xt78930nt57c https://exploreuk.uky.edu/dips/xt78930nt57c/data/mets.xml The Frontier Nursing Service, Inc. 1941 bulletins  English The Frontier Nursing Service, Inc. Contact the Special Collections Research Center for information regarding rights and use of this collection. Frontier Nursing Service Quarterly Bulletins The Quarterly Bulletin of The Frontier Nursing Service, Inc., Vol. XVI, No. 3, Winter 1941 text The Quarterly Bulletin of The Frontier Nursing Service, Inc., Vol. XVI, No. 3, Winter 1941 1941 2014 true xt78930nt57c section xt78930nt57c I h Q terly Bulletin of
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(See "Beyond the Mountains") ] “
Published Quarterly by the Frontier Nursing Service, Lexington, Ky. I  
"Enterucl as second class matter June 30, 1926, at the Post OfTlce at Lexington, Ky.,  i
under Act of March 3, 1879." .  [
Copyright 1941 Frontier Nursing Service, Inc.  

 , , i
 E . I
 1 (Irish Poems, Sidwick & Jackson, London)
 i I build a strong tower for the Children, the Children,
  With moat and portcullis I keep it still.
 p The foe clangs without, but within it the children _
_ Sleep soundly and sweetly till cock crow shrill.
2 I wage a holy war for the Children, the Children, '
 - My hand against the world that they may live,
. I am cunning and crafty as the fox for her children,
 · Wise as the serpent lest the children grieve.
 { I build a warm fire for the Children, the Children,
` To my tower oft beleaguered, allies I call, U
j They shine like the sun to the eyes of the Children,
V G0d’s men-at-arms keep us by gate and wall.
I leave in safe keeping the Children, the Children, t
· Down to the cities my way I take,
" Past the walls and the sentry, alert for the Children,
, I creep into the shadows for the Children’s sake.
` I gather rich stores for the Children, the Children,
The lowing of oxen is heard as I come.
I carry the sheaves in my arms for the Children,
{ O, sweet on the hill—t0p the lights of home.
Unless the Lord build it, the house for the Children,
Unless He be with me my labour’s vain,
He has thought it, and planned it, the fold for the Children,
r ,9 Where the lambs are folded without fear or stain.
 At I fight the holy iight for the Children, the Children,
i 1, The Sons of God, glorious, sit down at my board,
ii Though foes hem us in, shall I fear for the Children,
 ; Fighting the strong iight in the Name of the Lord?
l A

 ‘ s
i Q
ei ;
A Santa Claus Job Kay Bullcley 52 ’ i
Adventures in Midwifery 15   V
An Ounce of Prevention Beatrice L. M. Boxall :
A Pound of Cure Peggy Brown _ ·
Amateur Editor Mary Breckinridge 25 i 
Beyond the Mountains 56  
Field Notes 68 T 
For the Children Katherine Tynan 1  A
Old Courier News 20 E, 
Old StaH News 31 VV 
Report on Fourth Thousand I 
Coniinements Dublin-Steele 3  
The American Red Cross Harvard  
Hospital Mrs. Edwin A. Locke, Jr. 54  E;
The Invisible Guest Elisabeth Holmes 50 Q .
Anatomy of the Horse A Drawing 14  
Bargain Box 55 A
Culture at 3. Price A Book Review 19 v· `
Lines from the Last Speech of I 
Lord Lothian 49 Q
Not What She Meant! Church qf England Newspaper 24 ? 
What Is This—Union Now'? The New Yorker 30 in 

 l F1>.oNT1ER NURSING smnvicm s
  _ New York City A
  Third Vice-President p
_ and Statistician
  November 13, 1940.  
  Mrs. Mary Breckinridge
  Frontier Nursing Service
Q Wendover g ·
Q  Leslie County, Kentucky A
A  Dear Mrs. Breckinridge:
 ij I take pleasure in sending you a report prepared
· i by Miss Steele of this office on the last thousand ma-
  ternity records of your service. I have read this report
 li  with a great deal of interest. I believe you share with
  me the feeling that this is a very satisfactory report _
  on a most valuable service. I do not know of another
  instance in the literature where there have been such
 {. consistently good results shown in connection with a
  maternity service. You and your associates are cer-
  tainly deserving of all praise.
  I need hardly tell you that we thoroughly enjoyed
 ‘ this opportunity to study these records, and we hope
 - it is your plan to make the results of this study avail-
 ° _ able in the literature for the guidance of others.
·`  * Sincerely yours,
  Third Vice-President
  and Statistician

