the service patient except for the purpose of supervised teaching. At times either the hazardous nature of the operation or the poor condition of the pa- tient may require active participation of the attending gynecologist, but not to the degree that the responsible resident is de- prived of his surgical experience. Obstet- ric-gynecologic surgical judgment and technical skill are best acquired by per- sonally supervised individual effort rather than by passive observation or the anti- quated trial and error method. In some of the larger hospitals, an educational pro- gram is set up to include the entire house staff. Under this plan the Chairman of the Department of Obstetrics and Gynecology should cooperate with the Director of the Educational Program. RESIDENT ALUMNI SOCIETY Each hospital with an approved resi- dency training program should be encour- aged to establish a Resident Alumni Society. The chairman of the alumni com- mittee should be a member of the attend- ing staff who is interested in maintaining contact with the Residents following their departure from the hospital. The committee should plan a Resident return visit to the hospital at yearly inter- vals. A program should be arranged of such an interesting nature that the former residents will wish to come back to renew former acquaintances, to participate in the activities of the day, and to bring them- selves up to date on modern methods in Obstetrics and Gynecology. LIBRARY The Chairman of the Department should make available, with the aid of his staff, an adequate reference library to include current texts and journals to aid and stim- ulate postgraduate teaching. See Section XIII for recommended texts and journals. © Essentials of an Approved Internship, Council on Med- ical Education and Hospitals of AMA, 535 N. Dearborn St., Chicago 10, Illinois. ° Report of the Advisory Committee on Internship, Journal of the American Medical Association, Febru- ary 7, 1953. SECTION IV STANDARDS OF PRENATAL CARE Prenatal care may be defined as a planned program of observation education and medical management of pregnant women directed to- ward making pregnancy and delivery a safe and satisfying experience. Technically, the prenatal span extends from the time of conception to the onset of labor. PRIMARY INTERVIEW AND EXAMINATION A. History: The record should include the social, family, medical, and neurological, past surgical and past obstetric history with particu- lar reference to the conditions that might affect the outcome of this pregnancy. The present his- tory should include the questions as to the patient’s general condition as well as the consti- tutional and psychologic reaction to this preg- nancy. B. Physical examination should include notes upon the general mental makeup and the general physical characteristics as well as a complete medical examination from scalp to toes including blood pressure and weight. Par- ticular attention should be given to the breasts, the genital structures, and the size and confor- mation of the bony pelvis. C. Laboratory examinations should include: 1. Complete urinary analysis. 2. Blood count (red and white, and hemoglobin or hematocrit) 3. Serologic examination 4. Blood grouping and Rh determin- ation 5. Chest x-ray examination 6. X-ray pelvimetry at term or in early labor, when indicated by history or physical examination An Rh determination should be repeated with each pregnancy. Each Rh negative patient should have blood drawn for antibody determi- nation. If no antibodies are found the test should be repeated at 28-30 weeks, and again at 36-38 weeks. If antibodies are found at any time, more frequent studies of the titer are in- dicated. Each husband of an Rh-negative mater- nity patient should be tested for Rh and, if positive, as to whether he is homozygous or heterozygous. Blood group determination shall be made on the husband of every Group O pregnant patient before the onset of labor. If 16 this be A or B, the possibility of A- or B-O incompatibility should be entertained. This information, as well as a list of all Rh-negative patients who are expected to deliver, should be posted each month on the labor floor and in each nursery. D. Initial conference with patient and hus- band to discuss: 1. Expected date of confinement, diet, medi- cation, care of breasts, general hygiene, clothes, exercise, rest, travel, marital relations, and re- creation. 2. A simple book written for lay consump- tion that explains pregnancy, prenatal care, la- bor, and delivery should be recommended (see Recommended Publications). 3. Financial aspects. (a) Insurance plans. (b) Hospital costs and extras. (c) Cost of ob- stetric care should be explained specifically. An all-over obstetric fee with no additional charge for complications or operative proce- dures is strongly recommended. If the patient is to be charged for pre- and postnatal visits she should be so advised upon the first visit to the obstetrician. SUBSEQUENT EXAMINATIONS Schedule: These examinations should occur monthly for the first 7 months, every 2 weeks until 36 weeks and weekly thereafter. Prenatal care is the personal responsibility of the ob- stetrician. Upon each visit blood pressure, weight and urine status shall be determined. The patient should be interviewed, examined and advised by the obstetrician, and told when to return for her next visit. At 30-36 weeks the patient should be taken on a tour of the hos- pital facilities and given advice regarding onset of labor and when and whom to call, no food after the onset of labor, and a discussion of analgesia, anesthesia, breast or bottle feeding, and pediatric care. Care of the breasts: The breasts should be examined at least every 3 months during preg- nancy. Discrete masses should be handled as if the pregnancy did not exist. Breast feeding is usually better for both mother and baby and should be encouraged during prenatal care. Whether the mother plans to nurse her baby or not, she should be advised as to cleanliness, care of the nipples, and the use of a brassiere. LAY EDUCATION A. Husband. A conference should be ar- ranged with the husband, either privately or in the company of the wife, outlining his part in the program and his responsibilities. B. Mother and Mother-In-Law. Frank dis- cussion of the general program and the differ- ences in modern practice should be pointed out. Their place in the program should be indicated. C. Fathers and Mothers Classes. A course of 4-6 one-hour conferences conducted by spe- cially trained nurses and residents in large in- stitutions under obstetric staff supervision has proved to be beneficial and popular. The pur- pose of such lectures is the dissemination of factual information and not the false promise of a discomfort-free pregnancy, labor, and de- livery. 1. Physiology of pregnancy, fertilization, nidation, development. 2. Dict, exercise, clothes, marital relations, bathing, travel, sleep, and recreation. 3. Abortions, bleeding in later months, and toxemias. Need for hospital care. 4. Labor; first, second, and third stages. (a) Premature labor (b) Premature rupture of the mem- branes. 5. Puerperium, lactation, involution, exer- cise, and diet. 6. Newborn baby care (a) Bath, cord, eyes, circumcision. (b) Breast feeding, artificial feeding, diapers, and bowels. 17 NURSES’ RESPONSIBILITIES IN PRENATAL CARE 1. Check the weight and blood pressure. Reassure the patient and prepare her for examination by the physician. 2. Examine the urine if trained to do so, and record the results. 3. Record the next appointment as indi- cated by the physician. DESIRABLE SPECIAL PRENATAL CLINICS OR COMBINED TALENT ARRANGEMENTS 1. Obstetric-Cardiac Clinic Both physicians should see the patient together upon each visit. The cardiologist should be present during labor and de- livery with Class IIT and IV cardiac probiems. 2. Toxemia Clinic Run in collaboration with an internist interested in renal disease. 3. Diabetes-Obstetric Clinic Organized as above. Note: Clinics 1, 2, and 3, might be com- bined if the service is small. Experience has taught the value of these clinics for the purpose of both teaching and patient care in large obstetric services. While they should be modified to fit local conditions, segregation of the complicated prenatal prob- lems from the normal patients will pay off in end results. 4. Dystocia Clinic All former and potential dystocia prob- lems should be assigned for special study plus the routine prenatal observation. The same general plan of management is feasible and should be carried out for private patients. SECTION V NURSING CARE OF THE OBSTETRIC INPATIENT GENERAL PRINCIPLES A. Every effort must be made to protect the patient from infection. Each mother and her infant should be separated from other patients as much as possible. Use of common equipment without careful supervision is strongly discour- aged. 1. Personal equipment that is kept in the patient’s unit (wash basin, emesis basin, and trays) should be individual. Bedpans should be sterilized after each bowel movement and every 24 hours. Extra bedpans should be stored in an appropriate place other than the bedside stand. 2. Bedpan covers should be used once and discarded. B. Patients who develop contagious diseases or draining infections must be transferred to an isolation unit. C. An experienced graduate professional nurse should be present on the division at all times and should be directly responsible for all patients’ care and observation. D. Only experienced, graduate professional nurses, or other properly instructed and closely supervised personnel, should be allowed to give direct or indirect patient care. E. Since obstetric nursing differs from that of all other areas, thorough orientation of all personnel to obstetric technic, prior to the as- signment of patient responsibility is essential. F. The staff must assume responsibility for proper technic in all patient care, even though patients now may perform a large portion of their own care. G. Trays containing drugs and equipment, including a mouth gag, commonly used for emergencies (such as hemorrhage and convul- sion) should be kept in a convenient and easily accessible place. All staff members (profession- al and nonprofessional) must be aware of the location of the trays. NURSING CARE DURING LABOR AND DELIVERY A. PREPARATION OF UNIT 1. All personal equipment is to be ade- quately cleaned or sterilized between patients. 2. The rooms should be cool, well venti- lated, and without drafts. 3. All equipment should be checked for safety and mechanical efficiency daily. 18 B. ADMISSION OF PATIENTS An admission observation and preparation unit, close to but not a part of the labor floor, has many advantages. 1. Patients should be oriented to the labor and delivery suite and general procedures be- fore admission, if not, this should be done on admission, provided the patient’s condition per- mits. 2. All necessary admission information is collected with particular attention to possibility of infection. Suspicion of infection is reported to the physician immediately. The patient’s re- ligious preference is to be recorded. 3. The fetal heart rate and tone and the maternal blood pressure should be taken im- mediately upon admission. 4. All patients should be placed on bed rest except by order of the physician. 5. Perineal shave should be done only by order of the physician or if delivery is immi- nent. Care must be taken to avoid razor lacera- tions and entry of contaminated solutions into the vagina. Gloves should be worn during the procedure, or (3 min.) pHisoHex® or soap scrub used to clean hands before and after procedure. Equipment must be boiled 20 minutes, auto- claved, or discarded after use. 6. Enemas should be given in the prepa- ration room only on physician’s order. Patients must be observed carefully while expelling the enema for rupture of membranes or rapid progress of labor. All equipment used must be boiled 20 minutes, autoclaved, or discarded. Gloves must be worn, or a pHisoHex® scrub used to clean hands after procedure. 7. Bed or shower bath as indicated, un- less labor is too active. C. NURSING CARE DURING LABOR 1. Constant Observation Someone should be in constant attend- ance. The husband or a relative may stay with the patient during labor, pro- viding their presence is desired, they are informed as to the progress of labor, their influence is constructive, and ade- quate physical facilities are available. This does not relieve the physician and nurse of their responsibility for the patient. An experienced sympathetic nurse can do much to allay fear and en- hance the progress of labor. Patient teaching should be done in the early stage of labor. 2. General Supportive Care (a) During labor no solid or soft foods are given. Opinions among physicians vary concerning oral fluids. Some wish nothing by mouth throughout labor. Others permit high-caloric liquid diet in small amounts as long as desired by the patient. Others stop oral fluids at the beginning of the sec- ond stage. (b) Each obstetrician’s policy should be recorded and followed or, pre- ferably, specific orders should be written for each patient. (¢) Frequent bed baths and back care should be given. (d) Sacral pressure during contrac- tions and abdominal breathing, with relaxation between contrac- tions may be encouraged, if ap- proved by the physician. (e) Maximum opportunity for rest should be provided. 3. Care of Perineum (a) The perineum must be kept as clean and dry as possible. The perineal area should be cleansed frequently and fecal material re- moved promptly with large sterile cotton balls soaked in sterile wa- ter, quarternary ammonium chlo- ride solution, or other suitable solution. Care must be taken to prevent entry of solution into the vagina. (b) Perineal pads should not be used during labor. Disposable absorb- ent pads under the buttocks are preferred. . Care of the Urinary Bladder (a) The patient’s bladder must not be- come overly distended during la- bor. When this occurs and the patient is unable to void, the phy- sician should be notified. (b) Bladder distention should be esti- mated by palpation, since it is not always comparable to fluid intake. Catheterization should be done by aseptic technic with a small, flex- ible, well-lubricated catheter. . Observation of Condition The nurse who is responsible for care of the patient in labor must be aware 19 of the exact condition of her patient, and must inform the physician imme- diately of any and all untoward symp- toms as well as of imminent delivery. (a) The fetal heart rate should be checked every 30 minutes in the first stage and more often in the event of complications, oxytocics, or change in rate. It should be checked and recorded at least every 15 minutes in the second stage while in the labor room. (b) The maternal blood pressure should be taken every 30 minutes during labor and immediately be- fore delivery. (¢) The contraction pattern should be observed closely for signs of com- plication of labor as well as of progress in labor. (d) Temperature, pulse, and respira- tion should be observed at least every 4 hours. (e) When the membranes rupture, the physician should be informed promptly. The patient should be checked for evidence of fetal dis- tress, prolapse of the cord, or im- minent delivery. Fetal heart sound examination and rectal examina- tion should be done by a qualified nurse or physician. A qualified nurse is a graduate or senior stu- dent professional nurse who has received adequate physician in- struction and experience as to the technic and the interpretation of intrapartal rectal examinations. . Medications (a) Emergency drugs and anesthetics must be readily available. A com- plete list appears in Section II. This is to be modified with the introduction of newer and better drugs. (b) Safety precautions must be em- phasized for patients who receive sedative and amnesic drugs. All breakable objects must be re- moved. Side rails should be ap- plied, and the patient should not be left alone. (ec) Oxytocics. Oxytocic drugs should be administered to undelivered patients only upon written order of the physician in charge of the patient. Full responsibility for ob- servation of undelivered patients who have received or who are re- ceiving oxytocic drugs should not be assumed by the nursing serv- ice. The physician must be in con- stant attendance or in the labor room area. D. NURSING CARE IN THE DELIVERY ROOM 1. Preparation of equipment and facilities (a) The delivery room temperature should be 72°.75° F., without drafts. (b) The delivery room should be in- spected for all necessary supplies and equipment and emergency fa- cilities as to their mechanical effi- ciency and working order prior to each delivery. (c) The equipment and facilities should include the following: (1) An anesthesia machine with adequate oxygen supply. A warm blanket and a ster- ile pack for the infant. (2) A crib or incubator, which provides easy access to the infant, to be preheated to 85° F. for term and 90° F. for premature infants. (3) Suction devices for mother and for infant. (4) (5) Oxygen supply for mother and for infant. Each should have a flow measure and pressure control. The infant mask should be equipped with a reservoir bag and a spring loaded escape valve. Resuscitation equipment should include tracheal cath- eter, positive pressure oxygen mask, soft rubber catheter airway, aspiration tubes, and infant laryngoscope. (6) (7) The necessary material ac- cording to local require- ments for care of the in- fant’s eyes and umbilical cord and the approved means of infant identification. (8) Delivery packs, emergency instruments, sterile solutions, and medications as may be required. 