- Email: [email protected]
Antisepsis and Asepsis in Midwifery Practice.
1148
practice of aseptic surgery, and when we surroundings of the modern operating-room with those met with in most cases of midwifery in private practice, it is obvious that there can be no real analogy between the two. Further than this, if we were asked which required the greater degree of surgical training and the highest development of the so-called surgical conscience, we would at once For these reasons in answer the practice of aseptic surgery. LONDON: SATURDAY, APRIL ::3, 1910. attempting to answer the questions put to the Master of the Rotunda we would regard the maintenance of strict precautions in ordinary midwifery practice as a Antisepsis and Asepsis in Midwifery aseptic matter of considerable difficulty, in which view we believe Practice. w we should have the concurrence of the great majority of THE efficient safeguarding of the mother during childbirth tl the teachers of midwifery in this country. Asepsis is from the danger of septic infection is a problem which Sl in the if it be but to can maintained, antisepsis superior presents many difficulties from the practical point of view. ppresent circumstances we are concerned not with surgical If we accept the teaching that all cases of puerperal operations carried out under the best conditions but with septicaemia are due to the introduction of pathogenic 0operative midwifery carried out only too often under very organisms or their toxins into the patient’s body frombad b conditions. Dr. E. HASTINGS TWEEDY in his answer without, then in uncomplicated cases of labour the danger to t his correspondent describes a most ingenious method of can be averted to a large extent by the avoidance, as far as cconducting a labour, with the least possible danger to possible, of any manipulation, such as a vaginal examina- the mother of septic infection, in the circumstances t tion, which might result in the contamination of the patient. indicated, i which, however, depends for its success upon the While this is usually easy in a normal case it is impossible of strict asepsis. He relies upon the use of sterile 1 practice in any case of difficulty, and at least one vaginal examinaz rubber gloves and of sterilised instruments if we understand for the successful
I
contrast the
I
THE LANCET.
p0
tion must be
the most
made,
as a
uncomplicated
conduct of
rule, in and
of
labour, even ofhim i rightly, and apparently lays but little stress upon the straightforward type. Since the iemployment of antiseptic lotions either for the hands, the every
case
of labour without any
examinations
vaginal I3gloves, or the instruments used. Rubber gloves in the requires a greater degree of training and practice in abdo- conduct of labour cases are very useful, always provided minal palpation than fall to the lot of many students and that sufficient care is taken to render the hands as sterile most nurses, we must of necessity take care that internal as possible, that the rubber gloves themselves are protected examinations, which must be made, shall be as little by the use during the confinement of antiseptic lotions, and dangerous as is consistent with the exigencies of private that the further precaution is taken, which is insisted upon practice. How this end is to be attained best is a in most lying-in hospitals, of never touching the patient problem which teachers are by no means unanimous in except with hands wet with an efficient antiseptic lotion, answering. In a letter to the Master of the Rotunda Hos- even if covered with rubber gloves. It is, however, a pital, DubUIl,l a correspondent puts the very pertinent debateable question whether midwives should use rubber question as to what procedure the former would recommend gloves or not ; they are even at the present day costly with a view of preventing most certainly the occurrence of articles, they rapidly deteriorate, require careful cleansing any septic trouble if called upon single-handed to deliver and sterilisation, and a careless nurse or midwife is not a patient of a foetus or placenta and at the same time to likely to take any more care af her rubber gloves than keep the patient fully anaesthetised. He also asks for some she does of her hands. They are especially liable to be suggestion as to keeping forceps sterile after they have been torn in midwifery practice if instruments are employed, boiled when they are not required for immediate use. and if used as part of an aseptic technique require It is obvious, in attempting to give a practical answer to a greater amount of care to prevent them from consuch a query that we must first decide very clearly whether tamination than is the case if they are worn in conIs the aseptic we intend to practise asepsis or antisepsis. junction with the use of efficient antiseptics. Dr. TWEEDY treatment of a case of labour in private practice possible, considers that a benefit to humanity would be conferred or even desirable, and if it is, does it in these circumif the Central Midwives Board compelled the universal stances present any advantages over the antiseptic method of adoption of rubber gloves among midwives. If there treatment ?7 It appears to us that no profitable discussion was any means of ensuring that such gloves would only a case
,
of this question can be carried on unless to start with a clear distinction is made between these two methods of treat-
be
worn
when intact and after
a
careful
preparation
of the
hands
by washing and the proper certainly we would agree with this
use of antiseptics, then opinion, perfect asepsis is more difficult to but when we suggestion, maintain than perfect antisepsis, and the former method is see how the habitual use of rubber gloves only too often more likely to break down in unfavourable surroundings, produces a certain degree of carelessness in the proper while if any failure takes place the consequences are more cleansing and disinfection of the hands on the part of 1’ikely to be serious. When we consider the large amount dressers and even of some surgeons, we shudder to think of care and the elaborate precautions which are required of the condition of the ordinary midwife’s hands if she
ment.
