Prospective Mother — 11 - Chapter 9, part 1 - The Preparations for Confinement

Prospective mothers are anxious to learn how they shall prepare for the approaching confinement.

They desire their preparations to be thorough, reliable, and in accord with the most approved methods of treatment, for they realize that preparations along these lines will not only prevent haste and confusion at the time of birth, but will also promote a satisfactory convalescence.

Apparently trivial details often safeguard confinement against serious accident.

Indeed, measures which aim at the prevention of illness form the chief asset of modern obstetrics, and of these none takes higher rank than the maintenance of strict cleanliness during and after childbirth.

This fact fortunately is widely appreciated at present, and not a few women inquire voluntarily the means of observing the proper precautions.

It is true, of course, that even today many women are delivered in filthy rooms and upon dirty beds, and that in spite of such surroundings some of them make a good recovery.

Yet grave complications develop much more frequently among those who have not paid attention to the preparations for confinement.

The surgical dressings and other supplies do not require attention in the early months of pregnancy.

A number of articles, invaluable when delivery occurs at full term, are useless if the fetus is immature and cannot live, and therefore it is unnecessary to provide them until two or three months before the confinement is expected.

In the event of a miscarriage what is needed can be procured upon very short notice.

But, on the other hand, delivery subsequent to the twenty- eighth week may require all the equipment useful at full term so that everything should be in readiness by that time.

ENGAGING THE NURSE.

--As soon as the existence of pregnancy is clearly recognized the patient should select the doctor and the nurse who will attend her.

Prompt selection of a nurse will assure the widest choice, for proficient nurses are in demand and book engagements far in advance of the date they will be needed.

Furthermore, it is a relief to the patient to have her attendants selected.

The possibility of premature delivery never interferes with engaging the nurse very early in pregnancy, for that accident releases both patient and nurse from their contract.

Nurses demand that the date be specified upon which an engagement shall begin, as, unless their calendar is definitely arranged, they are unable to earn a livelihood.

This leads to a question which is difficult to answer, for the precise day of delivery is uncertain;

consequently to fix the beginning of the engagement may prove a troublesome matter.

On the one hand, there is risk of having to pay the nurse for a time before her services are actually needed; on the other, a false economy may result in the absence of the chosen nurse at the critical moment.

In finding a way out of this dilemma a patient must be guided by her means and the location of her home.

Those who can afford it will not hesitate to employ a nurse from one to two weeks in advance of the expected date of confinement; and for those who live where nurses cannot be procured quickly, a similar course is recommended.

But persons of only moderate resources, living in a city where, in an emergency, a substitute can be gotten from the local "Nurses' Directory," will find it convenient to engage the nurse from the calculated date.

The substitute will remain with the patient until the arrival of the nurse originally engaged.

Occasionally, it may happen that a patient will prefer to keep the substitute.

Such a course, however, would be unjust to the nurse who was first selected, unless she could immediately secure other work.

She has reserved a definite period of her time for the patient, and probably has declined work which seemed likely to conflict with the engagement already made.

She is fairly entitled, therefore, to assume charge of the case, and the patient who refuses to make the change is obligated to pay her according to the terms of the agreement.

How long will a nurse be needed after the child is born?

The answer to this question may be altered by so many circumstances that a hard and fast rule cannot be given.

Before the advent of "Trained Nurses," obstetrical patients were cared for by "Monthly Nurses," so called because they remained one month with their patients.

It is, likewise, customary to keep the trained nurse four weeks after the birth; but whenever possible it would be well to retain her six weeks, since this period elapses before the mother has entirely regained her normal physical condition.

Those who can afford to keep a trained nurse six months or a year are exceptional, but very fortunate.

Someone may feel that the suggestions I have made are not suitable to her case.

Very likely they may not be; to cover all the possibilities could scarcely be expected, for every case has its problems and peculiarities.

After consultation with her physician each patient will decide what is particularly advisable for her.

Nevertheless, I would emphasize the importance of securing a competent nurse and retaining her for at least four weeks.

Even with those who must guard their expense account the truest economy will lie in such a course.

Whenever lack of resources seems likely to prevent this arrangement, the patient who is looking to her best interests should enter a hospital where excellent care can be provided at a cost within her means.

DESIRABLE QUALITIES IN THE NURSE.

--It is rarely advisable to select as nurse a member of the family or an intimate friend.

Some of the motives governing such a course--sentiment, mutual devotion, and the desire to be humored--are inconsistent with the best kind of nursing.