20 2. Nursing Care (a) Patient should be moved in her bed to the delivery room upon or- der from the physician in charge, in adequate time to permit careful positioning of the legs and prepa- ration for delivery without con- fusion. (b) The table should not be broken until the obstetrician or assistant is scrubbing. (¢) The patient’s blood pressure and pulse should be taken and record- ed every 5 minutes. Fetal heart tones should be taken and recorded at least every 5 min- utes. Any change in character, re- gularity, or rapidity should be re- ported to the obstetrician, who should be in the delivery room by this time. The sterile preparation of the per- ineum must be done with care to avoid entry of contaminated solu- tions into the vagina. An experienced person must watch the perineum from the time the legs are elevated until the delivery is accomplished. No attempt to delay the delivery by physical means or deep anes- thesia should be made for the con- venience of the obstetrician. Operating room technic must be maintained in the delivery room. Caps, gowns, and masks must be be worn by all personnel. E. THIRD STAGE OF LABOR At least one experienced nurse must be in the room at all times to assist the physician. F. THE FOURTH STAGE OF LABOR (IMMEDIATE POSTPARTUM NURSING CARE) 1. The patient must be observed closely by an experienced nurse or physician for uter- ine relaxation, hemorrhage, elevation or drop in blood pressure or pulse, and other symptoms of complication. (d) (e) (f) (g) (h) 2. The patient should not be removed from the delivery suite or the recovery room for at least one hour after delivery or until the physician orders her removal. Complications such as toxemia, prolonged labor, traumatic delivery, deep anesthesia or hemorrhage indi- cate a longer stay and specific physician’s writ- ten order, following examination, before re- moval. G. CARE OF THE NEWBORN INFANT IN THE DELIVERY ROOM 1. The infant must be protected from gross contamination. Complete separation of equipment for mother and infant is recom- mended. 2. The infant must be protected from chilling and all other forms of trauma. 3. The establishment of respiration, care of the eyes, care of the umbilicus, and physical examination is the responsibility of the obste- trician or his assistant and is to be conducted with the aid of the delivery room nurse. H. IDENTIFICATION OF THE NEWBORN* Since this is a combined responsibility that is to be assumed by the physician and the nurs- ing personnel it is included under the nursing care. Principles (1) The hospital should make sure that every newborn infant is properly identified at the time of birth. This should be done in the delivery room before either the mother or the infant is transferred from the birth room. Both mother and infant should be removed from the delivery room before another mother is brought in for delivery. No infants born of different mothers should be permitted to be in one de- livery room at the same time. The following procedures are important for legal reasons so that the hospital can prove that a certain infant is the infant of a particular mother. (2) Two identical items of identification should be placed on the infant in the delivery room. These items should be clearly visible and should be viewed by doctors, nurses, and the mother each time the infant is moved. (3) Identification items should show the mother’s full name and admission number, sex of infant, date and time of birth, and other de- finite correlation with the identity of the moth- er. When fingerprints of mother and a foot- print of the infant are taken, they should be entered on the same page in the record while both are in the delivery room. Error in the designation of sex should be avoided by use of the term “boy” or “girl.” Specific rules for the identification of the newborn are necessary. The following regula- tions are suggested to be amended to fit local legal requirements and local hospital condi- tions. * For further details see “Hospital Care of Newborn Infants,” American Academy of Pediatrics, 1954, p. 73. 21 Procedure for Identification (1) Identification Items (2) la. 1b. Duplicate items of identification are fastened on the wrist(s) or ankle(s). Appropriate items are: tapes which may be tied or sewed; waterproof and oilproof bands; or any similar identification de- vice upon which the required in- formation is recorded. Delivery Room 2a. 2b. 2c. 2d. 2e. 2f. Items of indentification are pre- pared individually for each in- fant and are the responsibility of the nurse in charge of the de- livery room. All items of identifi- cation are secured to the new- born infant immediately after de- livery. Identification technic of mother and baby must be carried out by a designated, responsible, and trained person. Before the infant is taken to the nursery, all identification items are checked by the supervising nurse and the physician to see that the name of the mother, her admission number, the date and time of delivery, and the sex of the infant(“boy” or “girl”) are recorded. Simultaneously the same identification is placed up- on the infant’s birth record. The identification items on the infant should be acknowledged by the mother or the person re- moving the infant from the hos- pital. One of these identifications should be retained as part of the infant’s hospital record. All mothers in the obstetric de- partment should be informed of the identification system used and of the mother’s responsibil- ity to check the identification on the infant each time the infant is brought to her bedside and when she goes home. When infant’s footprints, finger- prints, or palmprints are ob- tained using proper technics un- der expert supervision, they are of value in positive identification. Without these precautions, prints are not helpful. I. CARE OF THE PREMATURE INFANT When an immature or premature birth is anticipated the physician or the labor floor nurse should notify the premature nursery as early as possible in order that preparation for the immature infant can be made. A portable incubator or a heated crib with available oxy- gen must be provided for transporting the in- fant from the delivery room to the proper nurs- ery. J. INFANT'S TRANSPORTATION TO NURSERY Each infant should be protected from ex- posure and infection while in the delivery room and during transit to the nursery. Oxygen and a heated crib or an incubator should be available for transportation whenever necessary. The at- tendant who transports the infant should wear a cap and gown except when a closed incubator is used. An elevator, when in use for this pur- pose should be free of other passengers. The records of the infant should accompany it to the nursery. K. TRANSPORTATION OF THE MOTHER No new mother should be transferred from the delivery and/or recovery room until the obstetrician or his physician delegate has ex- amined her and written the transfer order. The mother should be transported as comfortably as possible. If a stretcher is used body strap, side rails, or two attendants are necessary. When the mother is allowed to carry her infant either side rails or two attendants are required. POSTPARTUM CARE A. Vital Signs Extremely close observation of blood pres- sure, pulse, uterine contraction, and bleeding is imperative during the first 24 hours after delivery. B. Care of the Breasts 1. The nipples and breasts of the mother must be cleaned with soap and water, Phisohex, or other solutions acceptable to the physician, before the initial breast feeding. Subsequent care as ordered by the physician, with major emphasis on cleanliness. 2. A breast binder or brassiere which gives support from the sides of the lower portion of the breast, should be applied to all patients be- fore engorgement begins. This should be changed when soiled or at least every 24 hours, unless an adhesive suport has been applied. In this case adequate provision for cleanliness must be made. 22 3. The breasts of nursing mothers must be examined daily for evidence of trauma to the nipple or other complications. Abnormalities should be reported to the physician immedi- ately. 4. Careful supervision of breast feeding and sympathetic instruction of patients in prop- er technic are essential. C. Care of the Urinary Bladder The patient should be encouraged to void immediately following the postnatal rest of 6 to 8 hours. Every effort should be made to avoid catheterization by sitting the patient straight up in bed or assisting her out of bed to sit on the bed pan or to walk to the bathroom with assistance. She should be observed for urinary retention or distention with overflow. Cathe- terization, if necessary, should be carried out under strict aseptic precautions on physician’s order. A lubricated, soft catheter should be used, and one specimen should be sent to the laboratory for chemical and microscopic anal- ysis. D. Care of the Perineum 1. Utmost care must be taken to avoid contamination of the perineum with pathogens from the nasopharynx, hands, unsterile equip- ment, and organisms from other patients. 2. The perineum must be kept as clean and dry as possible by cleansing in a manner acceptable to the physician. This should be done with sterile equipment and with care to prevent entry of solutions into the vagina, or transfer of organisms from the anal region to the vagina by consistent use of the downward stroke. Vulvar pads should be changed fre- quently, particularly following each urination or bowel movement and whenever soiled. They may be completely omitted after the patient becomes ambulatory. 3. Patients who are ambulatory must be instructed in proper technic. Supplies should be provided and procedures should be adopted for maximum simplicity, protection, and con- venience. Individually wrapped packages con- taining all necessary supplies for each cleansing are recommended for this purpose. 4. Perineal pads should be applied se- curely enough to prevent slipping. This avoids contamination from the anal region. E. Bathing 1. Sponge bath (a) The breasts should be washed be- fore any other part of the body. (b) The perineal area should be cleansed as a separate procedure. 2. Shower—second day of ambulation and daily thereafter (a) Convenient, safe facilities are ne- cessary; sanitary conditions must be maintained. A stall shower with a nonslip mat is recommend- ed. (b) A clean wash cloth should be used to wash the perineal area, and clean sterile towel or cotton balls used to dry the area. F. Early Ambulation Early ambulation and increasing patient self-care do not justify less nursing time per patient, nor do they release the nurse from re- sponsibility for complications arising from breaks in technic. The nursing time previously devoted to direct physical care must now be utilized to teach and supervise the patient in proper technic. No patient should be allowed to give self care until she has been instructed and she demonstrates her ability to carry out the procedure safely. 2. Provision must be made for adequate observation of the patient’s condition as to: breasts, lochia, perineum, fundus height, and bladder and bowel function. G. Mothers’ Instructions in Infant Care During the puerperium each mother should be taught the fundamental principles of infant care through individual or group demonstra- tions or by supervised bedside participation of each mother in the care of her baby. H. Rooming-In Recently rooming-in has become popular in some areas and there is much to recommend it. It is suggested that the rooming-in be inter- mittent, as to day or night, until the mother has regained her strength and the will to do. Only graduate professional nurses who are experienced in both mother and infant care, or supervised student nurses thoroughly famil- iar with the instructions that are given and who enjoy patient teaching, should be assigned to the responsibility for the care of patients in the rooming-in suites. 1. During the first 24 to 48 hours the mother is to be helped with and instructed in the care of her haby by the nurses on nursery and floor duty. 2. The nurses on nursery duty are to make rounds each morning with the ward carriage, weigh the baby, dress the cord, take the tem- perature, collect the records of feedings and excretory function, and advise the mother about the baby’s care. Subsequently at regular intervals the super- visor of the nursery will make rounds and check on the condition and progress of babies in the rooms. This service is to be implemented by the nurses on general duty on the floor, who will be available upon call. 3. When a private nurse is in attendance upon the mother she may also care for the baby in the room, except that the morning rounds and dressing of the baby’s navel is to be attended to by the nurses from the central nursery. 4. The policy of early ambulation adapts itself very well to the plan of rooming-in of baby and is to be encouraged as far as the at- tending physician sees fit. 5. Upon occasion the baby may be re- moved from the room to the central nursery, particularly if it is very restless and not relieved by glucose water or by nursing. However, the policy of retaining the baby in the room once it is put there is to be encouraged. Standardization of patient instructions is es- sential. These instructions should be prepared in writing and amended verbally to suit indi- vidual problems. NURSING CARE OF PRE-ECLAMPTIC AND ECLAMPTIC PATIENTS GENERAL PRINCIPLES A. Only professional nurses experienced in this type of nursing should assume responsibil ity for the nursing care of these patients. The patient must be under constant observation ex- cept by specific order of the physician. B. The patient must be protected from ex- ternal stimuli (light, sound, touch). The physi- cian should be consulted before any of the rou- tine nursing procedures are conducted. C. The following items should be ready for immediate use: padded tongue blade, nasal oxy- gen and suction. D. The eclamptic patient should occupy a crib-bed in a dark, quiet, single room. SECTION Vi INTRAPARTAL CARE — THE OBSTETRICIAN GENERAL PRINCIPLES The welfare of both the patient and the in- fant is the ultimate responsibility of the attend- ing physician from both the professional and the legal point of view. The Chief of the Ser- vice is immediately responsible for service pa- tients while the individual obstetrician is re- sponsible to the private patient, her family, and to the Chief of the Obstetric-Gynecologic Ser- vice. The amount of delegated responsibility in both service and private areas depends upon local conditions as to the training and capa- bility of the attending, the house, and the nurs- ing staff. Under ideal circumstances the house officer may well be charged with complete care of service patients, unless complications devel- op, for which an attending physician is called immediately. This ideal is modified by varying degrees depending upon the capability of the house officer and the attitude of the Chief of Service at the time. Similarly the delegation of duty to the nursing staff may vary according to aptitude, training, and willingness in specific instances. However, in view of the fact that the ultimate responsibility lies upon the shoulders of the attending obstetrician and the Chief of Service, certain prerogatives and duties must be retained and met by the physician in charge of the patient. LABOR — FIRST AND SECOND STAGE 1. The obstetrician or his professional repre- sentative should write all orders for preparation of the patient including enemas, local prepara- tion, analgesics, amnesics, sedatives, fluids, and oxytocics. There is no adequate safe, routine analgesic agent universally applicable to labor. Since patients differ greatly in their response to labor and medication, the need for sedation and analgesia must be evaluated and individual- ized. Routine orders for medication are con- demned. No analgesic or amnesic drug should be ordered unless the progress of labor has just been evaluated by the responsible physician. 2. All drugs used for pain relief in labor apparently cross to the placenta and most of them cause some depression of the baby. The extent of the depression depends mainly on the dose of the drug, the route and time of administration before delivery. Barbiturates allay apprehension but do not relieve pain except in overdosage. Their use should be limited to mothers with undue ap- prehension early in labor. There is no effective antidote to barbiturate depression in the in- fant except artificial respiration. 24 The analgesic drugs should be used to relieve pain. The pain threshold is variable and each patient should be evaluated individually. Mor- phine and Demerol are examples of analgesic drugs useful in the first stage of labor. The dose depends on the pain threshold, the size and state of health of the mother, and the maturity and condition of the fetus as well as the ad- vancement of labor. For safety it is advisable to use small initial doses and to repeat them when necessary. Regional anesthetic drugs (procaine, Xylo- caine, etc.) cross to the placenta as innocuous break-down products, since they are hydrolyzed rapidly in the mother’s blood. The main danger in their use is the production of hypotension or convulsions, both of which result from giv- ing too much drug too fast. Scopolamine and atropine are not analgesics. but are sometimes used to inhibit secretions and counteract the emetic effects of the anal- gesics. Small doses have no effect on the infant. Scopolamine is a cerebral depressant and am- nesic agent; atropine is a cerebral stimulant * 3. Oxytocin: Pitocin and Syntocinon are val- uable drugs under certain definite fixed pre- cautions.Otherwise they are dangerous by any mode of administration. They should be given only upon written order of the physician, in specified dosage and dilution. (a) When oxytocin is administered by hypo- dermic injection, the patient should be observed for at least 30 minutes there- after by her physician. (b) When oxytocin is administered by in- travenous drip, the patient should be under constant observation. This means that a physician must be in the room with the patient at all times. If it be- comes necessary to leave the patient alone, this drip should be stopped be- fore the observer leaves the room, to be resumed upon his or her return. The following should be checked re- gularly by the routine technic: fetal heart sounds, frequency and character of contractions, blood pressure, rate of intravenous Pitocin flow, stability of the intravenous insertion, and other vital signs. * The Manual on Resuscitation, prepared by the Com- mittee on Fetus and Newhorn of the American Acad- emy of Pediatrics with the assistance of official repre- sentatives from the American Hospital Association, The American College of Obstetricians and Gynecolo- gists, The American Academy of General Practice, The American Society of Anesthesiologists, and The Amer- ican Public Health Association. 