Hospital or Home ?
The argument on the rather difficult subject of whether a mother should have her baby in hospital or at home has continued ever since maternity hospitals were first instituted well over fifty years ago. Hospital delivery provides the essential medical and nursing care, as well as the facilities to deal with any eventuality. Domiciliary, Or home, confinement provides social advantages and is convenient for the mother who has a young family. Gradually, however, more and more women are having their babies in hospital: at present more than 90 per cent are delivered in a maternity unit.
This increase is due to several factors. Modern obstetric care is designed not only to prevent complications occurring but also to recognize and treat them promptly when they arise. Since it is impossible to predict that a pregnancy, labour, delivery and puerperium (as well as the progress of the new-born infant) will be normal until after the events have occurred, most obstetricians prefer to look after their patients in hospital, because it is only there that they have all the facilities and ancilliary services that they may require.
All doctors and midwives, as well as the majority of women, now regard antenatal care as being an essential part of pregnancy. The safety of the mother and the safety of her unborn child are their prime considerations. In other words, safety has taken the place of convenience. All the evidence points to hospital confinement as being safer than home confinement since skilled nursing, obstetric, paediatric and anaesthetic staff are available both day and night. Most women prefer hospital delivery because they have complete and absolute confidence, so essential for the pregnant woman, that everything is prepared for them and only in hospital are they assured adequate rest after delivery.
Although a choice is still available, the number of women who are medically acceptable for home confinement is gradually becoming less as the criteria are made more stringent. Only those women in whom a normal pregnancy, labour, delivery and puerperium (and a normal baby) can be expected are acceptable. Ideally the doctor and the domiciliary midwife should continue to take care of their patient but the actual delivery should take place within a maternity unit rather than the patient’s home. The mother would then be transferred back to her own home as soon as her general condition and that of the new-born infant are considered satisfactory.
Planned Early Discharge
A compromise has to some extent been achieved by the arrangement for planned early discharge whereby the mother is admitted to hospital for delivery and allowed home with her baby as early as is deemed fit. By this means the mother has the advantages of both methods; the safety of hospital confinement is combined with her swift return to her children.
During the last few years the increased number of hospital confinements reflects a new social trend in Britain and with the average duration of stay in hospital of 7 to 8 days and planned early discharge from hospital it is now possible to provide hospital care for all mothers. Hospital is undoubtedly the best and safest place for a baby to be born and should be encouraged by all in the obstetric field.
Nevertheless, women are still allowed a choice between a home or a hospital confinement and this is sometimes critical to the future well-being of the mother and her baby.
Maternal mortality and illness, together with perinatal mortality and illness, have declined phenomenally during the past two decades but even lower rates could be achieved if all mothers were admitted to hospital for their confinement. Hospitals are geared for all obstetric emergencies that may arise and provide an impressive list of facilities, as well as the basic ward, delivery and nursery units. They include antenatal clinics, postnatal clinics, infant welfare clinics and special dental, infertility, tuberculosis, cardiac, diabetic, venereal disease and family planning clinics. The expert staff include obstetricians, physicians, paediatricians, anaesthetists, radiologists, bacteriologists, midwives and nurses spedally trained in the” care of premature and sick babies.
When a woman is having her first baby and any after her third, it is essential that the confinement should take place in hospital.
Only those women having their second or third baby and whose pregnancies are absolutely normal are acceptable for home confinement. Furthermore, any woman under 5 ft. in height, under the age of 17 or over the age of 35 should be delivered in hospital. If there has been a serious complication in any previous delivery or if there is any serious anaemia at the beginning of pregnancy, or at any other time daring pregnancy, then she should have her baby in hospital. Any woman who develops a rise in blood pressure or has a multiple pregnancy can only safely be delivered in hospital. Medical reasons, or any illness such as diabetes, kidney disease or heart disease, are also absolute indications for hospital confinement where the necessary facilities are easily available should they be required.
A great advantage of having her baby in hospital is that the mother is freed from a mass of worries and responsibilities. If she is at home it is easy for whoever is running the house to bother her with minor domestic problems. There may be a continuous stream of visitors who want to see the baby and it is almost impossible for the new mother to have peace and quiet. Rest and sleep are essential for any woman after labour if she is to recover rapidly from her, delivery and enjoy caring for her new baby.
The mother going into hospital will not need as much equipment as she would at home. Most hospitals provide a list of the articles that a mother needs to bring into hospital and she should pack these in a special case towards the end of pregnancy. The list usually includes: soap and flannel, brush and comb, toothbrush and tooth-paste, paper handkerchiefs in preference to linen ones, a sanitary belt or disposable paper panties, safety pins, nightdresses, a bed- jacket, dressing gown, slippers and two brassieres. A set of baby clothes will be required when the baby goes home, but while in hospital these are provided.