If the nurse knows the patient intimately, undue anxiety may interfere with her judgment; thoroughness in routine duties may be hindered by mistaken consideration for the patient; and in an emergency sympathy rather than reason may guide her.

A successful nurse must satisfy at least two requirements; she must be capable professionally and also personally agreeable to her patient.

Some regard advanced years as essential to the first of these qualifications, but this does not necessarily hold good.

The personal qualities generally welcome in a nurse are neatness, thoughtfulness, a sympathetic nature, an even disposition, and a cheerful view of life.

Since a short interview is insufficient for taking the measure of a nurse, patients usually rely upon the opinion of someone else in selecting her.

The judgment of her former patients is frequently prejudiced in one direction or the other, and such an estimate must always be accepted with caution.

Much the most trustworthy method is to allow the physician to select her.

He will know nurses who possess the requisite qualities, and certainly he is most competent to judge their professional attainments.

If the choice of a nurse be left to the doctor, the two are sure to work harmoniously, and the patient will benefit by their cooperation.

Otherwise she may suffer because of their dissensions, for, if the doctor is accustomed to one procedure and the nurse to another, misunderstandings may occur, although both methods yield equally good results.

Whenever he does not select her, she should be asked to confer with him long before the case is due.

Obviously, a physician cannot be held responsible for a nurse's ability unless he is acquainted with her training and methods of work.

In an effort to economize, many are inclined to employ "half-trained" or "practical nurses."

When the confinement is not the first and there is no reason to anticipate any irregularity during labor or thereafter, I can see no vital objection to such an arrangement.

It is of the first importance, however, to be assured that the "practical nurse" is neat and appreciates the necessity of keeping everything about the patient scrupulously clean.

But competent nurses who charge less than the customary fee will be hard to find.

The recommendations which these women receive are apt to be even more misleading than in the case of trained nurses, because more is expected of the latter.

My experience has taught me that patients form particularly unreliable opinions of practical nurses, and I have frequently witnessed incompetence in such women which was overlooked by the patient.

A low-priced nurse is seldom a cheap one, as her shortcomings may be reflected in the health of the mother or the infant long after she has left the case.

Especially when the baby is the first, the mother will depend upon the nurse for instruction which should be both sound and thorough.

The principles taught her will be put into practice and utilized for many months, playing a vital part in the training of the infant.

It becomes essential, therefore, to secure a nurse who will give the baby a good start, and instruct the mother along right lines.

Perhaps this is less needful if the mother has learned her lesson from previous experiences.

But even then a good nurse relieves her of responsibility and materially assists her to a quick and lasting convalescence.

In the end the most proficient nurses are the least expensive.

THE PRELIMINARY VISITS OF THE NURSE.

--Many of the precautions which safeguard a confinement should be considered by the patient and the nurse together.

The character and quantity of the supplies, the choice of a room for delivery and subsequent convalescence, the proper clothing for the infant--all these are problems which may be solved most satisfactorily in the light of the nurse's experience and the resources at hand.

Two visits are usually sufficient to arrange these details.

An interview early in pregnancy, soon after the nurse has been selected, provides an opportunity to lay plans and especially to review the list of articles needed at delivery.

Such articles as are already in the house may be checked off; the others may be procured at leisure.

Eight to ten weeks before the expected date of the confinement the nurse should pay a second visit and should inspect the supplies to see that they are complete.

Certain articles which I shall indicate must be sterilized.

As this procedure is more reliable when carried out by an experienced person it will be convenient to have all the dressings finished by the time of the nurse's second visit, in order that she may sterilize them.

The question may arise as to whether the nurse shall come to the patient upon the date for which she has been engaged or shall wait until summoned.

From the physician's standpoint it is often more acceptable to have the nurse in the house a few days before the confinement, though some patients strongly object to this.

Provided the nurse may be got quickly at any time of day or night, there can be no objection to leaving the decision to the patient herself.

THE NECESSARY SUPPLIES FOR CONFINEMENT.

--As to just what a confinement outfit should contain physicians differ to some extent;

but this disagreement pertains rather to luxuries than essentials.

In the lists here suggested nothing essential has been omitted, although economy, as far as is consistent with good judgment, has been kept in mind.

Any article not included in my list which the doctor or nurse in attendance recommends may be noted in the space for memoranda.

Some patients prefer to take no part in preparing the supplies for confinement.

Indeed, the demand for a ready-made confinement outfit has become large enough to lead several firms to put them upon the market.