4. The obstetrician or his alternate should do all vaginal examinations. The privilege of rectal examination must be accorded at the local level. With proper aptitude and training, certain of the nursing personnel may well be assigned this duty. 5. A qualified physician should be prepared to conduct delivery at the proper time. If this is impossible a qualified physician alternate should do so. Under no circumstances should attempts be made to delay the imminent birth of a child, by either physical restraint or deep anesthesia. DELIVERY — DELIVERY ROOM TECHNIC A. THE OBSTETRICIAN 1. Among the responsibilities of the ob- stetrician is that of making certain that com- patible blood is available prior to each delivery. 2. While the patient is on the delivery table being prepared for delivery, the fetal heart sounds should be checked and recorded every 5 minutes. 3. The obstetrician should decide in pre- paratory conference with the anesthetist, when one is available, the type of anesthesia and the agent to be used. The most important safety factor is the skill of the person administering the anesthesia. As little anesthetic agent should be used as will produce the desired effect for as short a time as possible. Some mothers will need none at all. There is no apparent difference in ma- ternal or infant mortality or morbidity, with any given anesthetic agent or method, if a skilled anesthetist is on the job. Since this may not be the case, the safest method is the one most familiar to the person giving the anesthe- sia. Aside from hypnoanesthesia, anesthetic methods fall into two groups, those which pro- duce anesthesia locally or regionally, and those which relieve pain by general depression of the nervous system. In the first group are local in- filtration and block of the pudendal nerves. These 2 methods are by far the safest for both mother and baby. Other regional technics in- clude spinal, and its variant saddle block, cau- dal anesthesia, and lumbar epidural block. Hypotension and convulsions must be avoided when using regional technics. Hypoten- sion is treated by putting the mother’s head down, raising her legs, administering oxygen, and giving her a vasopressor drug intravenously. Ephedrine 25 mg. is suggested. Convulsions are not a sign of sensitivity but of overdosage of a regional drug. Convulsions are treated by a 25 small dose of a soluble barbiturate intraven- ously. Oxygen should be given promptly. Ec- lampsia and other convulsive disorders must be differentiated from drug overdosage. The general anesthetic technics include inhalation and intravenous anesthesia. Inhala- tion anesthesia can be administered by the pa- tient herself, using a hand inhaler containing 15 ce. of Trilene. It is imperative not to help the mother hold the inhaler in place, for too deep anesthesia may be produced. An open- drop mask is a simple device which can be used for any of the liquid anesthetic agents. If trained personnel are at hand, a modern anes- thetic machine may be used to deliver gases as well as liquid agents. All the gases and va- pors reach the baby in about 2 minutes. The depression produced in the baby is directly proportional to the depth and duration of the mother’s anesthesia. The most likely and dangerous (to the mother) complication of general anesthesia is respiratory obstruction, especially from aspira- tion of vomitus. The stomach, especially when full, is displaced by the baby in the uterus. The emptying time of the stomach is greatly pro- longed during labor. If the mother has recently eaten, regional rather than general anesthesia should be given. The only indication for deep anesthesia is a uterus in spasm. Deep ether or chloroform anesthesia are the quickest and only ways to relax a tight uterus. Artificial ventilation for the baby must be provided in this situation. * The choice between local, regional, and conduction anesthesia depends upon many fac- tors such as the condition of the patient and/or the infant, the length of time since food intake by the patient, and the availability of profi- ciently administered conduction anesthesia. In the absence of favorable conditions for the lat- ter, regional or local are preferred. 4. Delivery should occur as a result of forces provided by nature rather than by the obstetrician. Where assistance in the natural process seems desirable it should consist of guiding as well as applying gentle traction to the presenting part. Spontaneous birth should not be impeded by any means or for any reason. 5. Care of the Infant, General Principles: In addition to the care of the mother, the ob- stetrician with his assistants is responsible for the infants care as to: 1. Establishment of respiration 2. Care of the eyes 3. Care of the umbilical cord 4. Physical examination of the infant 5. Adequate identification technic * See footnote on preceding page. B. THE NURSING SERVICE The Nursing Service should be responsible for the following: A trained nurse to assist in care of the newborn; a scrub nurse for delivery. Preparation and conditioning of the follow- ing facilities: Warm blanket and sterile pack Heated crib or incubator Suction device Oxygen supply Resuscitation equipment Supplies for the care of the eyes, the umbilical cord and the means for identi- fication. C. PROCEDURES 1. A qualified nurse shall be present in the delivery room to assist the obstetrician in the immediate care of the newborn. 2. The obstetrician should be trained in the resuscitation of infants. If an operative de- livery such as cesarean section or difficult for- ceps, or if a premature or a potentially hypoxic infant is anticipated, a second similarly trained physician should be present during the delivery of the child. 3. Infant Resuscitation: Resuscitation of the infant is the responsibility of the obstetri- cian with the help of qualified assistance. The normal baby usually breathes within a few seconds after delivery. Most normal ba- bies establish respiration within 1 minute. A delay of 2 or 3 minutes means the baby is in difficulty. Further delay (unless oxygen is supplied by artificial respiration) subjects the baby to the great danger of severe asphyxia. This may result in death or in serious brain damage. The condition of the infant and its need for help may be judged by five easily observed signs: (a) Heart rate. A heart rate below 100 beats per minute is a danger signal. (b) Respiratory effort. Spontaneous respi- rations should be well established within 1 minute. Apnea, inadequate respiration and re- spiratory obstruction are indications for im- mediate assistance. (¢) Muscle tone. Poor muscle tone is a danger signal. A flaccid baby is usually in shock. (d) Reflex irritability. Absence of reflex irritability indicates a depressed nervous sys- tem. A catheter placed just inside the nares should produce a cough or sneeze. 26 (e) Color. All babies are cyanotic at birth. With prompt onset of respiration and with a good circulation, the color changes to pink within 1-3 minutes. Persistent cyanosis is an indication for prompt diagnosis and treatment. Extreme waxy pallor and shock suggest hemor- rhage which may require transfusion. The basic aim of all resuscitation is to improve the oxygen and carbon dioxide ex- change. A nicety of judgment is required to choose the proper treatment for each infant. It is just as wrong to carry out unnecessary or harmful procedures as to do too little too late. Swinging, jackknifing, compressing the chest, spanking, dilating the anal sphincter, tubbing, or any manipulative procedures do no good, may do harm, and delay proper therapy. For all infants: A. Keep head down throughout delivery. Gravity helps remove vaginal mucus, blood and amniotic fluid from the pharynx. B. During or promptly after birth the mouth, throat and nose should be gent- ly aspirated. Too vigorous suction may damage the mucous membranes, partic- ularly in premature infants. C. Maintain normal body temperature. For an infant in good condition, nothing further need be done. For an infant not in good condition: A. Ventilation with oxygen is indicated after the airway has been cleared. This may be the only therapy needed. If the infant is flaccid, the tongue may lie against the posterior pharyngeal wall and obstruct the airway. A small-size tracheal catheter or pharyngeal airway properly placed will correct this type of obstruction. B. If respiration is still inadequate, in- flation of the lungs can be aided by use of a tracheal catheter or a snug- fitting mask, and oxygen under con- trolled pressure. Pressures between 15-20 cm. H20 are usually safe for re- peated inflations although initial infla- tion may require 40-50 cm. Although several machines are available which deliver safe pressures, at the present time no mechanical device delivering 02 under pressure is sufficiently flexible to meet all situations. The use of alter- nating positive and negative pressures is of no proved value and may do harm. C. Ausculation of the chest will determine whether gas is really entering the lungs. If no breath sounds are heard and the heart rate does not increase, direct la- ryngoscopy (premature blade, pencil handle) is indicated. Obstructing for- eign material (vernix, blood) should be removed by suction. D. A snugfitting endotracheal tube is placed in the trachea by direct laryn- goscopy. One or two short sharp puffs are given through the tube, by appro- priate mechanical device or, if neces- sary, by mouth. If this does not result in spontaneous respiration, subsequent inflations are administered at lower pressures. E. Antibiotic administration is indicated after extensive resuscitative measures. F. Respiratory stimulants are of no value (metrazol, alpha-lobeline, coramine, etc.). Opiate antagonists are indicated only in case of specific opiate (not bar- biturate or other) depression. How- ever, if the infant’s depression is likely to be related to excessive use of opiates in the mother, Lorfan introduced into the umbilical vein will usually improve ventilation in the infant. G. Transfusion is indicated when the baby shows extreme pallor and shock second- ary to fetal blood loss. * 4. Care of the infants eyes is to be con- ducted by the obstetrician or by his designee, in accordance with the state or local law. A. Penicillin ointment, if legalized. The eyelids should be separated gently (no gauze or other abrasive material should be used) and approximately 1 drop of the ointment should be placed inside the lower lid. The question of induced sensitivity to penicillin should be con- sidered. B. Silver nitrate solution, if legalized. 1. Only a 1% silver nitrate solution should be used. 2. Wax ampules are recommended. The ampule must not be used after the deterioration date. C. If open solutions are used, they must be kept in dark bottles, protected from light, and fresh solutions made every 24 hours. D. Only one drop is to be instilled in the eve. 27 E. Following the instillation, the eye may be rinsed immediately with copious amounts of sterile water or normal ton- ic saline. F. Great care should be exercised to avoid abrasion of the eyelid with gauze or other materials. 5. Care of the Umbilical Cord A. The cord should be tied or clamped and a dry sterile dressing may be applied by the obstetrician or his assistant. B. No sterile dressing is necessary after 24 hours. 6. Examination of Infant: The obstetri- cian should examine the infant for congenital anomalies, birth injury, respiratory distress, signs of intracranial hemorrhage, or bleeding from the cord before it leaves the delivery room. 7. Identification: The obstetrician should see that adequate identification has been ap- plied to the infant prior to its removal from the delivery room. Note: The principles and procedures that are suggested for identification of infants ap- pear under Infants Care in the section on Nurs- ing Care of the Obstetric Patient. 8. Care of Immature or Premature In- fants: When an immature or premature birth is anticipated, the physician or his deputy should notify both the premature nursery as early as possible in order that preparation for the immature infant can he made, and also the physician who will care for the infant. A physi- cian trained in the care of newborn infants should be present in the delivery room during the delivery of the premature infant. A portable incubator or heated crib with available oxygen should be provided for transporting the im- mature infant from the delivery room to the proper nursery. LABOR — THIRD STAGE This stage should be conducted by the ob- stetrician, who should not leave the patient until all active bleeding has ceased, the uterus is firmly contracted, and the general condition of the patient is satisfactory. FOURTH STAGE OF LABOR A. The fourth stage of labor is best conduct- ed in the delivery room or an adjacent recovery room equipped with suction and oxygen, plus the emergency appliances usually present in modern postoperative recovery rooms. * The Manual on Resuscitation. See footnote p. 24. B. During the first postpartum hour a com- petent nurse should be in constant attendance upon the patient. C. During this time the patient’s blood pres- sure, her pulse, the condition of the uterus and the amount of bleeding should be observed and recorded at intervals of 5 to 15 minutes. D. The patient should remain in the recov- ery room 1 hour or more until she has recov- ered from the anesthesia, pulse and blood pres- sure have stabilized, and there is no unusual genital bleeding. E. The obstetrician or his physician assistant should evaluate the mother as to her general condition and the condition of the genital tract, and write the order for her transfer before she leaves the delivery or recovery room. F. After evaluating the patient, the obstetri- cian or his alternate should write the postpar- tum orders before the patient leaves the de- livery room or the recovery room. These orders should be individualized according to the type of labor and delivery and the condition of the patient. CESAREAN SECTION A. Preparation 1. An important element of preparation is the inflexible rule that compatible blood be readily available to the op- erating room prior to each cesarean section. 2. The medication prior to cesarean sec- tion differs from that of ordinary pre- operative medication in that every effort should be made to eliminate infant narcosis. The anesthesia is se- lected for each patient by the obste- trician (in consultation with the anes- thetist). In general the use of local or regional is safe. If inhalation anesthe- sia is to be used, the type with which the anesthetist is most familiar is safest for the infant. B. The Operation Cesarean section should not be started until intravenous fluids have been insti- tuted and proved to be functioning satis- 28 factorily. The type of cesarean section should vary in accordance with the prob- lem. The obstetrician must be familiar with, and competent to perform the var- ious types of cesarean section. He should select the one appropriate for the given problem. It is the duty of the operator to plan ahead so that oxytocies will be administered at the proper time and in the proper dosage and manner. It is re- commended that the oxytocics be given immediately following delivery of the head and that the torso be expelled by uterine contraction. Following delivery of the infant the uterine suture should be accompanied by constant attention to the fundus in order to maintain proper contractility and to prevent the accumu- lation of blood in the uterine cavity. MATERNITY PATIENTS WITH POSSIBLE BLOOD INCOMPATABILITIES A. A list of all Rh-negative patients and all with possible ABO incompatibility who are ex- pected to deliver within the month should be posted on the floor and in each nursery. B. When the patient is admitted for deliv- ery, the blood type and antibody status are to be recorded on the mother’s record and on the sheet that will accompany the baby to the nurs- ery. When an Rh-negative patient is approach- ing delivery, the obstetrician should notify the pediatrician on call for the nursery and recount the relevant facts in this problem. The pedia- trician should be present at the time of the delivery of all mothers with antibodies. C. For each Rh-negative mother, specimens of cord blood are taken in the delivery room: one tube each of clotted and oxalated blood. Blood is allowed to flow from the cut end of the cord after the clamp is removed for this purpose, without milking of the cord or con- tamination with amniotic fluid. These tubes must be sent to the laboratory for proper tests immediately: Blood count, Coombs test, and serum bilirubin. The infant should be examined carefully by the obstetrician and by the pedia- trician before it is sent to the nursery, and the specimens that have been collected should be followed through the laboratory immediately. SECTION VII POSTPARTAL CARE POSTPARTUM CARE — IMMEDIATE Definition: From the time that the patient is returned to her bed to the time of her discharge from the hospital. A. THE INFANT The Obstetrician now has, in addition to the mother, one or more new patients. The care of the infant should have been planned pre- viously with two areas in mind: Its professional care during the stay of the infant in the nursery and its care following discharge from the hos- pital. Three possibilities for care are noted: by the obstetrician, the pediatrician, or the general practitioner of the mother’s choice. The ideal management: one or more pediatricians in charge of the nursery to supervise the care of all newborns. While the ultimate disposal must depend upon local customs, the following alter- natives present themselves. 