of _, 
We have just completed the tabulation of another thousand  
maternity records of the Frontier Nursing Service covering the  
period May 1st, 1937 to April 30th, 1940. In this thousand rec- · l
V ords there was only one maternal death. This is an improve-  
ment over the record of the last thousand cases although it is  
not quite as favorable as the record made in the first two thou-  
sand deliveries when there were no deaths assigned to puerperal I .
Altogether, the Frontier Nursing Service has now delivered  . 
- four thousand and four mothers with only five maternal deaths, ~ 
two of which were due to cardiac conditions. This is the equiva-  
lent of a puerperal death rate of .76 per 1,000 live births. In the    
white population in the United States, in approximately the l ?
same period, the average was 5.6 deaths per 1,000 live births. _ &
In Kentucky the comparable figure was 5.2 per 1,000. Such  A 
comparisons are not exact, of course, since the age of the moth-  
ers, the order of para, etc., which affect mortality, differ some-  _
what in the three groups. Adjustment for this would not ma-  I 
terially change the results however.  `
The age distribution of the women in the present series  V
of a 1,000 cases resembled closely that of the white mothers of ’ .,
Kentucky in 1936 and 1937, the last years for which general ` 4 
population data are available. That is, approximately 50 per- I 
cent of the women were less than 25 years of age, and about '
85 percent less than 35 years old. In spite of the similarity  T
in age distribution there was considerable difference in order j
of para in the two groups. The women delivered by the Frontier `4
Nurses were multipara in 78 percent of the cases and of sixth  
or higher para in 29 percent. In the white population of Ken-  

 ? ’ l
l Fnoiwxnn Nunsrm; snnvicii 5
Ti, tucky about 70 percent were multipara and about 20 percent
  sixth or higher order of para. Thus the favorable effect on
  mortality of the smaller proportion of primipara in the Frontier
"  Nursing Service series is largely counterbalanced by the larger
;·  proportion of women of high para where the hazards of preg-
1 nancy are above average.
l Since many of the women in the series were of a high order
  of para it is of interest to compare their record of pregnancy
  l wastage with the figures quoted by Dorothy G. Wiehl and Kath-
l _ arine Berry in an article on Pregnancy Wastage in New York
  Cityf, namely, "The rates for total pregnancy loss from natural
_   causes reported in these various studies show a surprising
; , degree of similarity, and the Wastage from stillbirths and spon-
 i  taneous abortion is too consistently about 11 or 12 percent in
  these studies of very different population groups to be dismissed
  as a mere chance phenomenon." In the present series, at the
Y  time of registration for care, excluding the current pregnancy,
 ·*  the thousand mothers totaled 3,425 gravida as compared with
Fi  3,109 para. That is, these women reported 316 previous abor-
if  tions or a rateof 9.2 abortions per 100 pregnancies. Since the
  stillbirth rate among these women appears to be approximately
  3 per 100 the total pregnancy Wastage is over 12 percent. Al-
_  though comparison with published data must be made with
¤ i extreme caution because of differences in definitions the above
  results seem to indicate that the pregnancy Wastage of these `
 * rural women in Kentucky is about average.
 f  The Service seems to be increasingly successful in its educa-
 ‘ tional program as to the need for early registration for prenatal
" care. In the present series, 8.7 percent of the mothers were
 ,-' registered before the end of the first trimester of pregnancy
. .  and 64.4 percent before the end of the second trimester. In the
 ' third 1,000 cases, these figures were 4.9 and 55.7 respectively,
N I and in the earlier series even less. In all series the date of
  registration has been computed from month of delivery.
j That the Frontier nurses kept in close contact with the
`4 women under their care is evidenced by the fact that 92 percent
4 . ..
  *From the Milbank Memorial Fund Quarterly, July. 1937, XV, No. 3, pp. 229-247.
J_ .