These outfits differ in completeness and vary in price from a few dollars up to fifty.

The majority of patients, however, still attend to such details themselves, and will find a list of the needful supplies convenient.

_Make-up and Sterilize_: 7 Dozen Sanitary Pads.

2 Sanitary Belts.

2 Delivery Pads.

5 Dozen Gauze Sponges.

2 Dozen Gauze Squares.

4 Dozen Cotton Pledgets.

2 Sheets.

Bobbin for tying the Cord.

A Pair of Obstetrical Leggins.

A Dozen and a Half Towels (Diapers).

_Obtain from the Druggist_: 100 Bichlorid of Mercury Tablets.

100 grams Chloroform.

4 ounces Powdered Boric Acid.

4 ounces Tincture Green Soap.

1 pint Grain Alcohol.

A small jar of White Vaselin.

A cake of Castile Soap.

A two-ounce Medicine Glass.

A Medicine Dropper.

A bent glass Drinking Tube.

_The following articles should be in the house, ready for use.

_ An ample supply of Towels, Sheets, and Gowns.

A new Hand-Brush; the cheap variety with wooden back and stiff bristles is preferable.

Two slop Jars or enamel Buckets with Covers.

A two-quart Fountain Syringe; an old one may be substituted provided it has been thoroughly boiled.

Three Basins and a one-quart Pitcher of agate or enamel-ware.

A Douche-Pan; the "perfection Bed-Pan" is preferable.

Two pieces of Rubber-Sheeting are required, one large enough to cover the mattress of a single bed (2 x 1-1/2 yds.

), the other smaller (1 x 3/4 yd.

).

Should this be too expensive, the best substitute is white table oil-cloth.

The nurse will explain how the various surgical dressings are made, but, as the patient may forget some of the directions, all the details will be given here.

At least three to four pounds of absorbent cotton will be used in the dressings.

To make the pads entirely of absorbent cotton is very expensive.

The cheaper cotton- batting is therefore employed to give them body, and they are faced only upon one side with the absorbent material.

Furthermore, the rolls of absorbent cotton, as purchased, may be separated into three or four layers, one of which is thick enough for the facing.

About six rolls of the batting should be purchased.

Surgical gauze, which tradespeople sometimes call dairy-cloth, is the most suitable material for covering the pads.

Bleached cheese cloth will answer the same purpose, but it is more expensive and rather heavy.

Approximately thirty-five yards of the gauze, which comes in a thirty-six-inch width, will be needed.

When the supplies are finished, they are wrapped in separate bundles and sterilized.

Old muslin or some of the diapers are generally used for covers.

_The sanitary pads_, also called vulval or perineal pads, absorb the discharge which always occurs after delivery.

They are made of absorbent cotton and cotton-batting covered with gauze; a convenient size is ten inches long and three to four inches wide.

Their thickness is approximately an inch, one-third of which is composed of absorbent cotton.

_The sanitary belt_ is used to hold these pads in place.

Very satisfactory ones are made of two strips of unbleached muslin, three inches wide.

The first of these must be long enough to reach around the waist; the second, which passes over the pad, is somewhat shorter and has two parallel slits in one end; through which the waist-band passes at the back; the three free ends are pinned together in front.

_The delivery pads_ are made of the same materials as the sanitary pads; preferably a yard square and four inches thick.

A

rather heavy top-layer of absorbent cotton must be used in them, and they should be quilted or tacked at several points to prevent slipping.

A rubber pad is ill adapted for use during delivery.

Some absorbent material made into proper shape proves much more satisfactory since it can be thoroughly sterilized and can be thrown away after it has been used.

I am told that cotton-waste is a good substitute for absorbent cotton in the delivery pads.

It is inexpensive, and will be rendered capable of absorbing fluids after it has been boiled in washing soda and dried in the sun.

Each delivery pad should be separately wrapped and sterilized.

_Gauze sponges_ will be needed by the doctor; about five dozen should be prepared.

The gauze is cut in eighteen-inch squares.

Opposite edges are folded toward one another, about two inches being lapped each time; this finally yields a seven or eight-ply strip, which is wrapped into appropriate shape about two fingers.

The ravelled ends are then tucked into the roll.

It is most satisfactory to divide the sponges and sterilize them in two bundles.

Small pieces of gauze about two inches square will also be needed in caring for the baby's eyes and mouth.

Several dozen should be cut, and they may all be sterilized together.

_Cotton pledgets_ are simply bits of absorbent cotton the size of a hen's egg, the rough edges of which have been twisted together.