1. Infant care by the obstetrician while in the nursery, then referral upon dis- charge to the pediatrician or the gen- eral practitioner. 2. Immediate referral for nursery care to the pediatrician or the general practi- tioner. 3. Continued care by the obstetrician dur- ing the stay in the nursery and subse- quent to discharge from the hospital. This alternative has many objectionable features and is being discarded. With any choice the responsibility for the care of the baby should rest solely upon one individual. The obstetrician should remain con- stantly conversant with the baby’s condition until it is discharged from the hospital even though he is not technically responsible for the infant. The pediatrician should see that the obstetrician is informed of any new develop- ment immediately in order that he may main- tain the proper rapport with the mother. The pediatrician should personally examine the baby on the day of discharge from the hospital and discuss its condition and subsequent care with the mother at that time, before she as- sumes complete charge of her newborn infant. B. THE MOTHER 1. Following delivery the mother requires rest. This may be assured by the aid of a seda- tive, barring visitors, and darkening the room. 29 The telephone should be disconnected and the baby should be placed in another room or in a nursery for at least 8 hours following birth. Women who have experienced any abnormality during pregnancy or delivery should be ob- served more closely than others because of the possibility of puerperal complications. 2. Care of the perineum. The perineum should be kept as clean and dry as possible. Vulvar pads may be omitted after 24 hours. For painful episiotomy wounds, Sitz baths in warm water, local anesthetic agents, and heat lamps are most helpful. 3. Care of the urinary bladder. The blad- der must not become overly distended. If cathe- terization was necessary, when the patient be- comes able to void spontaneously, she should be catheterized daily immediately after voiding until residuum is less than 30 cc. Such a patient should receive prophylactic antibiotics or chemotherapy and should imbibe an abundance of water. 4. Care of the bowels. Proper diet, mild laxatives or glycerine suppositories will elimi- nate the need for enemas in most instances. 5. Diet. Subject to the advice of nutrition- ist when available. The diet should consist chiefly of liquids on the first day. On the second day a regular full diet may be given which should be rich in protein for the purpose of increasing the supply of milk. 6. Laboratory tests. A hemoglobin deter- mination and either a clean voided urine or a catheter urine examination should be con- ducted and recorded on the chart within 48 hours following delivery. C. BREAST FEEDING AND BREAST CARE 1. Principles of Breast Feeding Generally breast feeding is physically and psychologically better than artificial feeding for both baby and mother. Preparation for breast feeding should begin during the prenatal pe- riod. Once an abundant and secure supply of breast milk is established, nursing gives both mother and baby emotional satisfaction. The obstetrician has a real responsibility to encourage the mother to feel adequate. Nine out of ten women can produce an abundance of milk if the baby is allowed to suckle enough and provided the mother can relax enough so that her let-down reflex is not inhibited. The obstetrician should give mothers who desire to breast feed as much information and encouragement as possible. Do not try to force breast feeding upon mothers who are disgusted with the idea, for this makes them unhappy and does little good. 2. Breast Feeding Technics A relaxed friendly attitude on the part of nurses and physicians toward breast feeding is more important than precise attention to de- tails of technic. The following general princi- ples are in order: : (a) Continued production of milk is large- ly dependent upon the amount of suckling the baby does. (b) The letting down of milk is a reflex process which is independent of milk secretion and gradually becomes established during early lactation. Since it is easily inhibited by emotional stimuli such as pain, fear, and em- barrassment, sympathetic encouragement and thoughtfulness will do much to aid the smooth establishment of an adequate let-down. (c) Breast feeding should start as soon as possible after delivery since suckling stimu- lates the secretion of milk. A new mother may need help in putting the baby to the breast. She should be instructed not to push the baby’s face, since the baby instinctively turns toward the point of pressure. The nursing position should be one in which the mother can be re- laxed. A mother propped up in bed with the baby on a pillow on her lap is often in a com- fortably efficient position in the early postpar- tum period. (d) Both breasts should be used at each nursing and the baby should be allowed to nurse as long as it wishes, unless the supply of milk is inadequate. At least 8 feedings a day for several days are often necessary for estab- lishing an adequate milk supply. If this cannot be arranged in the hospital, the mother should be told to give the baby the breast whenever it seems hungry as long as it wants it after they reach home. (e) Breasts and nipples should be washed daily. There is no need for other aseptic tech- nics. Lanolin can be applied to the nipples after feeding if desired. A breast binder or preferably a roomy brassiere should be worn and changed frequently, at least once a day and oftener if desirable. Talk to the mother of the baby about her breast feeding and leave her with the feel- ing that she is doing a good job and that the many difficulties are temporary. 30 (f) Pain inhibits the let-down reflex. Co- deine and aspirin may be prescribed one-half hour before feeding time if the mother has se- vere after pain, if her nipples are sore, or if her breasts are painfully engorged. Embarrass- ment and worry may inhibit the let-down re- flex. Allow the mother to relax undisturbed during nursing and give her a chance to talk over her worries freely. Make sure the baby is hungry when brought to nurse so that enough suckling stimulation will be provided. 3. Suggestions for Drying the Breasts In the event of refusal to begin or inability to continue breast feeding, the following meas- ures should be taken: (a) A firm breast binder (b) Analgesics as indicated (¢) Limit fluids (d) Stop all nursing, abruptly It may become necessary to pump breasts once because of severe engorgement. When the electric pump is used, care should be taken to start with very little suction and gradually in- crease the pressure. If let-down does not occur, Pitocin 0.3 cc. hypodermically will cause an artificial let-down a few minutes after injection, when pumping may be resumed. Mothers who are to use a hand pump at home should be carefully taught the technic before they leave the hospital. D. GENERAL SUGGESTIONS 1. Visitors Few visitors should be permitted to see the patient during the first week and all should be barred from the room while the patient is eating or is nursing her baby. The visitors are preferably limited to the patient’s husband and the grandparents of the new infant for no longer than 30 minutes per visit. All individuals with colds or infections should be barred from the patients’ and babies’ rooms. A physician who has visited a patient with a contagious or infectious disease should not visit a puer- peral woman for 24 hours. 2. An abdominal binder or girdle is advis- able for multiparas with relaxed abdominal walls. 3. Daily or twice daily visits should be made by the obstetrician or his alternate, at which time the condition of the baby should be determined and reported to the mother. The uterus should be palpated abdominally each day. Perineal sutures should be inspected when: ever indicated. 4. Patient Activity The normal patient is encouraged to move freely in bed from the first day on. This favors drainage from the uterus, encourages sponta- neous urination, and may reduce the frequency of thrombosis and embolism. On the first or second day the patient is permitted to sit in a chair, to walk around and go to the bathroom attended by a nurse or an assigned attendant. This applies also to those patients who have had cesarean section. 5. All patients with evidence of infection should be examined immediately in an effort to determine the cause. The perineum should be inspected and a vaginal examination should be done with greatest gentleness. Certain labo- ratory studies are indicated: white blood count, catheter urine examination, and cervical cul- ture. The question of isolation will arise. Spe- cific rules for universal application are imprac- tical. The clinical condition of the patient and the nature and site of the infection should serve as guides as to the need for isolation. E. DISCHARGE EXAMINATION AND INSTRUCTIONS 1. Hospitalized patients without complica- tions may return home 5 or 6 days following delivery. Prior to discharge, a personal inter- view and examination should be conducted by the obstetrician. During the interview the baby’s condition should be discussed as well as the patient’s labor and delivery. The patient should be instructed in the care of the breasts, lochia, what to expect with the next menstrual period, abdominal and pubococcygeal muscle exercises, and her activities for the ensuing 6 or 8 weeks. The following detailed instructions, with possible modifications, might well be given to the patient in writing. Mothers’ Instructions 1. Rest and Exercise Remain on one floor of the house during the first day at home. During the next week climbing steps once or twice a day—slowly—is permissable. Lie down for 1 hour every afternoon until the baby is 6 weeks old. Do not become fatigued. Avoid all heavy lifting and heavy house- work for six weeks. Above all, avoid over- fatigue. 31 Lie on stomach for one-half hour at bed- time, before arising in the morning, and during the afternoon rest period. Slight staining will persist for 2 or 3 weeks after leaving the hospital and may continue into the menstrual period. 2. Diet Eat regularly. Include in the diet plenty of vegetables, meat at least once a day, at least 3 glasses of milk a day if nursing, in addition to at least 4 glasses of water. 3. Bowels The bowels should be regulated by the ingestion of sufficient green vegetables, fruit, and fruit juices. It may be necessary to use a mild laxative such as milk of magnesia occasionally. 4. Corset It is advisable to wear some sort of ab- dominal support until the baby is 1 month old. Any good snug-fitting girdle or muslin binder is satisfactory provided it reaches from the widest part of the hips to the navel and provided it does not slide up when you are active. It is not necessary to wear this at night. [Some obstetricians advise abdominal exercises rather than corsets. ] 5. Hygiene Tub baths or showers as you wish. No douches or intercourse until after the check-up examination. Call Your Hospital or Doctor Immediately if you have continuous excessive bleeding, a pain- ful lump in the breast, or fever. [Note: “Before she leaves the hospital the mother should be instructed in regard to care of her infant. She should know how to maintain her supply of breast milk or to prepare the milk mixture.”*] POSTPARTAL CARE — INTERMEDIATE A. The intermediate postpartal period ex- tends from the time of discharge from the hos- pital through the first routine postnatal visit. A varying number of questions may arise dur- ing this period that should be answered by the obstetrician rather than the referring general practitioner or the office nurse. When indicated, the patient should be seen at home, in the office, or in the hospital. The question of fee for this service depends upon local custom, but the general tendency is not to charge an additional fee until after the first routine postnatal visit. B. The routine return interview and exam- ination usually takes place when the baby is 6 or 8 weeks old. The patient should be ques- * “Hospital Care of Newborn Infants,” p. 41. tioned as to the condition of the baby, her gen- eral health, bladder and bowel function, bloody discharge, leukorrhea, backache, perineal ten- derness, breasts, and specific complaints. The blood pressure, a simple blood count, and spe- cial studies in case of recent obstetric compli- cations should be obtained. Upon examination the physician should assess the condition of the breasts and nipples, of the abdominal wall, the perineum, and the vesicourethral and rectal support. The size and position of the uterus and the presence or absence of adnexal masses should be determined. The cervix should be both palpated and inspected. The patient should be advised of her condition and if ther- apy is indicated, a planned program should be set up. POSTPARTAL CARE — LATE A. This period extends from the first return examination until the next pregnancy, or until the patient’s pelvic structures and general con- dition are restored as nearly as possible to their original state. Medical complications should in- dicate the referral to the proper physician for continued care. B. A certain percentage of uteri will be ret- roverted. Unless this condition is known to have 32 existed prior to the first pregnancy, it should be classified as “acquired.” Under this circum- stance the uterus should be replaced and sup- ported by a fulcrum pessary for an adequate period. C. The cervix should not only be palpated but also inspected. Lacerations and eversions may produce leukorrheal discharge or may lead to more serious difficulty. Their presence indi- cates cytology smears. If the cytology smears are negative, treatment should be instituted promptly. If smears are positive or suspicious, further investigation is mandatory. D. The patient should be questioned care- fully concerning her bladder function and test- ed for pubococcygeal tone. She should be re- instructed concerning the exercise of the pubococcygeal muscles in the interest of future bladder continence. E. Semiannual interviews and pelvic exam- inations should be conducted and the patient should be urged to return for these examina- tions even in the absence of symptoms. By such a universal custom much invalidism would be prevented and many deaths from cancer of the breast and uterus would be avoided. ~ SECTION Vil CONSULTATION AND REFERRAL CONSULTATION The free use of consultation is encouraged as a necessary means to the maintenance of the high standards of both hospital and professional accomplishment. Consultation in no way sug- gests incompetence; rather, it indicates a high degree of maturity and judgment. It offers threefold protection: to the patient, to the phy- sician, and to the hospital. The patient is thus accorded the advantages of additional thought and experience in the management of her prob- lem. The physician shares the responsibility for his professional decision and also increases his own knowledge. The hospital maintains its high standards by the free use of additional profes- sional judgment, thus preventing avoidable er- rors. In general it is the duty of the attending physician to decide whether or not a consulta- tion is in order, but under certain specified con- ditions consultation is and should be manda- tory. REQUIREMENTS OF AN ADEQUATE CONSULTATION 1. A written request should be submitted to the consultant containing an outline of the patient’s history, the physical findings, and the results of the laboratory tests and other exam- inations. 2. The consultant should examine the pa- tient as well as the patient’s record, except when the consultant is convinced of his ability to give a legally and ethically valid opinion with- out examination of the patient. 3. Following the examination a verbal dis- cussion should take place between the consult- ant and the attending physician, during which the consultant’s recommendations are discussed in detail. 4. The consultant’s findings should be di- vulged to the patient only through her attend- ing physician or with his consent. 5. The consultant is to prepare a written statement containing his findings and recom- mendations. This statement is to become a part of the patient’s permanent hospital record and should be recorded on the chart of the patient prior to the institution of treatment suggested by the consultant, except in the event of acute emergency, when it should be recorded within 24 hours. 33 TYPE OF CONSULTATION AND PROFESSIONAL FEES 1. Voluntary. If the consultation is request- ed by the patient, her family, or the pa- tient’s physician, the consultant may charge for his services. The question of fee for consultation should be waived when the economic status of the patient renders such consideration desirable. 