A nurse must study for three years to qualify as a State Registered Nurse after which she can specialize in certain fields. The midwife is a specialist in maternal and child health and after her state registration she must work and study for a further year after which she must pass another examination before being allowed to practise as a midwife. A midwife may also train in a special two-year scheme. The midwives who staff maternity wards have had years of sound experience. During your time in hospital most of the help and advice regarding your baby will come from the midwife whose sole purpose is to guide you and to give you confidence in handling your baby in preparation for your return home.
In a maternity ward a woman has to adjust to a certain routine which may be very disconcerting at first, but it sets a pattern for each individual mother and baby which can be continued when they go home. This is an important fact to remember and it will help a woman organize her daily life when she no longer has the order of the hospital. There are usually no rigid rules about visiting times in maternity wards; they should not interfere with ward routine, the feeding of babies or mothers’ resting time, but otherwise any visiting restrictions are gradually being removed.
The one advantage of having a baby at home is that the other children feel they share in the event and will welcome the new baby right from the start. If you want to have your baby at home all the following conditions should be fulfilled at the time of booking:
1 As far as can be ascertained your general physical condition is excellent and you are 5ft. or more in height.
2 You are pregnant for the second or third time and the previous pregnancies, labours and the puerperiums have all been normal.
3 You are under 35 and over 17 years of age.
4 No Rhesus antibodies ate present in your blood.
5 Your home conditions are suitable.
6 There is adequate help at home.
The facilities available for patients having a domiciliary confinement are: doctors, consultations with an obstetrician, mobile obstetric emergency unit, maternity packs with sterile supplies and home help. Domiciliary midwives are provided by the local health authority under the National Health Service and the necessary arrangements can be made with your own family doctor after he has confirmed your pregnancy.
The standard of home conditions must be high before delivery at home can even be considered. There must be a suitable bedroom where the mother can be delivered in privacy. The doctor and midwife who are going to conduct the delivery will see the room beforehand so that any suggestions about particular changes in furniture can be attended to. The ideal room should be bright and quiet, conveniently near the bathroom and certainly on the same floor. Heating must be provided day and night in cold weather to prevent the baby getting cold. The mother’s bed must be accessible from both sides and well situated with regard to light. A cot for the baby, a comfortable chair and a table are necessary. A wash-basin with running water is a luxury which is much appreciated, but bowls, jugs and lots of hot water will do just as well. A really good light is vital. Flooring should be easily washable. If the carpet cannot be moved it should be covered for protection. A large plastic or polythene sheet must be placed over the mattress.
Requirements for a Home Confinement
A suitable room with furniture as above, two large basins—one for the mother, one for the midwife—one bed-pan, one bucket for soiled dressings, one 2-pint jug for water, plastic sheet to cover the mattress, a nail-brush, one or two hot water bottles with covers, and newspapers.
Personal belongings: two nightdresses, one dressing gown, one pair of slippers, toilet articles, one bath towel, one face towel and face cloth, two brassieres, sanitary belt, sanitary pads (maternity quality). For the baby’s immediate needs’, a soft towel to wrap the baby in when born, a baby bath, soft bath towel, soap, soft petroleum jelly, mother’s bathing apron, safety pins, cot, low chair for feeding as well as all his clothes, sheets and blankets. Your midwife will give you a full list.
Factors Affecting Safe Confinement
There are so many modem advances and factors that go towards safe confinement that it is impossible to list them all in detail.
Maternal health. The better a woman’s general health, the more easily can she maintain it throughout her pregnancy. This applies not only to the elimination of obvious infection and disease but also to the correction of anaemia and other such conditions.
Antenatal care is responsible for the elimination of anaemia, deficiencies, pre-eclampsia, the control of weight gain and the early diagnosis of complications amongst all other essential factors that lead towards safe confinement.
Midwives. The continued training of skilled midwives whose dedication and devotion to their patients has to be seen and experienced to be believed is probably one of the greatest influences on safe confinement in Great Britain.
Doctors. The increase in the necessary training of both general practitioners and specialists to a better understanding of the problems of pregnant women has gone a long way towards affecting the outcome of pregnancy.
Facilities. While many people may criticize the facilities available in Great Britain, there are not many countries that can match the overall standard of care that is provided during pregnancy nor the specialized and emergency facilities.