of the women registering in the first trimester received 10 or  ,
more prenatal visits and that 70 percent of those registering in  
the second trimester also were visited 10 or more times. On the ·  V
average the women registering in the first trimester received  
16.4 prenatal visits, in the second trimester 12.2 visits and in  
the last trimester 7 .9 visits.  
The proportion of women examined by the doctor during [
pregnancy was higher in this series than in prior thousands.  
The doctor examined 156 or 70.9 percent of the 220 primipara T,
during pregnancy. This may be compared with the 49 percent _E 
of primipara examined in the third thousand, 35 percent in the  » 
second thousand and 13 percent in the first thousand cases.  
Even the proportion of multipara examined in the present series  
of cases was as high as 42.8 percent. "  
Another example of the improvement of the Service in  
recent years is the increased proportion of laboratory tests per-  
formed. We find that 548 of the women in this 1,000 were  
given either a Kahn or Wasserman and in some cases both  
tests. Tests were made for practically all of the women regis- { 
tering at Hyden or Bowlingtown Centers or at Hyden Hospital. gg
Even for the outlying districts, the number of tests made each ji
years is increasing. ‘ 
` A
· I. Period of Pregnancy    
More complications of pregnancy were reported for this é}
thousand deliveries than for previous ones. This is largely due,   A
no doubt, to the improvement in record keeping. Altogether, ·
complications of pregnancy were reported for 372 women. Puer- j
peral complications were recorded for 236 women and non- ,, _
puerperal for 197. The specific causes are listed in Tables VII · _
and VIII.  `
In the present series, the most common non-puerperal com-  l '
plications reported were 45 cases of enlarged thyroid, 20 cases ¥
of cardiac disturbances, 18 cases of intestinal parasites, 17 of  
anemia, 11 of simple goiter, 10 of dental caries and 7 each of  
trichomonas vaginalis, positive Wasserman, gingivitis, and colds.  
From the very type of non-puerperal complications listed it is {

   1¤RoN·r1mR Nunsmc smzviom 7
  evident that the Frontier Nursing Service was checking closely
{  on the mothers under their care. _
 Q  Among the puerperal complications, the most common were
V ; the toxic symptoms. Albuminuria, high blood pressure, etc.
-  were recorded 81 times. In one instance the pregnancy was
{  - terminated prematurely resulting in the loss of the infant.
  After the toxic symptoms the most common complications
  were the varicosities which were reported 42 times. Bleeding
 ~.  was next in order of frequency, with 39 cases, being closely
f i l followed by 38 cases of yellow discharge without mention of
i. ; gonorrhea.
· 3 A generally contracted or an abnormal pelvis was reported
 _} during pregnancy for 21 primipara and 4 multipara. The condi-
  tion was confirmed by the doctor in each of the cases and the
 E mother transferred to the hospital or a center for delivery in
 j   14 instances. Twenty-two of the mothers were delivered of a
  live infant that survived the neonatal period. One case ter-
 gl minated in a late abortion and in one case the doctor delivered
 if a stillbirth at term. The remaining case was that of the mother
 si who died following a Cesarian section, the infant, although live
{i i born, surviving only 50 minutes.
 g  Malposition was reported for 23 cases, of which 19 were
  persistent breech. The doctor examined 10 of these during
  pregnancy and was present at the delivery of five, using forceps
  on one case of transverse arrest and on two of extended breech.
}   In an additional case of extended breech the Smellie Veit method
 Q ? was used by the nurse in attendance for the extraction ofthe
if A head for the second of a pair of twins. There were no stillbirths
°‘ and only one neonatal death in the group which included two
  pairs of twins.
 if The pregnancy was terminated prematurely in 52 cases,
 ·. 12 before the end of the 28th week and 40 between the 28th
l week and term. Among the 12 abortions one was therapeutic,
‘ performed because of a cardiovascular-renal condition. In 8 of
ig the remaining 11 cases the mother had suffered from complica-
  tions of one or more types during pregnancy.
  The premature births also were higher among the women