2. Required. If the consultation is manda- tory because of hospital or departmental regulations, the services of the consultant are to be given free of charge. While the list of indications for required consulta- tions should be formulated at the local level, the committee recommends the in- clusion of the following: A. All first cesarean sections. B. All procedures for the therapeutic ter- mination of preterm intrauterine pregnancy. * C. All procedures for the purpose of sexual sterilization. DEFINITION OF A CONSULTANT “A Consultant is the second physician called by the attending physician to examine and dis- cuss his patient. The consultant must be quali- fied by training and/or experience to give a competent opinion in the special phase of the patient’s illness about which he has been called to examine the patient.” ! A consultant should be a member of the Department of Obstetrics and Gynecology whose qualifications have been approved by the Chairman of the Department, or he should be a member of another depart- ment whose qualifications as a consultant have been approved by the Chairman of that particu- lar department. For all consultations that are required by hospital or departmental regula- tions, the consultant should not be associated economically with the physician who requests the consultation. In general the objectives of consultation will best be fulfilled if the at- tending physician has the humility to select a consultant from whom he may learn something and not one to sanction either his opinion or proposed management. The Chairman of the Department of Obstet- rics and Gynecology is officially responsible for the professional conduct of all physicians who practice in this specialty in a given hospital. It * For “B” and “C” see suggestions on Page 36. ! Bulletin No. 8 of the Joint Commission on Accredita: tion of Hosp., March, 1955. is also his responsibility to see that indicated consultations are requested. The consultant is responsible for seeing that his opinion and re- commendations are recorded on the patient’s chart, but the subsequent action of the attend- ing physician is the responsibility of this physi- cian and the Chairman of the Department. CONSULTATION RECOMMENDATIONS, SPECIALISTS IN THE FIELD OF OBSTETRICS AND GYNECOLOGY A. “Specialist” is one who limits his prac- tice to obstetrics-gynecology (see pre- vious definitions Section IV). For him, consultation should be required in the following: 1. First Cesarean section 2. Therapeutic termination of pre-term intrauterine pregnancy. 3. Operation for the purpose of sexual sterilization. * Consultations should be encouraged in the following: 1. Pregnancy with major medical com- plications. 2. Late toxemia of pregnancy. 3. Proposed induction of labor, whether medical or surgical. Hemorrhage. Fetal malpositions. Prolonged labor. Cervical incision. Version and extraction. Craniotomy and embryotomy. All problems that involve poor risk patients, doubt as to diagnosis, or doubt as to the choice or time of therapeutic procedure. FegRapns 1 NONSPECIALISTS IN THE FIELD OF OBSTETRICS AND GYNECOLOGY A nonspecialist is one who does not limit his practice to obstetrics and gynecology. Specific regulations concerning nonspecialists who practice obstetrics and gynecology must be established and executed at the local level. However, an attending physician who, in his request for assistance, indicates that he seeks only an opinion from the specialist, in so doing signifies that, with this opinion, he is qualified in training and experience to continue manage- ment of the problem at the proper level of pro- fessional care. Abuse of this principle should come to the attention of the Chairman of the Department of Obstetrics and Gynecology for appropriate action. For nonspecialists in obstetrics and gyne- cology, consultation should be required in the following: 1. All cesarean sections. 2. Therapeutic termination of pre-term in- trauterine pregnancy. 3. Operation for the purpose of sexual steri- lization. Consultations should be required for the fol- lowing: 1. All problems of the late toxemia of preg- nancy. 2. The induction of labor, whether medical or surgical. 3. Patients who do not make normal prog- ress after 12 hours of active labor, or after 8 hours following rupture of the membranes during labor. 4. Prolapse of the cord. 5. All hemorrhage—either ante-, intra-, or postpartal. 6. Any operative procedure other than the perineal phase of outlet forceps—with or without episiotomy. 7. Malpresentation of over 24 weeks gesta- tion. 8. Third-degree perineal laceration. 9. All pregnant or puerperal patients with major medical complications. 10. All cases of sepsis, either puerperal or abortal. 11. All situations with doubt as to diagnosis. 12. All situations with doubt as to the prop- er therapeutic procedure. 13. All poor risk patients for whom surgery is proposed. 14. All proposed major gynecologic surgical procedures. 15. All cases in which hazard of injury to vital structures accompanies the pro- posed surgery. 16. All instances of major postoperative com- plications. 17. All hysterectomies in women less than 40 years of age in whom no organic disease is demonstrable. 18. All patients for whom radium implanta- tion is proposed. * Note: For exceptions see suggestions paragraph b, Page 32. GENERAL REGULATIONS CONCERNING THERAPEUTIC ABORTION Definition: Therapeutic abortion is the re- moval with legal justification of the human fetus from its mother prior to viability. Legal Justification: The laws of 44 of the United States and the District of Columbia re- quire that to be lawfully justifiable the bring- ing about of an abortion must be a necessity to preserve the life of the mother. Maryland re- quires that “no other method will secure the safety of the mother.” Legal justification is not defined in the statutes of Massachusetts, New Jersey, and Pennsylvania. Alabama, the District of Columbia, and Ore- gon allow abortion to be performed when nec- essary to preserve the “health” as well as the life of the mother. Colorado permits abortion “to prevent serious or permanent bodily injury” as well as to save the woman’s life. New Mexico permits abortion “to prevent serious and per- manent bodily injury”, as well as to preserve the life of the woman. Brothers comments as follows:* “The neces- sity mentioned in the various statutes, and which as a matter of common law will justify the operation, is intended to cover only those cases where the death of the mother might reasonably be expected to result from natural causes, growing out of or aggravated by the pregnancy, unless the child is destroyed. Of course it need not appear that the death of the mother is inevitable and at hand in the absence of the operation.” . . . . “The threatened death must be the natural and apparent result of existing conditions.” There are no legal provisions for abortion because of rape, illegitimacy, or poverty, for eugenic or neuropsychiatric reasons or for re- moving a malformed fetus or one which may possibly become abnormal. Contrawise, there is no legal prevention except in civil courts. Consultation with another physician is de- manded by the statutes of Florida, Georgia, Illi- nois, Louisiana, Maryland, Nebraska, New Hampshire, New Mexico, Ohio, Oregon, and Wisconsin. Thus these states require that two physicians agree concerning the necessity of an abortion to preserve the mother’s life, and in the case of Oregon, health also, and in the case of New Mexico to prevent serious and permanent bodily injury as well. The following are further comments by Broth- ers. “Where a physician after proper examina- tion, and in good faith, concludes that an opera- tion is necessary to save the life of the mother 35 or child and his diagnosis and prognosis are con- curred in by other physicians, after independent investigation, he is justified in acting, even though the statute makes no provision for deter- mining when the necessity exists, or even does not except such cases. The mere belief of the operator that abortion is necessary, however con- clusively established, is not sufficient; the neces- sity must exist as a matter fact, and such condi- tions must be shown as reasonably to justify such belief.” In agreement with the statutes and Brothers’ interpretation of them, the Joint Commission on Accreditation of Hospitals has set the standard for consultations concerning therapeutic abor- tion in the following statements: “Except in emergency, consultation with another qualified physician shall be required in all first Cesarean sections and in all curettages or other procedures by which a known or suspected pregnancy may be interrupted. A satisfactory consultation in- cludes examination of the patient and the record and a written opinion signed by the consultant which is made part of the record. When operu- tive procedures are involved, the consultation notes, except in an emergency, should be record- ed prior to operation.” From the foregoing it is clear that the per- formance of therapeutic abortion must, with the few statutory exceptions cited, be lifesaving and hence based on strict medical indications which will be acceptable in courts of law. The incidence of this operation rarely exceeds 0.5 percent in well conducted practices and hospi- tals. Though desirable, a complete listing of strict indications is practically impossible. This is because each patient for whom abortion may be considered is an individual and special problem. Frequently the indications in any given case are subject to argument. Further- more, medical and surgical care before and dur- ing pregnancy has progressed so that many pre- viously strict indications are no longer valid. RECOMMENDATIONS CONCERNING THERAPEUTIC ABORTION AND SEXUAL STERILIZATION While the rules governing therapeutic ter- mination of pregnancy and sexual sterilization must be legalized and executed at the local level, the committee submits the following plan for consideration and alterations to fit local conditions. ABORTION AND STERILIZATION COMMITTEE 1. Professional Composition. The Abortion and Sterilization Committee should consist of * “Medical Jurisprudence”, Brothers, E. D., C. B. Mosby Co., St. Louis, 1930. three qualified obstetrician-gynecologists with the following exceptions. When the pricipal in- dication for abortion or sterilization falls with- in a specialty other than obstetrics-gynecology a member of the active medical staff from the appropriate specialty shall act on the invitation of the Departmental Chairman as a part of the committee for the consideration of that particu- lar case. When the service does not have three qualified obstetrician-gynecologists the consist- ency of the committee must be modified by the use of other qualified specialists in medicine, surgery, etc., one of whom specializes in the involved field. The membership of the Com- mittee shall remain anonymous except to the Chairman of the Department of Obstetrics- Gynecology and the President of the Medical Board of the Hospital, unless personal inter- view and/or examination of the patient in ques- tion is necessary for final opinion. 2. Function (a) Application by all members of the medical staff for permission to per- form therapeutic abortion or sexual sterilization shall be mandatory ex- cept those incident to indicated sur- gical procedures that require re- moval of the organ or organs of pro- pagation. (b) The Committee shall consider only such requests as come within the rules of the Departmental Staff and shall submit its decision to the phy- sician concerned through the De- partmental Chairman. (¢) Application for such permission shall be made in writing and shall include a summary of the medical history, findings on physical exam- ination, clinical laboratory findings, and the statement of the condition believed to require abortion or ster- ilization along with the recommen- dation of the required consultants. (d) A copy of the letter of application and all other pertinent information, as well as a letter of approval of the Abortion and Sterilization Commit- tee shall be made a part of the pa- tient’s permanent hospital record. (e) A physician regularly employed or regularly associated in practice with a physician requesting permission may not serve on the Committee un- der conditions for which decision has been made mandatory by these rules. 36 (f) The Departmental Chairman is to keep the records of the Committee in a confidential file which may be reviewed only by himself, by the Chairman of the Medical Board or by such persons who have obtained permission from the Departmental Chairman. (g) Statistical reports which maintain the anonymity of the patient, physi- cian, and members of the Commit- tee may be prepared with the ap- proval of the Departmental Chair- man. 3. Procedure (a) A member of the Departmental Staff who wishes to obtain approval for a therapeutic abortion and/or sexual sterilization in one of his patients must present a letter summarizing the medical history, physical find- ings, and laboratory results, and also containing a statement of the condi- tion believed to indicate the thera- peutic abortion and/or sterilization along with the recommendation of the consultants. He must also submit a letter from the patient and her husband or a legally responsible per- son, requesting the operation. This letter should be in the handwriting of the patient or her husband or legally responsible person. It is ad- visable that it not be dictated by the physician. After reviewing the submitted ma- terial to ascertain that all necessary and pertinent information is present, the Chairman of the Department of Obstetrics and Gynecology shall ap- point a Committee consisting of 3 Staff members. When the indication for the operation is not within the field of Obstetrics and Gynecology, a member of the staff of the special- ty concerned will be asked to review the data as one of the 3 members of the Committee and if desired, he will interview and examine the pa- tient. Each member of the Commit- tee shall examine the request in- dependently and each shall write his opinion on a separate sheet of paper and sign it. The Chairman shall in- form the patient’s physician in writ- ing of the decision of the Committee. Any member of the staff with reli- gious convictions concerning the procedure is not required to serve on the review committee. (b) For the purpose of simplification, it is recognized that a few obstetric- gynecologic operations (i.e., third cesarean section or extensive vaginal plastic repairs) should be recog- nized as standard indications for tubal ligation if and when requested and signed by the patient and her husband. Proposals for such ligation will be cleared through the Thera- peutic Abortion and Sterilization Committee in an expeditious man- ner by the use of a standard form attached hereto as Exhibit “A”. 4. Prerogatives. The Committee shall not act as a consultant party, and no member who has acted as a consultant in the case presented to the Committee shall serve on the Committee. The Committee has no authority to take puni- tive action; its only responsibility is to the ap- pointing authority, to independently review the case and render an opinion in writing, giving approval or disapproval of the proposed thera- peutic abortion or sexual sterilization. It is recommended that the Committee should function without fee inasmuch as its duty is that of a court of final appeal, serving as a pro- 37 tection to the patient, the hospital, and the physician in charge of the patient, rather than as a consultant body. Furthermore, the decision of the Committee should be on a plane at which the possibility of financial consideration could never be raised. PATIENT REFERRAL Referral of a patient is a step to transfer full responsibility for the diagnosis and manage- ment of a given illness to a specialist of greater knowledge, experience, and skill in this par- ticular area. Any physician or specialist is morally obligated to use referral if he cannot, with the aid of consultation, conduct the pa- tient’s treatment upon a standard at the level of modern medical care. Such referral will be ac- complished upon agreement of the attending physician and consultant and upon written or- der of the former. Any specialist who accepts referral must be qualified to take charge of and assume full responsibility for all treatment, in- cluding operative and postoperative manage- ment. The recording of postoperative notes and the writing of proper reports are also his duty. There should be no division of responsibility. When the current episode is terminated the patient is to be returned to the referring physi- cian, with an accompanying written report of the specialist’s care during the current episode. Exhibit “A” DEPARTMENT OF OBSTETRICS AND GYNECOLOGY THE THERAPEUTIC ABORTION AND STERILIZATION COMMITTEE To be signed by the patient and her husband and witnessed: We hereby give permission to Dr. to perform the operation of tubal ligation for the purpose of preventing future pregnancy. SIGNED: Wife Husband Witness: S— Date: nn ———————————————————————_——_-———-——————————— a —————— = = = To be filled in and signed by the physician in charge of the patient: The indication for tubal ligation upon Mrs. is as follows: SIGNED: M.D. Date: 38 SECTION IX STANDARDS OF OBSTETRIC-GYNECOLOGIC CARE The facts and principles regarding the care of gynecologic patients have been taught in our medical schools, have been reiterated in hospi- tal training programs, and are readily available in textbooks. Nevertheless, it is wise for hospi- tals to have in writing certain basic policies in this regard so that a good standard of care, consistent with acceptable practice in general and in the community, will be defined clearly. It is not possible or desirable to establish fixed rules or regulations to cover every contingency. Rather, it is the aim of the committee to make well-considered suggestions regarding those phases of gynecologic care about which ques- tions or discrepancies most frequently arise. Hospitals or Departments may deviate from these suggestions for sufficient reason and ac- cording to individual circumstances. THE CHIEF OF SERVICE The Chief of Service should be qualified as chief of the obstetric-gynecologic service and should be informed concerning the training, experience, and adherence to the general de- partmental policies of each member of the De- partment. It should be his responsibility to per- mit or restrict the operative privileges of the members of the Department and other physi- cians doing obstetric-gynecologic surgery who are not official members of the obstetric-gyne- cologic service. QUALIFICATIONS FOR OBSTETRIC- GYNECOLOGIC SURGEONS The senior obstetric-gynecologic surgeon con- fines his work to gynecology and/or obstetrics, possesses suitable background of training and experience (at least 10 years). He is certified by the American Board of Obstetrics and Gyne- cology or possesses comparable qualifications and is recognized by professional confreres as a specialist in the field. He should be author- ized to operate without consultation except in the case of therapeutic abortion and primary