A small pillow-case full of them ought to be made up and sterilized.

_Obstetrical leggins_ are preferably made of canton flannel;

they are cut to fit loosely and should reach the hip.

If they are prepared so as to extend to the waist at the sides, they may be held in place by a waistband, and in this way will prevent unnecessary exposure without interfering with the doctor.

They should be sterilized.

_Towels_, if used at all, should be without fringe.

It is economical not to employ them, but to use diapers in their place.

Three packages, each containing six diapers, should be sterilized.

_Sterilized sheets_ are often useful at the delivery; more than two are never needed.

They should be wrapped separately for the sterilization.

_Sterilized bobbin_ is generally used for tying the cord.

Several pieces are cut in nine-inch lengths and sterilized in a single package.

_A dressing for the cord_ will be required, but there is no necessity for preparing a special one.

It is generally satisfactory to wrap the cord in one of the sterile gauze sponges which has been previously soaked in alcohol.

Several methods of drying up the cord give equally good results, and it is usually a good plan to allow the nurse to dress it as she wishes, since the employment of a method with which she is familiar will more likely insure a satisfactory result in her hands.

A

dressing popular with many nurses is prepared as follows: In a piece of muslin four inches square cut a small circular opening; double the linen and dust boric acid between the folds.

If this method is preferred, several of the dressings should be prepared and sterilized together.

THE BABY'S OUTFIT.

--Preparations for the infant may be thorough without being elaborate.

Instinctively, the prospective mother leans toward extravagance in fitting out her baby's wardrobe, and easily slips into the error of providing too much.

Time and energy are frequently devoted to an extensive wardrobe which the infant quickly outgrows; in consequence many articles must be made over before they are used.

Even with modest resources a prospective mother can acquire everything the baby really needs.

A very sensible plan, in my judgment, is to prepare what will be wanted during the first two months; subsequently, articles may be made or bought as they are needed.

Accordingly, the quantity of wearing apparel and the nursery supplies I have suggested pertain only to the early weeks of infant life.

Although no essential has been omitted, the outline is plain and economical.

At present, outfitters supply a variety of ready-made, garments for the infant and conveniences for the nursery; in many of them notable ingenuity is displayed which aims at the child's comfort or the saving of labor to the mother.

Catalogs of these articles, which are often expensive, are furnished by dealers.

In preparing clothing for the new-born, several principles must be kept in mind.

The first is that the garments must be warm without being unduly heavy; and another that they should be roomy, permitting perfect freedom of motion.

A third no less important principle is simplicity.

Adornment of the clothing gratifies the mother, but does not serve a single useful purpose.

The lists which follow include all that is necessary for the young infant; they will also serve as a basis for elaboration if a more lavish outfit is desired.

_Necessary Clothing_.

4 Abdominal Flannel Bands.

3 Undershirts.

4 flannel Skirts.

4 Night Gowns.

12 White Slips.

3 Knit Bands.

4 Dozen Diapers.

Cloak and Cap.

_Nursery Equipment_.

An old Blanket.

Assorted Safety Pins.

Soft Damask Towels.

Wash Cloths.

Hot-Water Bag with Canton Flannel Covers.

Talcum Powder.

Olive Oil.

Bassinet.

_Additional Articles; Convenient but Not Essential_.

Rubber Bathtub.

Rubber Bath-Apron.

Flannel Apron.

Bath Thermometer.

Bath Hamper.

Quilted Mattress Covering.

Baby Scales.

Screen.

Low Chair without Arms.

Drying Frames.

STERILIZATION.

--Now and again, those who follow very rigid rules to avoid infection during childbirth are criticized for their pains.

The general public has not yet grasped the true relation of bacteria to this condition; a relation which, indeed, first became clear to medical men within comparatively recent years.

The development of our knowledge of the nature of infection forms one of the most entertaining chapters in obstetrics, and provides a simple way of showing the genuine need of preventive measures.

Several observant physicians had previously suspected the character of "child-bed fever" (as infection of the mother was once called), but convincing proof of its contagious nature was not forthcoming until the middle of the nineteenth century, when signal facts were pointed out by three men, each working independently, though all came to similar conclusions.

The evidence they gathered should have left no one doubtful that the disease is contagious, and largely preventable.

On the contrary, bitter opposition was encountered for the time, and only within the last two decades has their teaching found wide practical application.

In 1843 Oliver Wendell Holmes published the paper on "The Contagiousness of Puerperal Fever," which is now preserved in his volume of "Medical Essays."