suffering from complication of pregnancy. That is, the rate .of  
prematures was 75 per 1,000 among women for whom a com-  -,‘—
plication of pregnancy was reported as compared with 38 per  7
1,000 for mothers experiencing no difficulties in that period.  E 
II. Period of Labor  Y;
Again as in previous series, the majority of the women were  
delivered by the nurses of the Frontier Nursing Service in their  
own homes. In all, 47 or 21.4 of the primipara and 76 or 9.7 [ 
percent of multipara were transferred to the hospital for de- I 
livery. I 
The infant was born 153 times before either nurse or doc-  
tor arrived. In 780 cases the nurse delivered the infant alone ‘
while in 67 cases she had the assistance of the doctor in one Q ’
or more stages. An abnormal delivery was reported 19 times. Y_ 
In three cases there was a Cesarian section, in 2 cases an episi—  
otomy, in 13 cases forceps delivery, and in one case the Smellie  Yi
Veit method of delivery was employed. -· 
The history of one of the Cesarian sections may be noted  
as in the case the mother died. The mother, a secundigravida  
had a record of a difficult labor in her first pregnancy. In that  
instance she was delivered prematurely of a stillborn monstros-  Q
ity at Hyden Hospital by Duhrssen’s incision, low forceps, and  
manual removal of placenta by the surgeon after a labor of Q
64% hours. This time she was admitted to the hospital in pre-  
mature labor which was intermittent in type. She was originally  
arranged for a terminal Cesarian section with sterilization. Due  
to premature labor and premature rupture of membranes with  
signs that the cervix was dilating the operative procedure was  
deferred. When the dilatation proved not to be adequate the  _A '
Cesarian section was performed with removal of a viable foetus I 
of about 28 weeks gestation which expired within an hour after  
delivery. The patient did not respond to usual post-operative `
evacuation treatment despite the care with which this was ar-  
ranged. An obstinate fecal impaction developed leading to local it
peritonitis. The mother died six days after delivery of intestinal 1.
obstruction with fecal impaction, paralytic ileus and pelvic peri-  
V tonitis.  

l FRom·1ER Nuasmc smzviom 9
  The length of labor in the current thousand corresponded
  _ closely to that in the earlier cases. In general over two thirds
 if of the multipara were in labor less than twelve hours while
 °?‘ nearly the same proportion of primipara had labor of twelve
 . hours or more.
  Some 320 puerperal complications of labor were reported
 ’ for 252 women. The most common was excessive bleeding. In
» 96 cases there were hemorrhages (a loss of 20 ounces or more
` of blood being considered a hemorrhage), 20 of which were
.  accompanied by shock. The next most common condition was
  laceration or rupture of the perineum. There were 61 such
 Q cases as compared with 47 in the third 1,000 and 34 in the second
  1,000 cases delivered by the Service.
 ii Malpresentation of foetus occurred 23 times, while in
 Y addition, there were 25 cases of persistent posterior, 22 of im-
 Q pacted shoulders and one each of prolapse of hand and of cord.
 Q In 12 cases of malpresentation and one of persistent posterior
j  the infant was stillborn. In 12 out of the 23 cases in which
  _the foetus presented abnormally the mother had been examined
  by the doctor during pregnancy and in 10 cases had been trans-
 E ferred to the hospital for delivery.
 iq The toxic symptoms which, as previously stated, manifested
Q, themselves 81 times during pregnancy, were recorded as com-
ii plicating labor in only nine instances. Eight of these were
  women whose toxic condition had persisted from pregnancy. The
  remaining case and the only one where eclampsia developed,
  had shown no symptoms during pregnancy and the convulsions
 _{  at labor were quite unexpected. The toxic condition at labor
 Y  was in no case fatal to mother or child. Other complications of
I , labor which ocurred in more than occasional instances were
-—  19 cases of prolonged labor and 16 of retained placenta.
f To summarize the experience of the period we may note
( that there were 52 premature terminations of pregnancy result-
L ing in 34 livebirths and 22 stillbirths. In addition there were
Q, 11 stillbirths among the deliveries at term. That is, altogether
  there were 33 stillbirths. This may be compared with an aver-
i age of 29 stillbirths per 1,000 in the previous three thousand
ill deliveries.