sterilization, both of which require consultation for all members of the staff. The junior obstetric-gynecologic surgeon con- fines his work to the specialty and has had at least three years of supervised training in obstet- rics-gynecology (there may be exceptions in the training background of juniors). It is suggested that juniors be accepted tentatively for the first year, during which time their abilities should be observed by seniors in rotation. The junior 39 should be assisted or observed at all major op- erations by a senior during this period. Consul- tation should be required for hysterectomies in women under 45 years, for therapeutic abor- tions, and primary sterilizations. Definite Staff appointment should be based upon an affirm- ative vote of the Senior Staff at the end of the year. QUALIFICATIONS FOR NONSPECIALISTS WHO DO GYNECOLOGIC SURGERY General Surgeons: Certification by the Amer- ican Board of Surgery, or in possession of recog- nized surgical ability; recognition by the Senior Gynecologic Staff (and the Surgical Commit- tee) as competent in Gynecologic Surgery. At least 10 years of experience. General Practioner: Recognized by the Sen- ior Gynecologic Staff and the Surgical Commit- tee as competent to perform gynecologic sur- gery. At least 10 years of experience in surgical judgment and procedure. Junior General Surgeons and Junior General Practitioners must have had at least 2 years of hospital training and if applying for staff membership, they should be assisted at the operating table by Senior Gynecologists in ro- tation for 2 probationary years. Consultations should be required as outlined for the Junior Gynecologists plus consultations for vaginal plastic procedures and all operations during which no pathologic tissue is to be removed Consultations should be obtained before thr patient enters the hospital whenever possible and before a definite course of action has been advised, in the interest of avoiding embarrass- ment on all sides. SCOPE OF GYNECOLOGIC SURGERY This should depend upon local custom and/or upon the training of the men involved. Certain surgical conditions commonly found in women which, though not strictly gynecologic, have by tradition and custom been considered within the province of gynecologic surgery in some geographic areas. The regulation of breast, gallbladder, hemor- rhoidal, hernial, and urologic surgery should be implemented at the local level in accordance with the training and experience of the mem- bers of the gynecologic service under the super- vision of the Chief of the Obstetric-Gynecologic Service. The general trend would seem to per- form less breast and urologic surgery (other than repair of vesicovaginal fistulae, and the surgical correction of cystocele and stress in- continence) and fewer hemorrhoidectomies and all other operations dealing with structures outside of the female genital tract. However, in the coure of gynecologic operations it is gener- ally considered permissible to deal with neigh- boring structures as necessary (bowel resection, colostomy, bladder or ureteral repair) accord- ing to the training of the surgeon. If one is per- forming a vaginal plastic procedure, hemorrhoi- dectomy is permissible, but not as an isolated indication. The use of radium and radioactive agents should be carefully controlled, and the Chief of Service or someone responsible to him should be a member of the Hospital Radium Committee. Consultation is advisable for all patients in whom radium is to be employed. Close cooperation between the gynecologic ser- vice and the radiologic service is highly desir- able in the management of all radiotherapeutic problems. GYNECOLOGIC CARE All patients for whom gynecologic surgery is contemplated must be carefully studied in the interest of achieving an accurate diagnosis, of documenting an acceptable indication for the surgery, of eliminating contraindictions to operation, and generally of providing patients with the best possible opportunity for speedy complete recovery. A. DIAGNOSTIC PRINCIPLES 1. Abnormal genital bleeding before or any after the menopause should be investigated by vaginal smears, endometrial aspiration smear, careful examination under anesthesia, diagnos- tic curettage with exploration of the endome- trial cavity with polyp forceps and adequate cervical biopsy. 2. In the event of bleeding of uncertain tract source (bowel, genital, or urinary), com- plete study of all tracts is indicated. 3. Persistently suspicious or positive cy- tologic reports should be pursued to diagnosis except in the presence of obviously localized malignancy. 4. Further investigation of suspicious cy- tology by biopsy during pregnancy may not be deferred, especially when the clinical exam- ination suggests malignawcy. 5. Cervical biopsy: (a) Indication: History of abnormal bleeding not explained by preg- 40 nancy; pelvic findings of cervical erosion, polypoid or papillary le- sions of the cervix or upper vagi- na; any areas suspicious of malig- nancy by the Schiller test; any area that stains on slight cotton trau- ma; any persistently suspicious or positive cytology smears. Technic: Outpatient clinic or office: multi- ple punch biopsies by the four quadrant technic and of areas that appear suspicious usually suffice. Bleeding from the biopsy site should be controlled by tampon- ade and not by electrothermic methods. The cervix should not be treated electrothermically until the pathologist’s report is at hand. Inpatients: While multiple punch biopsies are sometimes used, the present tendency is to do liberal cold-knife biopsies in such a way that the underlying cervical stro- ma is obtained along with the suspicious area. The biopsy tissue should be stretched out and at- tached to cardboard before it is placed in the fixing solution. Fol- lowing this procedure immediate electrothermic therapy is indica- ted. (b) 6. Adequate study of infertility should in- clude in endocrine problems: (1) complete his- tory and physical examination; (2) examina- tion of the husband and his seminal secretion; (3) postcoital examination of the wife; (4) tubal patency test; (5) such female endocrine observations as basal temperature records, en- dometrial biopsy, basal metabolism, and pro- tein-bound iodine; sellaturcica x-ray; and eye examination; and (6) psychiatric evaluation in some instances. B. PREOPERATIVE CARE 1. The recorded history and complete physical examination and the results of blood and urine examination must be on patient’s chart prior to all elective surgery. 2. Recorded medical consultation and sig- nificant abnormalities of the heart, kidneys, respiratory system, or other diseases of the constitutional type should be recorded. 3. Appropriate tests: (a) To rule out diabetes. (b) To rule out pregnancy whenever the history or examination is sug- gestive and curettage or hysterec- tomy is contemplated in women under 45 years of age. (¢) In the case of most extrauterine masses an X-ray examination of the lower bowel and intravenous pyelogram. (d) Blood dyscrasia studies should be obtained preoperatively in the event of abnormal vaginal bleed- ing without obvious cause. Positive serology reactions pro- hibit operative procedures until the patient has been rendered non- infectious by treatment or until patient is declared noninfectious, by a qualified consultant. (e) 4. Correct anemia before operation. Pre- ferably no elective major procedure should be performed with a hemoglobin of less than 11 Gm. It is better to reach this level and wait 48 to 72 hours before proceeding with surgery. 5. Provide for transfusion should it be- come necessary, in the case of all major gyne- cologic operations, including vaginal plastic operations. The latter are best performed short- ly after a menstrual period to avoid excessive bleeding. 6. Infections should be treated before op- eration. No elective operation should be per- formed with temperature elevation until the reason is ascertained. 7. Special preoperative studies. Prepara- tion of elderly or debilitated patients or those for extensive surgery should include: (a) Determination of blood urea ni- trogen and fasting blood sugar. (b) Complete medical studies such as electrocardiogram, kidney func- tion test, chest x-ray, and intra- venous urogram. Such consultations as indicated, with particular reference to cardiac status, choice of anesthesia, and control of diabetes. (e) (d) Daily preoperative administration of vitamins, protein derivatives, and iron, parenterally or orally, in therapeutic dosage. 8. Anesthesia. The type of anesthetic agent, etc., should be discussed with the anes- thetist and the selection recorded by him after 41 he has reviewed the patient’s complete record and interviewed the patient. The anesthetist is an active consultant, not an ancillary techni- cian. C. INDICATIONS FOR OPERATIONS 1. Hysterectomy In the absence of gross findings that war- rant hysterectomy, microscopic examination of the curettings (which are to serve as the basis for the hysterectomy) must be made before per- forming the hysterectomy. No hysterectomy is to follow the curettage immediately if the de- cision for hysterectomy is based on findings at curettage. If the surgeon so decides, he must state his rationale in writing and the pathology report on the tissue should justify the procedure. When frozen section is used, the pathologists opinion should be recorded on the patient’s chart. Indications: (a) Excessive bleeding, whether asso- ciated with demonstrable fibro- myomata or not, which cannot be controlled by medication, curet- tage, or other alternative. The pre- vious therapy should be recorded on the hospital record. Fibromyomata which are growing rapidly, or which enlarge the uterus beyond the size of a 3- months pregnancy, or which cause pressure symptoms, or intractable bleeding. Myomectomy should be considered in young women, par- ticularly if pregnancy cannot be achieved or carried to term with- out it. Cancer of the endometrium—pre- liminary irradiation to be decided locally. (c) (d) In prolapsus of the uterus (as for a vaginal hysterectomy), where removal of the uterus would seem to make possible a better repair. This reason should be recorded on hospital record. (e) Usually whenever both ovaries must be removed. (f) Total hysterectomy should be per- formed unless some contraindica- tion makes is unwise, such as endometriosis, pelvic inflamma- tory disease, etc. A conserved cer- vix should be biopsied and coned, either as first step in major opera- tion or at a later date. 2. Uterine Suspension (a) Rarely indicated, except as a step in other pelvic surgery, in case of endometriosis, etc. (b) Occasionally, if it has been dem- onstrated that symptoms are re- lieved by holding the uterus for- ward with a pessary for at least 6 months and if the retroversion and symptoms recur following its removal. 3. Presacral Neurectomy: Should be undertaken for dysmenorrhea only after thorough trial of recognized conser- vative measures and procedures. These pre- viously tried methods should be recorded on the hospital chart. This is rarely indicated. 4. Ovarian Cystectomy 5. (a) Cysts which exceed 8 cm. in diam- eter. (b) Cysts which grow appreciably un- der observation. (¢) Rarely the cyst which is associated with pain (except that associated with the twist of a pedicle or in- tracystic hemorrhage). (d) In young women, enucleation if possible when the cyst is benign. Usually there is a considerable portion of ovary which can be saved. (e) All ovarian cysts should be opened for inspection in the operating room following removal, prior to peritoneal closure. Suspicion of malignancy indicates immediate frozen section. This is not always infallible, but usually it enables accurate diagnosis. The opposite ovary should be bisected for pos- sible biopsy purposes. Intrauterine Radium (a) Used less frequently today, except for cancer. (b) For benign bleeding its use, under certain sociologic or medical con- ditions, is preferable to that of more extensive surgical proce- dures. Radium for benign bleed- ing should be confined to women who bleed excessively and uncon- trollably despite diagnostic, thera- peutic curettage, and medical and endocrinologic measures. Prelim- inary consultation is advisable. 6. Diagnostic Precautions 7. 8. (a) Metrorrhagia indicates dilatation and curettage, when hysterectomy is contemplated. (b) A diagnostic curettage should in- clude the following policies: (1) For dysfunctional bleeding the curettage should be done while the patient is bleeding. (2) In the absence of bleeding, vaginal and endometrial as- piration smears should be made for cytologic study. (3) A fractional curettage should be conducted (first the endo- cervical then the endometrial wall). (4) Endometrial exploration by means of polyp forceps should be done routinely. (c) Every extirpated uterus should be opened immediately for inspec- tion before the peritoneum is closed, even if a preliminary cu- rettage has been done, unless both the ovaries and the cervix have also been removed. Radium and Radioactive Substances in Gynecology See Section X, Precautions in Radiation Therapy Sterilization Procedures (per se) Only after approval by the proper com- mittee (see Section VIII). Therapeutic Abortion Only after approval by the proper com- mittee (see Section VIII). POSTOPERATIVE CARE FOLLOWING MINOR SURGERY OR SURGERY ON OUTPATIENTS When to be done under general anesthesia the patient should be admitted to the hospital or operating suite, properly examined, and pre- pared for anesthesia. Hospitalization should conunue until complete postanesthetic stabili- zation occurs and until all danger of bleeding has passed. A regular (abbreviated) hospital record should be completed for each operating room or hospital admission. When local anesthesia is used, preparation and hospitalization may not be necessary, but an abbreviated hospital record must be completed. POSTOPERATIVE CARE —MAJOR SURGERY A. Before the patient leaves the operating room the operation should be entered on chart, noting number and location of drains, packs and sutures to be removed. The removal of each should be recorded and signed by the physician who removes it. B. Establishment of a Recovery Room with suction, emergency drugs, and piped oxygen is essential to safety. A specially trained nurse and/or physician should be in constant atten- dance. The patient should not leave the Re- covery Room until she has reacted from anes- thesia and all vital signs are stable. C. The chemical content and the quantity of fluids should be governed by many factors with 43 which the obstetric-gynecologic surgeon should be familiar. The important considerations are that lack of familiarity or complications beyond the limits of familiarity should indicate profi- cient consultative advice. D. Careful attention to electrolyte balance is essential. The immediately preceding advice should be implemented. E. Indwelling catheters are advised after laparotomies until next morning; after vaginal plastic procedures for several days if the pa- tient is unable to void readily. Antibiotic or chemotherapy are advised if in longer than 24 hours. F. Ambulation first day for most patients. G. Intake and output chart for first 24 hours, and during the time that an indwelling catheter is in place or a tube is in the gastrointestinal tract. H. Postoperative notes should be recorded daily for first 3 days, then twice a week and more often when the patient is ill. I. A final discharge note should be made on all patients to be signed by the gynecologist for private patients and by the attending physi- cian in charge of the service for service patients. SECTION X RADIATION HAZARDS SOMATIC AND GENETIC HAZARDS IN DIAGNOSTIC RADIOLOGY* Fall-out radiation following nuclear deton- ations has focused attention upon the risk of somatic and genetic injury following exposure to all types of radiation. Three factors affectin the degree of biologic effect are: (1) Total amount of radiation; (2) time period over which the total dose is applied or accumulated; (3) body part irradiated. This may be the whole body or only a section of the body. Dif- ferent parts of the body also vary in suscepti- bility to injury. TYPE OF INJURY 1. Somatic: (a) Direct damage to specific tissues of an individual. Recovery from such radiation, unless excessive, is to be anticipated. (b) Malformations that may occur in a fetus irradiated in utero during early pregnancy or if excessive in amount, later. 