Modern advances. While some of the medical advances in pregnancy and delivery are not absolutely recent, the advances in the care of the woman and her baby, such as new drugs, the control of infection, better anaesthesia, the understanding of blood groups, the Rhesus factor, blood transfusion, together with the use of certain modern and specialized techniques and apparatus, all contribute to a safe confinement.
The paediatrician. Enormous advances have been made in recent years in the care and Welfare of the infant especially the care of the new-born and premature baby. The credit for this must go to the paediatricians as well as to the nurses who take care of these babies in special units.
Liaison. The increasing liaison between all the various medical, social and administrative departments that have to do with the care of the pregnant woman contributes towards an efficient, and therefore safe, confinement.
The term ‘natural childbirth’ is a phrase that has achieved a great deal of notoriety and confuses many people. It seems to have conjured up an image that the majority of doctors and midwives wish to make childbirth ‘unnatural’ and that they wish to deny women some of the pleasures and experiences of childbirth. Nothing could be further from the truth. Nobody, least of all doctors and midwives who have devoted several years to learning how to deliver women normally and naturally, would attempt to interfere with any normal or natural delivery unless there was some reason to do so.
It is of the utmost importance that all available help should be given in early pregnancy to enable the woman to accept and understand all the physiological, anatomical, as well as the emotional and psychological, changes that are going to occur throughout pregnancy, delivery and the puerperium. These three phases of reproduction must be kept in their correctly balanced perspective and labour itself must not be chosen as the only, or even the most important, event in the whole process if natural childbirth is to be achieved.
The erroneous conception that ‘natural childbirth’ refers only to ‘normal’ delivery is commonly held. However, many doctors believe that natural childbirth starts with a harmonious sex life, resulting in conception at a time of choice, with the full implications of the conception being realized before it occurs. A careful understanding of pregnancy and all its changes is perhaps more important than an understanding of delivery itself, but an understanding of the process of labour is essential if labour is to be conducted with the full co-operation of the doctors and midwives, as well as with pleasure to the mother.
Pregnancy, including childbirth, is often stated to be a natural physiological function which may sometimes present physical discomforts and mental strains, but which, when carried out by a healthy, normal, well balanced person, should be accompanied by an immense sense of achievement and satisfaction. This is undoubtedly true, and the more thoroughly educated the pregnant woman is, the greater will be her confidence and her co-operation with her midwife and doctor during the three vital phases of reproduction. Any physical danger or emotional difficulty that might arise is therefore eliminated.
Classes for antenatal instruction and relaxation are provided by most maternity units attached to hospitals. These may be inadequate for the patient who wishes to have a greater knowledge and insight into her pregnancy and delivery, but there are only a certain number of doctors and midwives available for the whole maternity service and extensive antenatal instruction has not yet become a practical possibility.
This book is meant to be educational. It is meant to help. It is meant to instruct. It is meant to assist you in understanding what your pregnancy is all about. An easy and pleasurable pregnancy and delivery depends upon two main factors. Firstly, that you should really want the child you have conceived and, secondly, that you should not be afraid of producing it, nor of the process of pregnancy or your ability to look after the child after he has arrived. The second of these two is by far the more important factor. A great deal of this book has been spent in describing the normal changes of pregnancy and also the complications that can occur. The description of the complications is not meant to frighten or to disturb, but is mentioned so that you can understand some of the things that can go wrong and appreciate why midwives and doctors do various tests and insist on your attendance at the antenatal clinics.
The whole syndrome of fear, pain and tension has been propounded at length for a number of years. This is a syndrome which becomes a vicious cycle. Fear of the unknown begets tension and tension in its turn begets pain, which then in turn creates further fear. A complete knowledge of what pregnancy and labour are all about is half the battle in overcoming this fear, but the other half is self-confidence: you should have sufficient knowledge to start your pregnancy with some degree of assurance and to begin your labour with complete confidence in your own ability to do what is expected of you, knowing exactly what is happening to you and why various investigations are being done.
The Birth Rate
There are approximately 9 million Women between the ages of 14 and 45 in England, and during 1977 there were 569,000 live births, which represents a birth rate of 11.6 per thousand of the population. The birth rate has been falling in England for several years but has recently stabilized between 11 and 12.
There was a total of 5,400 stillbirths during 1977 which represents 0.94 per cent of all live births.
The maternal mortality during the year 1976 was 0.012 per cent which means that approximately one woman in every 7,720 died in childbirth, but it must be remembered that these figures are for the entire country and therefore include those who had no antenatal care and those who suffered from severe heart and lung disease.