. it
III. Period of Puerperium  ’ 
The number of complications reported in the puerperium  gi
was much higher in this thousand cases than in the earlier series.  
As we noted under the discussion of the "Period of Pregnancy"  » ;
this is largely due, without doubt, to the further improvement  2
in the keeping of the records. For example, we find a startling IQ 
increase in the number of cases for which septicemia was re-  vb 
ported. That is, in this series, there were 88 cases of endocer-  
vicitis and endometritis as compared with 12 in the previous  ip  
thousand, 13 cases of low grade temperature, where there were _
none before and 15 cases of gonococcic vaginal discharge as -  
compared with one in the last series. Also it may be noted that    
the toxic symptoms increased from 14 to 23, the breast com- 3 -Q
plications from 16 to 25 and the cases of subinvolutio_n of the I 
uterus from 45 to 65.  
At the same time some of the more common terms showed _ 
little change in incidence. For instance there were two cases  
of hemorrhage and 11 of flowing in this series as compared with  
3 and 10 respectively in the previous series. The cases of sal- Qi
pingitis numbered three in both series while pyelitis was record-  
ed 8 times in this series and 7 times in the previous thousand.  
Likewise the number of cases with elevation in temperature  
differed little in the two series. ig
The non-puerperal complications of the puerperium were  
similar in type to those reported last time although somewhat §`;
higher in number. The one exception was the respiratory con- A 
ditions. In the present series there were only 10 cases of re-  
spiratory disease, as compared with 24 cases in the third 1,000. ; f
The diseases with higher incidence this time than last were those   3
of the circulatory and of the genitourinary system. Heart con- { 
ditions were reported for nine women in this series as compared ·  ·
with three in the previous series and chronic pelvic disease  
seven times as compared with two previously.  Q
The condition of the mother was reported as satisfactory  '
in 939 cases at the end of the month’s post-partum care. In 53 I
cases the condition was fair and in 7 unsatisfactory. The one
death in the series occurred in the puerperium.  
The infant mortality during the first month was 29.5 per
1,000 livebirths or slightly below the rate for Kentucky during  
. it 

 I .
 A  F the same period. Nineteen of the 29 deaths occurred among
 li premature infants. That is, the neonatal rate for babies carried
 Vg to term was only 10.5 per 1,000 as compared with 558.8 per
  1,000 for those delivered prematurely. The neonatal deaths
  E among the ten infants delivered at term included 2 cases of
Q, malformation, 5 cases of asphyxia, one case of weakness at
j , birth—the mother having fallen in the 8th month, one case of
  probable pneumonia and one case of an unknown origin. In six
"f f of the 10 cases, pregnancy or labor had been complicated for
’  the mother.
  IV. Comparison with Earlier Studies
  Finally, it may be of interest to compare the outstanding
  results of the four thousand odd cases delivered by the nurses
  of the Frontier Nursing Service.
, 1. In the first and second thousand cases there were no
  puerperal deaths, although there were two deaths charged to
  chronic conditions. In the third thousand cases there were two
  pneumonia deaths, which under "joint cause precedure" as indi-
  cated by the Manual of the International List of Causes of
*  Death and Joint Causes of Death would be charged to the puer-
  peral state. In the fourth thousand there was one death
  charged to a puerperal cause. That is, the Service would record
_ Q a puerperal death rate of .75 per 1,000 pregnancies or .76 per
  1,000 livebirths in the total of 4,004 cases.
  2. There were 52 premature terminations of pregnancy
  in the fourth thousand as compared with 69, 41 and 42 respec-
i l tively in the third, second and first thousand cases.
  I 5. In the first series of 1,004 pregnancies there were 27
9  stillbirths, in the second series of 1,000 cases 29 stillbirths, in
 ~  , the third series 32 stillbirths, and in the present series 33. That .
  is, the stillbirths in the 4,004 pregnancies occurred at the rate
 V; of 30.2 per 1,000 pregnancies.
 ' 4. There were fewer neonatal deaths in this series than
, in the last thousand although more than in either the first or
second thousand. The death rate per 1,000 live births in the
= present series was 29.5 as compared with 25.3, 26.5 and 39.8 in
J the first, second and third series.
4 5. The nurse was assisted more often by the doctor in this