2. Genetic: For an individual, these effects apply only to radiation dose accumulated prior to termination of reproductive activity. One generation is taken as a span of 30 years. Gene- tic effects are of special significance for the population as a whole in succeeding genera- tions. These effects are thought to be cumulative, no matter how small the dosage in each in- stance. SOURCES OF RADIATION EXPOSURE A. Natural Background, derived from cos- mic rays, earth, housing, atmosphere, etc., and totals about 0.1 rem per year. For one genera- tion, a 30-year period, an accumulated dose on the order of 3.0 rems. Values for men and wom. en expected to be about equal, and gonadal dose in each instance is about the same. B. Man-made radiations, derived from medi- cal and dental uses, occupational exposure, fall- out, etc. Values for this exposure are only roughly estimated, and as such, show wide vari- ations. Estimates are usually given in man rems per million population. Annual estimates fall between 170,000 and 330,000 rems. Gonadal doses estimated to be on the probable order of 120,000 to 330,000 rems. Individual variations may be extremely wide, and, in general, some- what higher doses may apply to the female due to greater technical difficulties encountered in shielding the ovary in certain radiographic procedures. At age 30 the gonadal accumulation may be 1,500,000 to 4,700,000 rems per million population. C. Comment: Despite the fact that more than half the estimated total gonadal dose at age 30 is derived from natural background radi- ation (3,100,000 of a probable 4,600,000— 7,800,000 rems per million persons) it is evident that the annual contribution from artifically created sources can be important to the indi- vidual. One person might accumulate a large portion of total man-made dose within a short period of time. Most of the artificially created radiation is derived from medical and dental sources. If, however, we exclude certain unusual circumstances it is probable that gonadal dose for the population at large falls within allow- able limits. Whether it will remain so is the problem. TOLERANCE DOSES Tolerance doses have been established by the National Committee on Radiation Protection as allowable exposures for certain conditions. For exposed workers after age 18, the value is 0.3 roentgens per week, but not more than 5.0 roentgens per year for total body exposure. For hand exposure the value is 1.5 roentgens per week. For large segments of the population the value should be reduced to 1/10 the stated amounts. Data have been accumulated experimentally in animals and by study of the human to sug- gest dose levels of potential risk. The data at hand vary, of course, for time of exposure and for whole or sectional body irradiation. Men- tion might be made of sensitivity of blood-form- ing structures, embryonic tissues particularly during the first trimester of pregnancy, and genetic changes following gonadal irradiation. Studies have also been made in the attempt to assess gonadal exposure in radiographic procedures. Some possible amounts are extreme and cannot be accepted as occurring in good clinical practice. Modern equipment, including the best shielding, cones, filters, and fast film technics will greatly reduce gonadal exposure. Probable ranges in exposure dose for some of the more common present-day diagnostic pro- cedures are as follows: * Largely from the recent report of The American Col- lege of Obstetricians and Gynecologists Committee on Radiation Hazards, A. N. Arneson, M.D., Chairman. ya A-P roentgenography of the pelvis Testes: 300 to 1000 millirems (In some instances as little as 20 mrem possible). Ovary: 200 to 700 millirems (In some instances as little as 80 mrem possible). Lateral roentgenography of the pelvis Ovary: 220 to 1700 mrems. Pelvimetry Ovary: 200 to 3700 mrems. Fetus: 100 mrems upward. Some parts might receive 10,000 mrems. Hysterosalpingography Ovary: 2500 mrems. 1700 to 3600 mrems combination fluoroscopy-roentgenography. Obstetric examination of the abdomen Fetus: 20 to 200 mrems. Ovary: 20 to 1000 mrems. Fluoroscopic examinations can be the more costly in exposure. The testis can be very effec- tively shielded, whereas it may be impossible to shield the ovary. SUMMARY A. Risk of radiation injury is real, and it is pertinent to the specialty of obstetrics and gynecology. B. Individual requirements make futile any fixed limitation upon the clinical use of radi- ation. It is important, however, that we employ the least amount of radiation to accomplish the most good. C. Physicians should observe the following: 1. Discontinuance of any “routine” use of pelvimetry and any “routine” ra- diologic examination of the abdomen. 2. Consider both need and urgency of any radiographic procedure during the earlier stages of pregnancy. 3. Attempt to utilize the time immedi- ately following menstruation for clin- ical uses of radiation in the nongravid patient. 4. Consider the qualifications of the ra- diologist to whom he may refer pa- tients with the same care and caution employed in selecting consultation in other medical specialties. 45 PRECAUTIONS IN RADIATION THERAPY RADIUM AND RADIOACTIVE SUBSTANCES The increased use and diversification of radio- active agents, vehicles, and modalities requires a modern set of safety standerds. Each hospital in which these substances are used should have a Radiation Safety Committee to supervise the routine procedures upon occasion and advise as to matters of exposure. There are two general types of therapeutic radiation: (1) electromagnetic which is ob- tained from x-ray machines (“x-radiation”); and (2) gamma radiation which arises from ra- dioactive substances such as radium, radioactive cobalt, or gold. With the first, risk to either patient or personnel exists only as the therapy is administered through the machine. The ra- diation does not cause the patient to become “radioactive.” With the second the radioactive substance is either fixed to the patient or is in- troduced into either the body tissue or a body cavity. This renders the patient “radioactive” until (a) the substance is removed, (b) it is eliminated from the body by way of the ex- creta, (c) the radioactivity is lost by “decay.” The decay rate varies from a few minutes for some radioactive substance to millions of years for others and generally the slower the decay rate the greater the hazard from exposure. The three most important factors to minimize exposure to radiation are: 1. Time. The less time spent in the immedi- ate vicinity of the radiation source the less ra- diation received. 2. Distance. The avoidance of inhaling, in- gesting, or coming into direct contact with ra- dioactive materials is advised. A relatively small increase of distance from the radiation source decreases the exposure considerably. 3. Shielding. The more the material and the denser the material between the person and the radiation sources, the less radiation the person will receive. In the effort to prevent inadvertent exposure to radiation, the Radiation Safety Committee should establish and enforce rules and precau- tions for the safety of other patients, visitors, and personnel. The following recommendations are made with the knowledge that they will be modified to fit each local situation. In x-radi- ation the gynecologic personnel is relieved of danger since the patient is not radioactive fol- lowing treatment. With the other type, gamma radiation, radium salt, radioactive pellets, etc. the risk may be great in (a) the storage and distribution of the radiation substance, (b) preparation for introduction into the patient, (c¢) the actual procedure of introduction, (d) care of the patient while the substance is in place, (e) the removal of the radioactive sub- stance, (f) the disposition of the radioactive material following its removal. STORAGE, DISTRIBUTION, AND RECORDS* Radium and all other radioactive substances should be stored in lead-lined containers that fulfill the requirements of the Radiation Safety Committee. Preferably this storage is done in a locked safe (removed from all stationary per- sonnel), that may be opened by only a small number of particularly trained individuals. The storage should be arranged in such a way that the sources and substances are readily accessible without undue handling. Should accidental spil- lage occur, the proper radiation safety authori- ties should be notified immediately and a plan of clean-up and decontamination should be put into prompt effect. A radiation source localization board or book should be maintained and kept up to date at all times. The following information should be posted in the book at each application: Name of patient, location of the patient in the hospi- tal, the amount of radioactive material, the time for removal. When the radiation sources are returned to the safe a note should be made and initialed in the book or on the board to that effect. Physicians, nurses, and technicians who han- dle radioactive substances frequently should wear monitor tags and have blood counts made at regular intervals. No one should be assigned to this work until he is thoroughly oriented as to the proper technic by which the sources are to be handled and as to the dangers of break in such technic. PREPARATION OF RADIUM OR RADIOACTIVE SUBSTANCES All preparation of radium or other radioac- tive materials should be carried out on a spe- cial table equipped with an L-shaped 2-inch lead shield to provide body protection for the person who is loading and packing these ma- terials so as to minimize exposure to the hands. The loading of the radium or the radioactive substance should be rotated between 2 or 3 people so that the same individual is not ex- posed repeatedly. Radiation sources should be sterilized and placed in appropriate lead containers awaiting application. They should not be placed on the operating table while the patient is being pre- pared. * Arneson, A. N,, and Holm, W. M.,, Facilities for Ra- dium Storage, Preparation, and Transportation. Plan- ning Guide for Radiologic Instillations; Year Book Publishers, Chicago, 1953. 46 THE INTRODUCTION OF RADIOACTIVE MATERIALS This procedure is a major operation from the point of view of safety to both the patient and professional personnel. It should not be dele- gated to an untrained house officer, unless the procedure is personally supervised by one who knows and appreciates the hazards of careless- ness as to overexposure and as to faulty appli- cation. The radioactive substance is transported from the preparation room, either on a portable lead- shielded table or in a bucket-type lead-lined carrier to the operating room. It is kept at a safe distance in the container until all prepa- ration for its introduction has been completed. It should not be placed on the operating room instrument table until the surgeon is ready to apply it. Prior to the introduction the radio- active substance should be tested with a Geiger counter as a final check upon the degree of radioactivity. The introduction should be con- ducted with long instruments and the sources should never be touched with fingers or allowed to lie in the lap of the operator or the nurse. Following the introduction of the radium or radioactive substance, the operating room per- sonnel should come into contact with the pa- tient as little as possible during the preparation of the patient for transfer to her bed or litter. CARE OF THE PATIENT FOLLOWING INTRODUCTION OF RADIOACTIVE MATERIAL Radioactive substances that are introduced in gynecologic work consist of two general types: (1) those suspended in a fluid medium to be introduced into the body tissues or a body cavity; (2) those encased in metal or glass ap- plicators or in solid radioactive form spoken of as “encapsulated” or “solid.” The charts of patients who receive treatment doses of radio- active material, whether fluid or encapsulated, should accompany the patients to their beds. The chart should contain special radioactive warning markers and special instruction sheets to fit the type of substance that has been intro- duced. An acceptable marker consists of a ma- genta radiation symbol and the word RADIO- ACTIVE, in bold type, on a yellow background. This marker may be attached by scotch tape. A marker should be placed on the first sheet inside the chart, on the nurses sheet, on the doctor’s order sheet, and on the special pre- cautions sheet. This sheet should be titled “Pre- cautions to Personnel in Handling Patients Who Have Received Radioactive Material.” (Sample sheets are attached as exhibits “A” and “B”). In addition to precautions to personnel, certain general precautions in patient care are in order. General Precautions in the Care of Radio- active Patients * 1. Following the introduction of fluid radio- active material: A. Observe the hazard label and read the personnel precaution sheet carefully. B. The radioactive body fluids will be either ascitic, pleural, or leakage from the site of introduction of the radioactive substance. C. Rubber gloves should be worn if con- tact with these fluids is expected. Other patients and visitors should maintain a distance of 3 feet and ad- jacent beds should not accommodate bedridden patients. 2. Following introduction of encapsulated or solid radioactive substances: These consist of 2 types. (A) Those to remain in the patient’s body permanently. (B) Those to be removed at a designated time. A. Permanent implants lose their radio- activity in a few days. The time of loss of activity should be noted on the personnel precaution sheet. In the in- terim the precautions for radioactiv- ity should be observed: (i) Observe the hazard label. (ii) The body fluids and excreta are not dangerously radioactive. (iii) See the precaution sheet for management of escaped seeds or particles. (iv) Other patients in adjacent beds should be at least 3 feet away from the radioactive patient and should not be bedridden. Visitors should maintain the same distance. B. Encapsulated or solid applicators that are to be removed at a designated time. (i) Observe the hazards and read the precaution sheet carefully. (ii) Review the patient’s order sheet on arrival from the ope- rating room. It should contain specific orders for the patient’s position in bed, interval change of position, catheter care, diet, 47 and medication, and instruc- tions as to the removal of the radiation sources as to specific time, whom to call, required instruments for removal, and location of the lead-lined radi- tion source carrier. (iii) Special cases. Needle place- ments: Careful observation of all bed linens and dressings for escaped needles; dressings and bed linens should be kept sep- arately for daily survey with a radiation detection meter. They are not to be discarded or laundered until this survey is conducted. Encapsulated sources, radium capsules: Pa- tient recumbent in bed, one pillow, turned from side to side frequently, indwelling catheter throughout treatment. Maintain recommended dis- tance for other patients, visi- tors, and nursing personnel during the recommended time limit of close contact. (iv) REMOVAL OF ENCAPSULATED OR SOLID RADIOACTIVE AGENTS A. This is best done by a physician with the patient on a gynecologic examining table. B. The exact time of removal should be pre- determined and designated on the order sheet. Preparation should be made and the physician should be called 15 minutes ahead of time. C. The lead-lined radium carrier should be placed at hand prior to the removal of the sources. D. Long instruments should be used for the procedure. E. Immediately following removal of the applicators their number should be checked with the number recorded as having been placed at the time of the application in the operating room. The applicators are then placed in the lead-lined radium carrier. * U.S. Department of Commerce, National Bureau of Standards. Safe Handling of Radioactive Isotopes, Handbook No. 42, 1949. * See footnote, p. 137. t DeAmicis, E., and Cowling, R. F., Personnel exposures associated with the therapeutic use of radium, radon, og cobalt-60. New England J. Med. 251:1-4, July 1. 1954, F. The time of removal, the count of the ap- plicators, and the remover’s signature should be placed on the patient’s chart as a part of the postoperative record immediately. DISPOSITION OF THE APPLICATORS A. The carrier containing the applicators, in cleansing solution, should be Sion in the ra- dium storage area behind the lead protective shield on the special work table. B. The sources are removed from the appli- cators, cleansed, inventoried, and returned to the lead-lined safe. C. The inventory is to be recorded and signed in the appropriate place by the person conducting the inventory. SPECIAL INSTRUCTIONS IN CASE OF DEATH OF PATIENT The death of a radioactive patient should indicate the following steps and precautions: 1. Notify the physician in attendance im- mediately. 2. He will consult the proper authorities for advice as to the proper care of the body. 3. The body must not be handled or moved without specific authorized instruction. 4. Autopsy is forbidden until the pathologist has consulted the proper authorities as to the degree of radioactivity and the necessary pre- cautions, 5. Tissue samples should be handled with double-thickness rubber gloves unless the ra- dioactivity has been determined to be safe by the radiation monitor. 6. The autopsy room, its contents, and the wearing apparel of the pathologist and his as- sistants should be monitored following the pro- cedure. 7. Radioactive cadavers should not be re- leased to the mortician unless accompanied by a statement of the degree of radioactivity at the time of the release. * U.S. Department of Commerce, National Bureau of Standards, Safe Handling of Cadavers Containing Ra- dioactive Isotopes, Handbook No. 56, 1956, Washing- ton, D. C. t Cowling, R. F., and DeAmicis, E.; Suggested Proce- dures for Performance of Autopsies on Radioactive Cadavers. New England J. Med 251:380-382, Sept., 1954. Exhibit “A” PRECAUTIONS FOR HOSPITAL PERSONNEL TO OBSERVE WHEN HANDLING PATIENTS WHO HAVE RECEIVED LARGE DOSES OF FLUID RADIOACTIVE MATERIALS This patient has received a large dose millicuries, or radioactive on at M The method of administration was NOTIFY THE PROPER AUTHORITIES IMMEDIATELY: In case of any doubt as to safe procedure. In case of any emergency, such as leak of fluid. If an unexpected complication arises. In case of death: Before postmortem care is given; Before an autopsy is performed; Before the body is released. EXTERNAL RADIATION HAZARD: Under ordinary conditions the hazard to hospital personnel from radiation in the vicinity of this patient is not great. This patient will be potently radioactive for days. RADIOACTIVITY CONTAMINATION HAZARD: Body fluids from this patient may contain hazardous amounts of radioactivity for days. PRECAUTIONS TO BE OBSERVED: 1. Do not stay in the immediate vicinity (within 3 feet) of this patient longer than is necessary to give proper care and attention—maximum one-half hour at a time. 2. Avoid direct contact with patient’s blood, urine, vomitus, and other body fluids. Wear rubber gloves if such contact is anticipated. Wash bedpans thoroughly after each use. 3. If bed clothing becomes wet from body fluids and hence contaminated with radio- activity, save it for monitoring by the proper authorities. 