Physicians were startled to be frankly told the responsibility they assumed if they neglected the truth taught by epidemics of this disease.

"The dark obituary calendar" which marked the progress of these epidemics clearly indicated that "the disease is so far contagious as to be frequently carried from patient to patient by physicians and nurses."

A violent controversy followed this arraignment, and, consequently, the preventive measures which Holmes so convincingly urged were not adopted as promptly as they should have been.

The full justice of his conclusions has since been universally admitted, and medical men now find it difficult to understand how anyone could have taken issue with the sentiment which he expressed.

"For my part," Holmes said, "I had rather rescue one mother from being poisoned by her attendant than claim to have saved forty out of fifty patients to whom I had carried the disease."

But the most important early observations upon child-bed fever were made in 1847 by a young Hungarian, Semmelweiss, while he was an assistant in the large Lying-in Hospital in Vienna.

In thoroughness, power of conviction, and practical value his work was masterful.

It is no exaggeration to regard his observations as the rock upon which antiseptic surgery, the glory of the nineteenth century, was built.

Semmelweiss had been seeking an explanation of the dreadful scourge, and his mind was ready for the reception of the truth when it was revealed through the death of one of his colleagues.

This physician injured his finger accidentally in performing an autopsy upon a patient who had died from child-bed fever.

And the condition disclosed by examination of his body after death was identical with that found in cases of child-bed fever.

Here then was the clew; the disease was contagious.

Semmelweiss was ignorant of Holmes' views;

what had happened before his eyes suggested to him that the disease was due to a poison which could be conveyed from one person to another.

Moreover, his interest and his power of insight led to further comparison.

Clearly, the open wound on the physician's finger had been the portal through which the poison entered; but where was there a similar portal in obstetrical patients?

The answer was plain.

The birth-canal at the time of delivery is always an open wound.

There the poison entered, and child-bed fever was a wound infection!

Several years later Tarnier, who was to become an eminent obstetrician, but was then a student in Paris, chose the diseases of the lying-in period as the subject for his graduating thesis.

He was unacquainted with the work either of Holmes or of Semmelweiss, and approached the problem from still another standpoint, drawing attention to the much higher deathrate among women delivered amid unsanitary surroundings.

Tarnier also considered that the disease was a form of poisoning, that it was contagious, and that measures should be instituted to protect patients against it.

Of these pioneers, by far the greatest credit is due Semmelweiss, who devoted his life to the problem, although his opinions continually met with scepticism and even ridicule.

More convincing proof than he could furnish was demanded before his contemporaries would believe that child-bed fever was due to lack of precaution.

Fortunately the evidence was soon produced.

In 1880, Pasteur obtained bacteria from the organs which had been infected, and was able to grow the bacteria in his laboratory; thus the ultimate cause of the disease became firmly established.

With the harmful agents in their hands, Pasteur and his followers were enabled to study their characteristics and to recommend means of destroying them.

Much as we must regret that the warnings of Holmes and of Tarnier passed unheeded; lamentable as may be the blindness of the generation of Semmelweiss to the truths revealed by his research, it is not surprising that such radical teaching met with a hostile reception.

As we measure time in retrospect from the vantage ground of to-day, the three to four decades required for full acceptance of their revolutionary doctrines seem a brief span.

Antiseptic methods would not have prevailed so quickly as they did, had not the same epoch which gave us a Pasteur also given a surgeon with a receptive mind, ready to seize and apply the discoveries of the French genius.

This was the great service of Joseph Lister.

Impressed with Pasteur's studies on fermentation, Lister saw an analogy between this process and the putrefaction of wounds, a condition which he was eager to prevent.

He had reason to believe that carbolic acid would check decomposition, and he employed a weak solution of it in the treatment of wounds; later he devised a "carbolic spray," by means of which when his operations were performed the atmosphere round about might be sterilized.

It is but a short step from antiseptic operations to our own era of aseptic surgery, and that a step in the direction of simplicity.

Now we know that the sterilization of the air is rarely necessary and have dispensed with Lister's elaborate apparatus.

Furthermore, and of far greater moment, experience has taught that the destruction of bacteria before they have opportunity to come in contact with the wound is more effective than efforts to kill them as they approach or after they have invaded the tissues.

Initial freedom from bacteria is the ideal of asepsis; to secure it, the modern surgeon is ever watchful of the cleanliness of his hands, his instruments, his dressings, and of the site of operation or whatever may come near it.