In
our
,
1
THE
LANCET, April 9th, p. 1026.
thought
that she could
always safeguard
her
patient
from
I
1149 infection by the very
ingenious
use
manner
of rubber
gloves.
We admire theiare extremely likely to be torn, and unless they lit well are i a hindrance to the introduction of the hand into the genital
in which the Master of the Rotunda
arranges for the carrying
out of the various
manipulations,
first with one gloved hand and then with the other, during the course of a labour lasting perhaps for some hours, but at the same time we wish that he had laid greater stress upon the use of antiseptics, since we believe that in this way the safety of the patient still more certainly would be assured. The chief reason for substituting aseptic surgery for antiseptic surgery is the injury inflicted upon the living tissues by the use of strong antiseptics, but this reason is of little
of labour where the lotions are applied mainly to intact skin or mucous membranes ; and since it is easier for a person with but little training in unfavourable surroundings to carry out the
importance
of
in the conduct of
a case
rather than that of
passages. Dr. HASTINGS TWEEDY has given further a long list of all the things to be done when a case of midwifery is undertaken single-handed. Now although it is true that there are many things to be attended to, yet there is ample time, fortunately, in most cases, in which to carry them
out, provided that the attendant makes proper
preparations
beforehand, for the various emergencies which may Just
as
in the
preparation
of the hands
we
must
occur.
depend
upon antisepsis as well as asepsis, so in the disinfection of the instruments used asepsis alone is not sufficient.
After
boiling, the safest plan
is to immerse the instruments in
efficient antiseptic lotion such as lysol, and to use them direct from that. The chances of contamination in a midwifery case are many, and no other plan is so safe in allinstances. For the easy administration of chloroform in
some
practice regard antisepsis asepsis, the practice of asepsis as more difficult than that of antisepsis and therefore less likely to be certainly accomplished in private midwifery practice. The protection these cases the use of a Junker’s inhaler is found by many of the patient in these cases should be assured by means of to be the most convenient, and the method is simpler and the most certain and the most simple measures, and by such in some respects safer than the administration of chloroform on a mask. In such details, however, every practitioner will means as are least likely to fail in the emergencies which follow the routine recommended to him by his experience. may occur in this class of practice. The use. therefore, of The main point which we wish to make is that the first measures which, when properly and intelligently applied, are of the greatest value, but which present special difficulties essential in every case is the conscientious and efficient use and dangers unless practised in this most thorough manner, of a combination of asepsis and antisepsis, as far as possible,appears to us to require safeguarding. This can be readily in all conditions, and above all the avoidance of meddleaccomplished, not only by the wearing of rubber gloves, some midwifery. As to the manner of carrying out the the most important safeguard of all, but further by the details of such treatment no doubt there is room for 8r intelligent and conscientious use of antiseptic lotions and legitimate difference of opinion, but so long as this the observance of strict surgical cleanliness. In this respect principle is strictly adhered to we do not think a patient alone would we wish to amend a little the advice given by would run any undue risk of infection, even when a difficult the Master of the Rotunda Hospital. To surgeons accus- case of labour had to be undertaken without any assistance. tomed to operating in hospitals, surrounded by all the highly organised technique of aseptic surgery, and assisted by The Surgery of the Lymphatics. workers all trained to the highest degree in the observance THE lymphatic system has been, as it were, the Cin-of the necessary details, it is often a little difficult to realise how easily such a system may break down in other sur- derella of anatomy, and surgery has thought it of butroundings. For our part, while we cordially agree with small importance. The student in his dissection learns Dr. HASTINGS TwEny’S methods, we would like to render little of the lymphatic vessels and he pays no