. 2
' than in the earlier series. The doctor’s assistance was required yl
in one or more stages of labor in 52 cases in the first series,  
in 61 in the second series, in 53 in the third series, and in 67  `
in the fourth series.  ;  Y
6. The mother has been transferred to the hospital for  
delivery in an increasing number of cases in each thousand.  “
While 16 mothers were delivered in the hospital in the first  
thousand, 66 were transferred there in the second thousand,  
85 in the third thousand and 123 in this last thousand.  j
7. The baby was born before the nurse arrived in 115 1 ;
cases in both the first and second thousand, in 134 cases in the  
third thousand and in 153 cases in the fourth thousand.  
8. The average date of registration for prenatal care is  
earlier in this series than in prior ones—41 percent registering V =
before the sixth month as compared with 32 percent, 21 percent Q2
and 18 percent in the third, second, and first series, respectively.  
9. There were 236 women with puerperal complications Qi
in pregnancy in the present series as compared with 193 in the  
second group and 182 in the third group. In the first series f 
puerperal complications were reported for 287 women. The j 
toxic symptoms, which are the most common puerperal compli- . 7
cations of pregnancy, dropped sharply in the fourth thousand  
as compared with the earlier series. They were recorded only 1i E
81 times in this series as compared with 200, 101 and 129 times  
in the first three thousands. The varicosities which were re-  
corded 120 times in the first series and dropped sharply to 48  
in the second series_ and to 37 in the third series rose slightly V 
to 42 in the fourth series. . `  
In the present group of 1,000 cases a generally contracted  [
or abnormal pelvis was reported 25 times as compared with I 
isolated instances reported in earlier series. A part of the in-  
crease is, no doubt, due to a change in recording. 74
10. In the first series of cases, 366 _women reported 434  A
puerperal complications in labor. In the second series, 277 .
women reported 343 puerperal complications, in the third series A 
235 women reported 306 complications and in the fourth series ‘
252 women reported 320 complications. A difference in the “
definition of "excessive bleeding" in the first and later series {

  . FRoN·i·1mR NURSING smzvxcm is
 ‘ L
ji accounts for a large part of the apparent decline in complica-
_¥  11. The number of malpresentations (23) were identical
 y. ‘ in the third and fourth thousands. In the first and second thou-
 .   sand there were 13 and 22 such complications, respectively.
jj ; 12. There was more interference necessary in the delivery
  of the fourth thousand cases than in the earlier ones. In this
? § series there were 3 Cesarian sections, 13 forcep deliveries and 2
 Z episiotomies, and one delivery by the Smellie Veit method. In
  the first group there was one Cesarian and nine forceps deliv-
  eries; in the second group two Cesarian sections, one episiotomy
T 5 and four forceps cases and in the third group one Cesarian, one
  Duhrssen’s incision with low forceps and one episiotomy. Also,
  in the third thousand, internal version with ether was necessary
  for four cases.
  13. There was another rise in the number of women for
Eg whom puerperal complications were reported in the puerperium
. ; in this series as compared with the last, which in turn had shown
 - _ an increase over the earlier series. The cause which was largely
‘  responsible for the apparent rise in complications last time was
 ,  "subinvolution of the uterus". In addition there was a slight
,= rise in septic conditions. This time, both conditions are reported
l g still more often. For example, the cases of endocervicitis and
  endometritis accounted for 88 complications this time as com-
ii  pared with 12 in the last thousand and none in the second thou-
  sand, while cases of subinvolution of the uterus increased from
 I  zero in the second thousand to 45 in the third thousand and to
  65 in the present series. Altogether, the complications of the
 [  puerperium have increased from 95 in the first series and 92
 ` in the second series to 137 in the third series and to 299 in the
` fourth series.
 ` 14. The proportion of mothers considered as in satisfac-
tory condition at the end of the puerperium was slightly less in
p this fourth series than in any of the earlier ones, 939 as com-
V  pared with an average of 958 in the prior three thousand.
`i Statistical Bureau.
{ November 12, 1940.

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