The importance of the changes wrought by the adoption of aseptic methods requires no emphasis, for the marvels of modern surgery are even more impressive to laymen than to the medical profession.

Everybody now understands that strict cleanliness is indispensable to the success of a surgical operation.

But the general public has not fully awakened to the same profound necessity in connection with childbirth, although it was child-bed fever that called forth the observations and experiments upon which modern surgical technique rests.

Although most obstetrical patients appreciate the fact that there is an advantage in sterilized dressings and sanitary surroundings, few realize the risk they run without them.

One must know the mournful history of the past to be adequately impressed with that danger, for we no longer see the epidemics of childbed fever which formerly swept over communities, sacrificing ten of every hundred women as they became mothers.

Precaution is no less necessary on that account; the scourge would be rampant again if the reins were loosened.

Most instances of puerperal infection are, it is true, referable to lack of care.

Nevertheless, the complication develops now and then where all precautions have been conscientiously observed.

Under such conditions the infection will in all likelihood be a mild one, and a tedious convalescence usually proves its most disagreeable feature.

Such stringent preventive measures as are now practiced in many hospitals have reduced the frequency of infections to the point where only one fatal case, or even less, occurs in a thousand deliveries.

These rare cases remind us that vigilance must never be relaxed, and that patients who are confined at home require just as much care as those in hospitals, where conditions are the best to prevent infection and the complications, which follow.

The first essential toward the avoidance of infection in obstetrical cases is clean dressings.

Naturally, these should be clean to the sight, but it is in invisible dirt that serious danger lurks;

bacteria are the causative agents of this disease.

Experiments have taught the bacteriologist that disease-producing organisms are killed in half an hour when subjected to a high atmospheric pressure and the temperature of steam.

Special apparatus has been constructed for carrying out the procedure.

It is unnecessary for our purposes, however, since the essential conditions may be secured, though with less convenience, in any kitchen.

If a prospective mother finds it awkward to do the sterilizing at home, and her nurse is unable to take charge of the matter, she may arrange with a local hospital or the nearest nurses' directory to sterilize her dressings.

Yet a very little ingenuity suffices to do the work at home with perfect satisfaction.

Installments of the smaller bundles may be sterilized in a galvanized bucket.

To do this place an inverted bowl, with a depth of three to four inches, at the bottom, and pour in water until the bowl is almost covered.

A breakfast plate rests on the bowl, and upon this the dressings are stacked; a second larger plate which fits the top of the bucket is utilized as a lid to close in the sterilizing chamber.

This will not accommodate the larger packages; a more satisfactory method for all of them is to use a wash-boiler in which has been swung a muslin hammock.

To arrange the latter form of home sterilizer, cut an oblong piece of unbleached muslin large enough to sink far down into the boiler and run a drawing-string of stout cord about the edge.

Cover the bottom of the boiler with several inches of water; tie the hammock in place, passing the cord beneath the handles of the boiler to hold the muslin securely.

Pack in the dressings, which have been wrapped in appropriate bundles; put the lid in place, thus closing the sterilizing chamber, and leave the dressings exposed to the steam for at least half an hour.

After the operation has been completed, the bundles are taken out of the boiler and allowed to dry in the air.

They must not be opened until the occasion for which the supplies were prepared arrives; awaiting this event, they are laid away in a convenient closet or drawer.

A word of caution may be added concerning a method of sterilization employed at home more frequently, perhaps, than any other.

According to this procedure, the supplies are wrapped in paper, thrust into a hot oven, and left there until the paper is scorched.

From the standpoint of economy as well as of thoroughness, this method is likely to prove unsatisfactory.

Frequently, the dressings themselves are scorched; I have known patients to ruin several installments of their supplies in this way.

Moreover, dry heat is not so trustworthy as steam for sterilizing purposes.

Judicious management means the preparation of the supplies necessary for confinement before turning to the selection of the infant's outfit.

Ordinarily, both these tasks should be finished by the end of the eighth month, and final arrangements for the approaching delivery will then claim attention.

If the patient expects to remain at home, she must decide which is the best room to occupy; she will wonder how it ought to be equipped, and she will be anxious to learn what personal preparations are advisable at the beginning of labor.

Intelligent answers to these questions are important.

A patient should request the physician to criticize her plans when he pays the preliminary visit four to five weeks prior to the expected date of confinement.

If she has acted unwisely in any respect, he will point it out, and may suggest changes which will enable her to employ to the best advantage the resources at hand.