attention to the likelihood of any failure on the part of the practitioner lymphatic glands unless they happen to be enlarged. Yet more remote by advocating the employment in all such many years ago much work had been done on this subject, circumstances of both asepsis and antisepsis. In this way and SAPPEY’S monumental treatise suffices to show how he will doubly safeguard his methods from any risk of extensive has been our knowledge of the lymphatic system failure and his patient from the danger of infection. At a for many years. Up to a very recent date surgery has recent discussion on the treatment of labour in contracted contented itself with excising enlarged lymphatic glands, pelves one of the speakers expressed the opinion that especially when the cause of enlargement has been tuberthe use of rubber gloves was ’merely a passing fad and one culosis or malignant disease. A definite change of view not likely to survive. This is a view with which we cannot is now to be seen. Our knowledge of many obscure points in agree. When used intelligently, and with due regard to the the minute, and even in the gross, anatomy of the lymphatics surgical cleanliness of the hands, rubber gloves are un- has been increased, and Professor STARLING, in his work on doubtedly a most valuable addition to the surgeon’s outfit ; the fluids of the body, has advanced our knowledge of it must be remembered, however, that their cleansing and lymphatic physiology. Much has also been done of recent preparation requires special care, and must be done with years in the pathology and surgery of the lymphatics, and to we
extreme conscientiousness if they are not to prove an actual danger to the patient. If the gloves are torn the gloved
hand may be a more potent factor in the production of sepsis than if no glove at all is worn, and for this reason some of the strongest upholders of the principles of asepsis do not In operative midwifery, as we have said, they wear them.
this advance Mr. W. SAMPSON HANDLEY has contributed in no small degree; while his recent Hunterian lectures at the Royal College of Surgeons of England on the Surgery of the Lymphatic System will bring the whole subject forcibly before the medical profession. Mr. HANDLEY dealt mainly with the subject of the surgical
practice of aseptic surgery, and when we surroundings of the modern operating-room with those met with in most cases of midwifery in private practice, it is obvious that there can be no real analogy between the two. Further than this, if we were asked which required the greater degree of surgical training and the highest development of the so-called surgical conscience, we would at once For these reasons in answer the practice of aseptic surgery. LONDON: SATURDAY, APRIL ::3, 1910. attempting to answer the questions put to the Master of the Rotunda we would regard the maintenance of strict precautions in ordinary midwifery practice as a Antisepsis and Asepsis in Midwifery aseptic matter of considerable difficulty, in which view we believe Practice. w we should have the concurrence of the great majority of THE efficient safeguarding of the mother during childbirth tl the teachers of midwifery in this country. Asepsis is from the danger of septic infection is a problem which Sl in the if it be but to can maintained, antisepsis superior presents many difficulties from the practical point of view. ppresent circumstances we are concerned not with surgical If we accept the teaching that all cases of puerperal operations carried out under the best conditions but with septicaemia are due to the introduction of pathogenic 0operative midwifery carried out only too often under very organisms or their toxins into the patient’s body frombad b conditions. Dr. E. HASTINGS TWEEDY in his answer without, then in uncomplicated cases of labour the danger to t his correspondent describes a most ingenious method of can be averted to a large extent by the avoidance, as far as cconducting a labour, with the least possible danger to possible, of any manipulation, such as a vaginal examina- the mother of septic infection, in the circumstances t tion, which might result in the contamination of the patient. indicated, i which, however, depends for its success upon the While this is usually easy in a normal case it is impossible of strict asepsis. He relies upon the use of sterile 1 practice in any case of difficulty, and at least one vaginal examinaz rubber gloves and of sterilised instruments if we understand for the successful
I
contrast the
I
THE LANCET.