There were 52,000 illegitimate live births during 1977 which represents 9.1 per cent of all live births. One-third of these would be women of under the age of 20 years.
|Age of mother||11||12||13||14||15||16||17||18||19|
|Number of illegitimate births||1||2||34||201||1100||2594||4590||5319||4793|
The total number of abortions during 1976 was 101,900 resulting in the deaths of 6 women, as compared with a total of 68 maternal deaths from child-birth out of the total 555,722 mothers who gave birth to live or stillborn infants in that year.
During 1976, 97.4 per cent of all women had their babies in hospital where the average length of stay for each patient was approximately 7 days.
Women should enjoy having babies because happiness for the parents means an equally happy and well-adjusted son or daughter. This attitude is becoming more important as the pressure of living increases. The mental and physical development of children rests with the individual parent, so that the child’s happiness and attitude to life will reflect not only the attitude of the parents but will also decide the sort of community in which he will live and shape his future. Where does happiness like this come from? It starts from the simple acceptance of pregnancy with all its implications; the confidence that the woman builds up in her own ability and her absolute trust in the medical people who will guide her. Pregnancy should be regarded as the time when women are healthier than ever before, despite some of its occasional discomforts, but much will depend on how well they listen to their medical advisers and how efficiently they carry out instructions.
Most maternity units have a course of mothercraft classes, which every pregnant woman should attend. The classes usually comprise:
1 Antenatal care, including hygiene of the pregnant woman, the importance of fresh air and exercise during pregnancy, rest and sleep, relaxation, suitable clothing, the bowels, care of the teeth, bathing, smoking, marital relations and diet during pregnancy.
2 The development and growth of the baby in the uterus.
3 Labour, including the signs of labour and what happens during the first, the second and the third stages of labour. Demonstration of the analgesic machine which is used during labour.
4 Breast-feeding and artificial feeding, which should also include care of the nipples and the latest in maternity wear.
5 Planning the baby’s layette, including style and fabrics available.
6 Bathing the baby.
7 A visit to the maternity ward and the labour ward.
The New Father
A new baby at home means a big upheaval in a father’s life. Women rightly expect their husbands to be loving towards them and to admire their recent achievement, but it should be remembered that men are sometimes neglected when their wives are pregnant and therefore require just as much attention as the new arrival. Every woman should make sure that the new member of the family does not mean that her husband has less of her love, time and affection. It takes a long time to get used to having a new baby in the house, particularly if you have to get up during the night to cope with a crying, infant. During the first few weeks the young mother needs extra sympathy and understanding. By sharing some of the responsibilities, life will become easier for both the husband and wife and the household will settle quickly and smoothly into the new routine.
There are no set rules about a baby’s layette and the list below is intended only as a general guide:
Three vests. Wool is warm and soft.
Two dozen nappies in Turkish towelling.
Disposable nappies. More and more mothers use disposable nappies to save time and effort. Even if not used all the time they are invaluable for travel or when you are particularly busy. Nappy liners, which are squares used inside towelling nappies, are also useful. The cost of using disposable nappies is not much higher than the total cost of using traditional nappies.
Six pairs of plastic pants, which should not be too tight round the baby’s thighs.
Three nightdresses in wool and cotton mixture. Babygros are very useful and practical. Flameproof fabric is essential.
Booties, helmet and mittens. These are really only needed for winter babies.
The above items will see a baby through the first few months and some, of course, will continue in use longer.
The Baby’s Room
Many items are a matter of taste and the size of your budget:
The cot. A crib isn’t absolutely essential: the baby can go straight into a cot. The cot should have the British Standard ‘Kitemark’ regarding safety. Special baby mattresses are firm and covered with waterproof material, not loose plastic sheeting as this is a hazard to the baby. No pillow is needed in the first year.
Four cot blankets. The cellular type are warm and light in weight. Cot sheets. Buy those of a warm flannelette material.
Carry-cot. This is a very useful item and the baby can even stay in it at night for the first few weeks.
Bath. Choose a plastic type, making sure that the stand is absolutely steady.
Two bath towels. These should be reserved entirely for the baby’s use.
Toilet box. The main things you will need in the baby’s box are a baby hairbrush, a supply of large curved safety pins, baby soap, cream, petroleum jelly, talcum powder, cotton wool, swabs and a small bowl for swabs.
Nappy bin. Useful but not essential. Any pail with a lid will serve. Low feeding chair. Ideally the chair will be without arms and will have a padded seat for comfort.