4. Wash hands after bathing patient or giving patient other personal attention. SIGNED: Surgeon in charge of patient DATE: 49 Exhibit *‘B" PRECAUTIONS FOR HOSPITAL PERSONNEL TO OBSERVE WHEN HANDLING PATIENTS WHO ARE UNDERGOING TREATMENT WITH ENCAPSULATED RADIOACTIVE MATERIALS — millicuries of radioactive _ _ This patient has received (gold grains, radon seeds, radium needles, etc.) on at M. The site of application of implantation is NOTIFY THE PROPER AUTHORITIES IMMEDIATELY: In case of any doubt as to safe procedure. In case of any emergency, such as the escape of a needle, grain or seed. If any unexpected complications arise. In case of death: Before postmortem care is given. Before an autopsy is performed. Before the body is released. EXTERNAL RADIATION HAZARD: Under ordinary conditions the hazard to hospital personnel from radiation in the vicinity of this patient is not great. PRECAUTIONS TO BE OBSERVED: 1. Do not stay in the immediate vicinity (within 3 feet) of this patient longer than is necessary to give proper care and attention—maximum one-half hour at each time. 2. Do not handle or touch directly any of the encapsulated radioactive sources (radi- um needles, radon seeds, gold grains, etc.). Should one be found in the bed, pick up with a long instrument, place in a small container, place the container in a safe distant location and call the designated authority immediately. SIGNED: — Surgeon in charge of patient DATE: 50 SECTION XI DEFINITIONS Abortion: All or any product of conception that weighs less than 500 Gm., alive or dead. Apnea: Cessation of respiration, from any cause. Anoxia: The absence of O2 in the body. Hypoxia: Insufficient 02 for normal body functions. Asphyxia: Anoxia and CO2 retention result- ing from failure of respiration. Deaths: Fetal (stillbirth, deadborn): Any ter- mination of pregnancy that does not re- sult in a live birth. The period of gestation, weight at birth, or any other factor have no part in the definition. However, the World Health Organization has suggested the following categories for analytic pur- poses. (a) Early — under 20 weeks’ gesta- tion; (b) Intermediate—20-27 weeks’ gestation; (c) Late—28 weeks’ gesta- tion and over; (d) Gestation period unknown. Infant: Death of a live born infant at any time during the first full year of life. Neonatal: Death of a live-born infant prior to the 28th day of life. Perinatal: Combined fetal and neonatal mortality. Distress (fetal) Fetal heart rate below 110 or above 180 and/or marked irregularity of fetal heart and/or passage of meconium in a vertex presentation. Hemorrhage (postpartum) A blood loss of 600 cc. or over. Morbidity: Puerperal infection—100.4° F. or 38° C. occurring once during each of two 24-hour periods (excluding the first 24 hours) or remaining elevated longer than 24 hours. All febrile puerperiums fall into this classification unless they can be at- tributed to some cause such as mastitis, pyelitis, or intercurrent infection. Mortality Rate (perinatal) Components: Peri- natal mortality should be measured in terms of both fetal and neonatal loss to account for all pregnancy wastage at or around the time of birth. Consequently, there should be included some portion of the fetal deaths and some portion of the infant deaths. For all purposes there should be included late fetal deaths (i.e., 28 weeks’ gestation and more) regardless of weight at birth, and all early neonatal deaths, regardless of gestation or birth weight. Infant mortality rates and fetal mortality ratios should also be separately calculated. Calculation of rate: The perinatal mortality rate is calculated by dividing the sum of perinatal death by the aggregate of all live births (regardless of pe- riod of gestation or birth weight) plus all late fetal deaths. The re- sulting quotient should then be multiplied by 1000 to provide a rate “per thousand deliveries.” Fetal deaths (28 weeks’ gestation and over) + Infant deaths under 7 days of age X 1000 Fetal deaths (28 weeks’ gestation and over) total live births }- Parity: The number of infants of premature or full-term weight that a patient has had. Gravidity refers to the number of times a patient has been pregnant, whether intra or extrauterine. (A primigravida delivered of twins is para 2, gravida 1). Toxemia: Classification: I, acute toxemia of pregnancy—onset after 24th week; IA, pre- eclampsia (mild and severe) ; IB, eclamp- sia (convulsions and/or coma, when asso- ciated with hypertension proteinuria or edema). II, chronic hypertensive vacular dis- ease with pregnancy; ITA, without su- perimposed toxemia (no exacerbation of hypertension or development of proteinuria) ; ITA (1) hypertension known to have antedated pregnancy; ITA (2) hypertension discovered in pregnancy (before 24th week and with postpartum persistence) ; IIB, with su- perimposed toxemia (data sufficient to differentiate the diagnosis). Twins: The weight of the larger infant should be the deciding factor in classification as to prematurity or full term. (Premature, 500-2499 Gm.; full-term, over 2500 Gm.) RECOMMENDED PUBLICATIONS JOURNALS A CT A Endocrinologica Periodica, 8-A, Boes- lundevej, Copenhagen Bok, Denmark. American Journal of Obstetrics and Gynecol- ogy: C. V. Mosby Co. Obstetrics and Gynecology: Paul B. Hoeber, Inc. Obstetrical and Gynecological Survey: Williams and Wilkins Co. Excerpta Medica, Obstetric and Gynecology Sec- tion X: Excerpta Medica Foundation. Fertility and Sterility: Paul B. Hoeber, Inc. Journal of Clinical Endocrinology and Metabo- lism: Charles C Thomas. Yearbook of Obstetrics and Gynecology: J. P. Greenhill (Ed.), Year Book Publishers. “~urnal of Obstetrics and Gynaecology of the British Empire: 58 Queen Anne St., Lon- don, W. 1, England. urgery, Gynecology, and Obstetrics with Inter- national Abstracts of Surgery: Franklin H. Martin Memorial Foundation, 54 East Erie Street, Chicago 11, Illinois. Cancer: J. P. Lippincott Company. Journal of the American Medical Association. STANDARD TEXTBOOKS ON GYNECOLOGY BREWER: Textbook of Gynecology, 2nd Edition, 1958, 742 PP- Williams & Wilkins . . CURTIS and HUFFMAN: A Textbook of Gynecology, 6th Edition, 1950, 799 pp. Saunders . . : LOWRIE: Gynecology; Yelawe 1, Dis- ease and Minor Surgery, 1953, 952 pp. Thomas. . ® MEIGS and STURGIS: Progress? in Gyre cology, Volume 3, 1957, 780 PP- Grune and Stratton NOVAK and NOVAK: Toutbaok "of Gynecology, 6th Edition, 1958, 856 pp. Williams & Wilkins SCHAUFFLER: Pediatric Canecoloats 4th Edition, 1958, 349 PP- Year Book. . TAYLOR: Essentials of Gynecology, 1958. Lea & Febiger. . . . $15.00 11.00 22.50 15.50 11.00 9.00 12.00 OPERATIVE GYNECOLOGY BALL: Gynecologic Surgery and Urology, 1957, 547 pp. Mosby. . . BURCH and LAVELY: Hysterectomy, 1955, 104 pp. Thomas. . . 20.00 5.00 52 FALK: The Gynecological Management of Urological 1ajries; 1957, 265 pp. Davis. . GRAY :Vaginal Hysterectomy, 1955, 137 pp. Thomas. . GREENHILL: Surgic al Gynecology, 1957, 377 pp. Year Book. . . LOWRIE: Gynecology: Surgical Tech- niques, 1955, 523 pp. Thomas. . McCALL and BOLTEN: Martius Gyne- cological Operations, 7th Edition, 1957, 434 pp. Little, Brown MEIGS: Surgical Treatment of Concer of the Cervix, 1954, 474 PP: Grune and Stratton . . MUSGROVE: Abdominal Total Fystor ectomy: A New Technique, The Posterior Approach, 1957, 32 pp. Thomas. PARSONS and ULFELDER: An Atlas of Pelvic Operstions, 1953, 231 PP: Saunders . RICCI: The Cystocele in America, 1950 435 pp. Blakiston (McGraw-Hill). TE LINDE: Operative Gynecology, 2nd Edition, 1953, 902 pp. Lippincott. . $1750 4.75 9.50 22.50 20.00 12.00 2.25 18.00 6.00 22.50 STANDARD TEXTBOOKS ON OBSTETRICS BECK and ROSENTHAL: Obstetrical Practice, 6th Edition, 1955, 1100 pp. Williams & Wilkins. ww EASTMAN: Williams’ Obsrourics, 11th Edition, 1956, 1210 pp. Appleton. GREENHILL: Obstetrics, 11th Edition, 1955, 1088 pp. Saunders. . REID: Textbook of Obstetrics, to be published in 1958. Saunders. SPEERT and GUTTMACHER: Obstet- ric Practice, 1956, 478 pp. Blakis- ton (McGraw Hil], WILLSON: Titus’ The Management of Obstetric Difficulties, 5th Edition, 1955, 724 pp. Mosh. 6th Edition due 1959. + ie 12.00 14.00 14.00 7.00 12.00 OTHER TEXTBOOKS AND MONOGRAPHS DOUGLAS and STROMME: Operative Obstetrics, 1957, 735 pp. Appleton. BOWES: Obstetrics and Gynecology, 2nd Edition, 1955, 407 pp. Hoeber. . DOBBIE: Obstetrics and Gynecology, 1949, 370 pp. Hoeber. . 20.00 12.00 5.50 EVERETT: Gynecological and Obstetri- cal Urology, 3rd Edition, 1956. Williams and Wilkins. ‘ FLUHMANN: Medical Treatment in 0b. stetrics and Gynecology, 157 PP- 1951. Williams and Wilkins HEARDMAN: Physiotherapy in Obster. rics and Gynecology, 1951, 228 PP: Williams and Wilkins. : HUFFMAN: Gynecology and Obstetrics, due 1958. Saunders. REYNOLDS: Physiological Bases of Gynecology and Obsiotriis, 1952, 168 pp. Thomas. SCHAEFER: Tuberculosis in Obstetrics and Gynecology, 1956, 307 PP- Lit- tle, Brown. ‘ SCOTT and VAN WYCK: Essentials of Obstetrics and Gynecology, 1946, 390 pp. Lea and Febiger. . WENGRAF': Psychosomatic A pproach to to Gynecology and Obstetrics, 1953, 368 pp. Thomas . . . WILLSON, BEECHMAN, "FORMAN, and CARRINGTON: Obstetrics and Gynecology, 1958, 610 pp. Mosby. . § 6.00 3.00 3.50 5.50 8.75 5.50 6.75 10.75 OTHER TEXTBOOKS AND MONOGRAPHS ON OBSTETRICS ALLEN and DIAMOND: Erythroblasto- sis Fetalis, 1958, 143 PP- Listle, Brown. . . ATLEE: The Gist of Obsterris, 1956, 327 pp. Thomas. ATLEE: Natural Childbirth, 1056, "19 pp. Thomas. . BARNES: The Care of thee Rontant Mother, 1957, 270 pp. Philosophical Library. . . BERMAN: Qbseceriond Roentgenology, 1955, 616 pp. Davis. BOWLBY: Maternal Care and Mental Health, 2nd Edition, 1951, 194 PP: Columbia. BROWN and GALLAGHER: Mann of Practical Obstetrics, 3rd Edition, 1956, 265 pp. Williams & Wilkins. . BROWNE and BROWNE: Antenatal and Postnatal Care, 8th Edition, 1955, 672 pp. Little, Brown. ‘ BURWELL and METCALFE: Heart Disease and Pregnancy, 1958, 338 pp. Little, Brown. . CALKINS: Normal Labor, 1954, 128 Pp Thomas. 4.00 6.00 2.75 7.50 12.50 2.50 7.50 8.00 10.00 4.00 CALKINS: Abnormal Labor, 1958, 70 pp. Thomas. . CROSSE: The Premature Baby, 1957, 242 pp. Little, Brown. DELAFRESNAYE and OPPE: Andi of the Newborn iii 1954, 248 pp. Davis . DENNEN: Forceps Deliveries, 1055, 242 pp. Davis DIECKMANN: The Toxomias of Preg. nancy, 2nd Bitistor, 1952, 689 Pp: Mosby . DILL: Modern Perinatal Care, 320 pp. Appleton DILL: The Obstetrical Forcens, 1953, 176 pp. Thomas. DUNHAM: Premature Infants, ond Edi. tion, 1955, 459 pp. Hoeber. ENGLE: Pregnancy Wostogs, 1953, 272 pp. Thomas. . . 1957, FISH: Hemorrhage of Linte Pregnancy, 1955, 180 pp. Thomas. FLEXNER: Gestation; Transactions of the First (1954) Conference, 1955, 229 pp. Josiah Macy, Jr. : FRANCIS: The Human Pelvis, 1952, 210 pp. Josiah Macy, Jr. GREENHILL: Analgesia and Anesthe- sia in Dbssesries, 1952, 90 PP Thomas. HEATON: Difficult Labor, due 1957, Davis. HERSHENSON: Obstetrical Auiesthesis 1955, 403 pp. Thomas. HINGSON and HELLMAN: Anesthesia for Dbstntrics 1956, 344 PP: Lippin- cott. . JAVERT: Spontaneous and Habitual Abortion, 1957, 490 pp. Blakiston- (McGraw-Hill) s . KING: Occipito Posterior 1957, 106 pp. Thomas. LANMAN: Physiology of Prematurity; Transactions of the First Confer- ence, 1957, 139 pp. Josiah Macy, Jr. LITZENBERG and McLENNAN: Syn- opsis of Obstetrics, 5th Bdirion, 1957, 403 pp. Mosby. i von MACK: The Plasma Proteins in Preg. nancy, 1955, 118 pp. Thomas. MACY: Transactions of the First Con- ference on Qesgiriom;, 1954, 238 pp Macy. . Positions, . $275 6.00 5.50 6.50 14.50 6.50 5.25 8.00 8.50 5.50 5.00 5.00 2.75 9.50 12.50 11.00 3.75 3.25 6.00 3.50 5.00 Mechanism of Congenital Malforma- tions, Proceedings of the 2nd Scien- tific Conference of the Association for the Aid of Crippled Children, 345-46 S. 4th St., New York, 1955, 137 pp. . . . . $3.00 MENDELSON: The Heart in wn Dregnan cy, due 1958. Davis. MONTAGU: The Reproductive Devel- opment of the F emule, 1957, 234 Pp: Julian Press. : NESBITT: Perinatal Loss in Obsteric, 1957, 450 pp. Davis. . ‘ NIXON and HICKSON: Guide to 0b- stetrics in General Practice, 1953, 301 pp. Degrafi. PAGE: The Hypertensive Disorders of Pregnancy, 1953, 135 pp. Thomas. PARMELEE: Management of the New- born, 1952, 358 pp. Year Book. ‘ POTTER and ADAIR: Fetal and Neo- natal Death, 2nd Edition, 1949, 173 pp- University of Chicago. REIS, DECOSTA, and ALLWEISS: Dia- betes and Pregnancy, 1952, 87 PP: Thomas. REYNOLDS: Digsiologt of the Uterus, 2nd Edition, 1949, 609 pp. Hoeber. REYNOLDS, HARRIS, and KAISER, Clinical Measurement of Uterine Forces in Pregnancy and Labor, 1954, 341 pp. Thomas. . RUSS: Resuscitation of the Newborn 1953, 72 pp. Thomas. RYDBERG: The Mechanism of Labor, 1954, 196 pp. Thomas. SEWARD: Inhalation Arnasthesia in Childbirth, 1957, 56 pp. Thomas. THEOBOLD: The Pregnancy Vowomins, 1956, 499 pp. Hoeber. THOMS: Lelcineuy, 1956, 120 PP: Yor ber. . . 5.00 TILLMAN: Toxemias of Pregnancy, due 1957. Davis. WIENER: An Rh-hr Syllabus, 1954, 94 5.00 12.50 5.00 3.75 7.00 5.00 2.50 12.50 9.50 7.50 7.50 1.50 15.00 pp. Grune and Stratton. 3.75 WINDLE: Asphyxia Neanatorum, 1950, Thomas. «o.oo. 2.00 OTHER TEXTBOOKS AND MONOGRAPHS ON GYNECOLOGY ATLEE: Glironic Iliac Pain in Women, 1953, 80 pp. Thomas. . 2.50 BERNSTINE Ba RAKOFF: "Vaginal Infections, Infestations and Dis- charges, 1953, 433 pp. Blakiston (McGraw-Hill). . —. 10.00 BUXTON and SOUTHAM: Infertility, -$ 1958, 240 pp. Hoeber. . . . . CORSCADEN: Gynecologic Cancer, 2nd Edition, 1956, 500 PP: Williams and Wilkins. . . DECKER and DECKER: Practical of. fice Gynecology, 1956, 388 pp. Davis. ENGLE: Studies on Testis and Ovary: Eggs and Sperm, 1952, 256 PP: Thomas. FALK: The Gynecological Manesemens of Urologic dnpurice, 1957, 265 PP- Davis. FLUHMANN: The Management of Men. strual Disorders, 1956, 350 PP- Saun- ders. GREENHILL: Office Gynecology, 6th Edition, 1954, 517 pp. Year Book. HAMBLEN: Facts for Childless Couples, 1950, 136 pp. Thomas. HENSHAW: Adaptive Human F entity, 1955, 332 pp. Blakiston (McGraw Hill). + ve ees HOMBURGER and FISHMAN: "The Le boratory Diagnosis of Cancer of the Cervix, 1956, 70 pp. Karger. HOTCHKISS: Etiology and Diagnosis in the Treatment of Infertility in Men, 1952, 84 pp. Thomas. HUNT: Diseases Affecting the Vulva, 4th Edition, 1954, 236 pp. Mosby. JONES: The Management of Endocrine Disorders of Menstruation and Fer- tility, American Lecture Series, 1954, Thomas. KOTTMEIER: Careinonms of ie F. entle Genitalia, 1953, 213 PP Williams and Wilkins. . . MASTERSON: Cancer in the Fame Genital Tract, due 1958. Davis. MAZER and ISRAEL: Diagnosis and Treatment of Menstrual Disorders and Sterility, 3rd Edition, 1951, 600 pp. Hoeber. 4th Edition in prepara- tion. . MURPHY: Heredity in , Uorine Cancer, 1952, 127 pp. Harvard. . SCHLEYER and SAUNDERS: Buck ache in Women, 1955, 80 PP- Wil- liams and Wilkins. . STONE and LEVINE: The Premarital Consultation, 1956, 96 PP- Grune and Stratton. . TAYLOR: Manual of Gynecology, 1952, 204 pp. Lea and Febiger. 2 7.50 10.00 10.50 1.75 7.50 8.50 9.50 2.75 5.50 3.00 2.50 9.00 4.75 4.25 10.00 2.50 2.25 3.00 4.50 TRUSSELL: Trichomonas Vaginalis and Trichomoniasis, 1947, 292 pp. Thomas. . . . ULLERY: Stress Trcomtincinees In the Female, 1953, 168 pp Grune and Stratton. . PATHOLOGY HERBUT: Gynecological and Obstetri- cal Pathology, 1953, 683 pP- Lea and Febiger. : NOVAK and NOVAK: Gynecologic and Obstetric Pathology, 4th Edition, 1958, 650 pp. Saunders. PAPANICOLAOU: Epithelia of Wo. man’s Reproductive Orgins, 1948, 53 pp. Harvard. PAPANICOLAOU and T RAUT: Diag. nosis of Uterine Cancer by the Vag- inal Smear, 1943, 58 pp. Harvard. VALDER DAPEND: An Atlas of Fetal and Neonatal Histology, 1957, 200 pp. Lippincott. . . . $ 6.00 6.75 12.50 14.00 10.00 5.00 16.00 STANDARD WORKS ON ENDOCRINOLOGY DODDS: Biochemical Contributions to Endocrinology, 76 pp. 1957. Stan- ford University Press. . . JONES and SCOTT: Hermaphroditism, Genital Anomalies, and Related En- docrine Disorders, 1958, 464 PP: Williams and Wilkins. . . . KUPPERMAN: Endocrinology, due 1958. Davis. PASCHKIS, RAKOFF, and CANTA.- ROW: Clinical Endocrinology, 2 2nd Edition, 1958. Hoeber. . BOOKS FOR PATIENTS ATLEE: Natural Chibi, 79 PP: 1956, Thomas. BONSTEIN: Painless Childbirth, 1958, 143 pp. Grune and Stratton. EASTMAN: Expectant Motherhood, 3rd Edition, 1957, 198 pp. Little, Brown. MEAKER: Preparing for Morkerhood, 1956, 196 pp. Year Book. . ROBINSON: Having a Baby, 1954, 92 pp. Williams and Wilkins. THOMS: Training for Childbirth, 1950. McGraw-Hill. ; There are many other commendable publica- tions. The present list is abbreviated because of space limitations. $ 3.00 16.00 18.00 2.75 2.50 1.75 2.95 2.50 3.00 PUBLISHERS’ ADDRESSES Academic Press, Inc. 125 East 23rd St. New York, N. Y. American Medical Association 535 N. Dearborn St. Chicago 10, Ill. Appleton-Century-Crofts, Inc. 35 West 32nd St. New York, N. Y. Blakiston Division McGraw-Hill Book Company 330 West 42nd St. New York, N. Y. Cambridge University Press Bentley House, 200 Euston Rd. London N. W., 1, England Columbia University Press 2960 Broadway New York 27, N. Y. F. A. Davis Co. 1914-16 Cherry St. Philadelphia, Pa. John Degraft 64 West 23rd St. New York 10, N. Y. Elsevier Press D. Van Nostrand Co. Prineton, N. J. Excerpta Medica Foundation 2 E. 103rd St. New York 29, N. Y. Free Press 119 N. Lake St. Chicago 1, IIL Grune and Stratton, Inc. 381 Fourth Ave. New York, N. Y. Harvard University Press Cambridge, Mass. Hoeber, Paul B., Inc. 49 East 33rd St. New York 16, N. Y. Interscience Publishers, Inc. 250 Fifth Ave. New York 10, N. Y. 56 Julian Press 251 Ninth Ave. New York 10, N. Y. Lea and Febiger 600 Washington Square Philadelphia, Pa. J. B. Lippincott Co. East Washington Square Philadelphia, Pa. Little, Brown and Company 34 Beacon St. Boston, Mass. Longmans Green and Company 55 Fifth Ave. New York 3, N. Y. Macmillan Company 60 Fifth Ave. New York, N. Y. Josiah Macy, Jr., Foundation Packanack Lake, N. J. C. V. Mosby Company 3207 Washington Blvd. St. Louis, Mo. W. W. Norton and Company 101 Fifth Ave. New York, N. Y. Oxford University Press, Inc. 114 Fifth Ave. New York, N. Y. W. B. Saunders Company West Washington Square Philadelphia, Pa. Stanford University Press Syracuse, N. Y. Charles C Thomas 301 E. Lawrence Avenue Sprinfield, Ill Williams & Wilkins Co. Mt. Royal & Guilford Avenues Baltimore, Md. Year Book Publishers, Inc. 200 East Illinois St. Chicago, Ill. WA