p0
tion must be
the most
made,
as a
uncomplicated
conduct of
rule, in and
of
labour, even ofhim i rightly, and apparently lays but little stress upon the straightforward type. Since the iemployment of antiseptic lotions either for the hands, the every
case
of labour without any
examinations
vaginal I3gloves, or the instruments used. Rubber gloves in the requires a greater degree of training and practice in abdo- conduct of labour cases are very useful, always provided minal palpation than fall to the lot of many students and that sufficient care is taken to render the hands as sterile most nurses, we must of necessity take care that internal as possible, that the rubber gloves themselves are protected examinations, which must be made, shall be as little by the use during the confinement of antiseptic lotions, and dangerous as is consistent with the exigencies of private that the further precaution is taken, which is insisted upon practice. How this end is to be attained best is a in most lying-in hospitals, of never touching the patient problem which teachers are by no means unanimous in except with hands wet with an efficient antiseptic lotion, answering. In a letter to the Master of the Rotunda Hos- even if covered with rubber gloves. It is, however, a pital, DubUIl,l a correspondent puts the very pertinent debateable question whether midwives should use rubber question as to what procedure the former would recommend gloves or not ; they are even at the present day costly with a view of preventing most certainly the occurrence of articles, they rapidly deteriorate, require careful cleansing any septic trouble if called upon single-handed to deliver and sterilisation, and a careless nurse or midwife is not a patient of a foetus or placenta and at the same time to likely to take any more care af her rubber gloves than keep the patient fully anaesthetised. He also asks for some she does of her hands. They are especially liable to be suggestion as to keeping forceps sterile after they have been torn in midwifery practice if instruments are employed, boiled when they are not required for immediate use. and if used as part of an aseptic technique require It is obvious, in attempting to give a practical answer to a greater amount of care to prevent them from consuch a query that we must first decide very clearly whether tamination than is the case if they are worn in conIs the aseptic we intend to practise asepsis or antisepsis. junction with the use of efficient antiseptics. Dr. TWEEDY treatment of a case of labour in private practice possible, considers that a benefit to humanity would be conferred or even desirable, and if it is, does it in these circumif the Central Midwives Board compelled the universal stances present any advantages over the antiseptic method of adoption of rubber gloves among midwives. If there treatment ?7 It appears to us that no profitable discussion was any means of ensuring that such gloves would only a case
,
of this question can be carried on unless to start with a clear distinction is made between these two methods of treat-
be
worn
when intact and after
a
careful
preparation
of the
hands
by washing and the proper certainly we would agree with this
use of antiseptics, then opinion, perfect asepsis is more difficult to but when we suggestion, maintain than perfect antisepsis, and the former method is see how the habitual use of rubber gloves only too often more likely to break down in unfavourable surroundings, produces a certain degree of carelessness in the proper while if any failure takes place the consequences are more cleansing and disinfection of the hands on the part of 1’ikely to be serious. When we consider the large amount dressers and even of some surgeons, we shudder to think of care and the elaborate precautions which are required of the condition of the ordinary midwife’s hands if she
ment.
In
our
,
1
THE
LANCET, April 9th, p. 1026.
thought
that she could
always safeguard
her
patient
from
I
1149 infection by the very
ingenious
use
manner
of rubber
gloves.
We admire theiare extremely likely to be torn, and unless they lit well are i a hindrance to the introduction of the hand into the genital
in which the Master of the Rotunda
arranges for the carrying
out of the various
manipulations,
first with one gloved hand and then with the other, during the course of a labour lasting perhaps for some hours, but at the same time we wish that he had laid greater stress upon the use of antiseptics, since we believe that in this way the safety of the patient still more certainly would be assured. The chief reason for substituting aseptic surgery for antiseptic surgery is the injury inflicted upon the living tissues by the use of strong antiseptics, but this reason is of little
of labour where the lotions are applied mainly to intact skin or mucous membranes ; and since it is easier for a person with but little training in unfavourable surroundings to carry out the
importance
of
in the conduct of
a case
rather than that of
passages. Dr. HASTINGS TWEEDY has given further a long list of all the things to be done when a case of midwifery is undertaken single-handed. Now although it is true that there are many things to be attended to, yet there is ample time, fortunately, in most cases, in which to carry them
out, provided that the attendant makes proper
preparations
beforehand, for the various emergencies which may Just
as
in the
preparation
of the hands
we
must
occur.
depend
upon antisepsis as well as asepsis, so in the disinfection of the instruments used asepsis alone is not sufficient.