If you can possibly manage to give your baby a room of his own, try and make it as bright and cheerful as possible. Babies love clear, bright colours and there is no reason why one should stick to the traditional pastel shades. Babies like to watch things that move, so it is a good idea to have an inexpensive mobile hanging from the ceiling within his field of vision. All paint should be leadless and this is vitally important for such things as repainted cots which the baby will be chewing and licking later. Linoleum or plastic tiles are the best floor coverings, perhaps with a brightly coloured rug. Curtains should be in light washable material, lined to keep out the light when the baby is to sleep. Safety items such as fireguards and window bars are essential and should be installed well before the baby becomes mobile.
There is a great choice of prams available today and one must be guided by particular needs and the cost. If restricted for space at home it may be best to buy a collapsible pram, or, for the baby’s first months, it may be more convenient to have a carry-cot with a chassis on wheels which folds into a very small space. When buying a pram the following features are important:
1 The pram should be the right weight and height. It should be easy for you to push.
2 It is important to be able to see over the hood when it is up.
3 Safety is vital. Only buy a pram which has the British Standard ‘Kitemark’. The brakes should be secure and easy to adjust.
4 A good, firm mattress.
5 It should have an attachable canopy to provide protection against the sun and a pram net to keep cats off when the baby is outside.
Bathing your Baby
It is important to have everything ready before starting to bath your baby each day. The room should be warm and the windows closed. Everything should be within easy reach before you begin. A table or trolley should be arranged with something for holding the soap or a bottle of special baby bath solution, a sponge or flannel, hairbrush, cotton wool swabs, talcum powder, lotion, cream or petroleum jelly and a warm towel. A nappy bin should be ready for the soiled nappies and you should wear a waterproof apron to keep your own clothes dry. A comfortable chair is necessary for you to sit on.
Method of bathing a baby.
1 The bath should be half filled with warm water. Test with your elbow for temperature. Have everything within easy reach.
2 Undress the baby, leaving on nappy. Wrap him in a warm towel. Clean face very gently using cotton wool soaked in clean water, and then dry face very gently.
3 Shampoo his head with soap, rinse thoroughly and dry his head. Unwrap the towel and remove his nappy.
4 Soap him all over with your hand and put him into the bath. Hold securely.
5 Rinse the soap off with the water in the bath and let him kick about if he wants to.
6 Lift him out of the bath and lay him face down on the towel on your lap.
7 Dry the baby all over, paying particular attention to the creases around the neck, underarms, knees and bottom.
8 Rub a little cream of petroleum jelly between his legs and on his buttocks.
9 Powder the baby’s body lightly to make sure it is properly dry.
10 Dress him.
Bathing should always be a happy time for both mother and baby. The time of day you do it depends on whether it makes him sleepy or not. If it does, do it in the evening; if it seems to wake him up then bath him in the morning. The bathing of the baby should fit into the established routine of the household. Fathers should participate if possible so evening may be more convenient, especially as the room is often warmer and the mother more relaxed.
Changing a Baby’s Napkin
Babies should be as comfortable as possible so the baby’s napkin may need to be changed both before and after each feed.
There are two widely accepted methods of putting on a baby’s nappy:
1 Lay the nappy out flat, fold it into a triangle and then fold into a smaller triangle. Place the baby on the triangle with the point down between his feet. Fold each of the side points downwards between his legs and tuck them well under him, then bring the central point up between his legs. All three thicknesses can then be held in place with one nappy pin. When pinning have two of your fingers between the baby and the nappy to avoid sticking the pin into him. Always use safety guarded pins.
2 Lay out the nappy and fold it lengthwise to produce three thicknesses. Fold up the lower third at one end so that you have an area of six thicknesses. Lay the baby lengthways on the nappy and fold it up between his legs, securing it at the sides with two safety pins. With boys it is best to have the thickest part in front and with girls at the back.
A good deal of work can be saved if a piece of nappy liner is put inside the nappy as this will avoid heavy soiling of the nappy and make washing so much easier. Disposable nappies are increasingly used and these entirely avoid nappy washing.
This should be flexible; here is a routine type of day:
On waking change him, feed him and put him back in his cot. He will probably go back to sleep again.
10.0 a.m. Bath him or just top and tail him. That means his face, hands and bottom. Feed him, dress him and if the weather is good put him in the garden in the pram.
2.0 p.m. Feed him and change him. If he is wakeful, mother him for a short time.
6.0 p.m. If you have bathed him in the morning, just top and tail him, change him and feed him. It might fit into the daily routine better to bath him in the evening. Put him in his nightclothes and tuck him into his cot. The temperature in the bedroom should not fall below 65°F (18°C) when a baby is very young.
10.0 p.m. Change him and feed him.
During the night the baby will probably wake for a feed for the first few weeks of his life. Feed him, change him, make him comfortable and then put him back into his cot and he will probably go back to sleep.