After
boiling, the safest plan
is to immerse the instruments in
efficient antiseptic lotion such as lysol, and to use them direct from that. The chances of contamination in a midwifery case are many, and no other plan is so safe in allinstances. For the easy administration of chloroform in
some
practice regard antisepsis asepsis, the practice of asepsis as more difficult than that of antisepsis and therefore less likely to be certainly accomplished in private midwifery practice. The protection these cases the use of a Junker’s inhaler is found by many of the patient in these cases should be assured by means of to be the most convenient, and the method is simpler and the most certain and the most simple measures, and by such in some respects safer than the administration of chloroform on a mask. In such details, however, every practitioner will means as are least likely to fail in the emergencies which follow the routine recommended to him by his experience. may occur in this class of practice. The use. therefore, of The main point which we wish to make is that the first measures which, when properly and intelligently applied, are of the greatest value, but which present special difficulties essential in every case is the conscientious and efficient use and dangers unless practised in this most thorough manner, of a combination of asepsis and antisepsis, as far as possible,appears to us to require safeguarding. This can be readily in all conditions, and above all the avoidance of meddleaccomplished, not only by the wearing of rubber gloves, some midwifery. As to the manner of carrying out the the most important safeguard of all, but further by the details of such treatment no doubt there is room for 8r intelligent and conscientious use of antiseptic lotions and legitimate difference of opinion, but so long as this the observance of strict surgical cleanliness. In this respect principle is strictly adhered to we do not think a patient alone would we wish to amend a little the advice given by would run any undue risk of infection, even when a difficult the Master of the Rotunda Hospital. To surgeons accus- case of labour had to be undertaken without any assistance. tomed to operating in hospitals, surrounded by all the highly organised technique of aseptic surgery, and assisted by The Surgery of the Lymphatics. workers all trained to the highest degree in the observance THE lymphatic system has been, as it were, the Cin-of the necessary details, it is often a little difficult to realise how easily such a system may break down in other sur- derella of anatomy, and surgery has thought it of butroundings. For our part, while we cordially agree with small importance. The student in his dissection learns Dr. HASTINGS TwEny’S methods, we would like to render little of the lymphatic vessels and he pays no attention to the likelihood of any failure on the part of the practitioner lymphatic glands unless they happen to be enlarged. Yet more remote by advocating the employment in all such many years ago much work had been done on this subject, circumstances of both asepsis and antisepsis. In this way and SAPPEY’S monumental treatise suffices to show how he will doubly safeguard his methods from any risk of extensive has been our knowledge of the lymphatic system failure and his patient from the danger of infection. At a for many years. Up to a very recent date surgery has recent discussion on the treatment of labour in contracted contented itself with excising enlarged lymphatic glands, pelves one of the speakers expressed the opinion that especially when the cause of enlargement has been tuberthe use of rubber gloves was ’merely a passing fad and one culosis or malignant disease. A definite change of view not likely to survive. This is a view with which we cannot is now to be seen. Our knowledge of many obscure points in agree. When used intelligently, and with due regard to the the minute, and even in the gross, anatomy of the lymphatics surgical cleanliness of the hands, rubber gloves are un- has been increased, and Professor STARLING, in his work on doubtedly a most valuable addition to the surgeon’s outfit ; the fluids of the body, has advanced our knowledge of it must be remembered, however, that their cleansing and lymphatic physiology. Much has also been done of recent preparation requires special care, and must be done with years in the pathology and surgery of the lymphatics, and to we
extreme conscientiousness if they are not to prove an actual danger to the patient. If the gloves are torn the gloved
hand may be a more potent factor in the production of sepsis than if no glove at all is worn, and for this reason some of the strongest upholders of the principles of asepsis do not In operative midwifery, as we have said, they wear them.
this advance Mr. W. SAMPSON HANDLEY has contributed in no small degree; while his recent Hunterian lectures at the Royal College of Surgeons of England on the Surgery of the Lymphatic System will bring the whole subject forcibly before the medical profession. Mr. HANDLEY dealt mainly with the subject of the surgical