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The incidence of puerperal infection in patients delivered in the hospital as compared to patients delivered at home
THE
INCIDENCE
OF PUERPERAL
DELIVERED
IN THE PATIENTS
HOSPITBL DELIVERED
MERRELL L. STOUT, M.D., (From.
the Department
of Obstetrics,
the Johns
F
INFECTION
IN PATIENTS
AS COMPARED
TO
AT HOME BALTIMORE, MD. Hopkins University
and
Hospital)
OR many years there has been considerable discussion concerning the incidence of puerperal infect,ion following delivery in the home There have been frequent as contrasted with the lying-in hospital. statements made in the literature to the effect that the average obstetric patient is safer at home than in the hospital, and the following study has been undertaken in an effort to compare the incidence of puerperal infection in institutional and domiciliary practice. At the outset it was felt that there were two factors which had to be considered in order to present comparable figures : first, t,he large number of late admissions of abnormal a.nd neglected patients to a hospital service with its resulting high incidence of operative deliveries and its attendant increase in morbidity; and second, the relative lack of postpartum supervision of patients delivered in the home as compared to those in the hospital. In consideration of the first factor WC have included as a control group the cases of multiparas who were delivered spontaneously of viable children without operative induction by bag or bougie on the Hospital Service of the Johns Hopkins Hospital between May 1, 1932, and April 30, 1934, inclusive, and have compared them to multiparas delivered in like manner by the Outside Service during the same period of time. Concerning the second factor, it has long been noted that mild cases of puerperal infection are demonstrable by fever only in the afternoon and evening, and it has been thought that many of them have been missed on the Outside Service owing to the fact that the nurse in making her postpartum visits was able to record only one temperature reading per day, and this usually between the hours of eight and eleven in thtb morning. Therefore, in order to obtain closer supervision of the cases delivered at home during the years 1933 and 1934, temperatures have been taken every four hours from eight in the morning to eight at. night in t,he following manner: Four thermometers were left at each house in separate envelopes marked with the appropriate hour, The patient was instructed to place each in hrr mouth for five minutes at Ihe proper time and then to replace each in its envelope for the nurse to read on her morning rounds. Patients mere cautioned not to drink hot liquids before taking the temperature and to keep the thermometers 588
STOUT
:
PUERPERAL
589
INFECTION
in a cool place when not in use, If fever was noted by the nurse, t&c externe was immediately notified and the cause investigated. The criterion employed for a febrile pucrperium is that of the Obstetrical Service of the Johns Hopkins Hospital, namely, two elevat’ions of temperature to 100.4” F. or higher on two or more days of the puer. perium not necessarily consecutive, and excluding the first twenty-four hours after delivery. A diagnosis of puerperal infection has only becrr made in those cases in which the fever could not he adequately explained on a basis of pyelitis, upper respiratory infection, mastitis, or other causes, and in whom there was some direct evidence of uterine involvement as shown by abdominal pain and tenderness, foul lochia, and other signs. No patients were included who had been altended during prtrgnancy or labor by midwives or outside physicians. Finally, we wish to state that the patients in t,he series, both hospital and home. comprise material from t.he tenement district, of a large city and are about equally divided between whites and blacks. We, therefore, feel that while this series of cases may not. be comparable to another from a different city or class of individuals, they are certainly cornparable to each ot.hcr. TABLE
I.
HOSPITAL
CASES
May 1, 1932-April Multiparas delivered spontaneously Cases of puerperal infection Incidence of puerperd infection Febrile, other causes
30, 19.73
May 1, 1933-April Multiparas delivered spontaneously Cases of puerperal infection Incidence of puerperal infection Febrile, other causes
30,
340 15 4.4% 10 1934 365 18 4.9% 10
Table I shows the incidence of cases of puerperal infection among 705 normal women delivered at the Johns Hopkins Hospital during a period of two consecutive years, and it should be pointed out that there is only a very slight difference (0.5 per cent) bctwecn one year and the ot hr r. TABLE
II.
OUTSIDE
CASES
May 1, 193%--April Multiparas delivered spontaneously Cases of puerperal infect,ion Incidence of puerperal infection Febrile, other causes
30, 1933
dlay 1, 1933-April Multiparas delivered spontaneously Cases of puerperal infection Incidence of puerperal infection Febrile, other causes
30,
1934 510 43
8.4% 5
Table II shows the incidence of puerpcral infection as recorded on t,h(x Outside Service during the samcb two-year period and includes 989 cases.
590
AMERICAN
JOURNAL
OF
OBSTETRICS
AND
GYNECOLOGY
During the years 1932 and 1933, there was but one temperature reading per day taken by the nurse on her morning rounds, while during 1933 and 1934, temperatures every four hours were obtained as described a.bove. The increase in the incidence of puerperal infection from OS per cent to 8.4 per cent is entirely the result of the closer supervision of cases during the second year, since only the nurses’ record of morning temperatures had been used, there would have been four rather than forty-three cases diagnosed, a figure identical with that of 1932 and 1933. That the general character of puerperal infect,ion did not change in the locality in question from one year to the next is suggested b> the fact that during each year there were three cases on the Outside Service considered sufficiently severe to warrant transfer to the Hospital, and also by the fact that the average duration of fever for both years as well as its maximum height among the Hospital cases was approximately the same. A careful study of the comparative severity of the infections occurring in the hospital and the home revealed nothing of significance. The height of the temperatures and their duration was about the same in both series of cases. Of the cases included in this study, there was one death on the Hospital Service which followed a prolonged labor of forty-five hours and severe perineal lacerations with an ensuing streptococcus septicemia, and one death on the Outside From Servic.e which was the direct result of a fulminating eclampsia. the similarity of the character of the infections occurring in the two series and from the definitely increased frequency of puerperal infection among patients delivered in the home (8.4 per cent as against 4.69 per cent), we believe that hospitalization of the lying-in woman is an important factor toward her well-being. CONCLUSIONS
1. The incidence of puerperal infection was almost twice as great in a series of normal women delivered in the home as in a comparative group delivered in the hospital. 2. No difference in the severity of the infection could be elicited between the two groups. 3. This study would seem to indicate that in the modern maternity hospital the patient has a better chance of escaping infection than in the home.
INCIDENCE
OF PUERPERAL
DELIVERED
IN THE PATIENTS
HOSPITBL DELIVERED
MERRELL L. STOUT, M.D., (From.
the Department
of Obstetrics,
the Johns
F
INFECTION
IN PATIENTS
AS COMPARED
TO
AT HOME BALTIMORE, MD. Hopkins University
and
Hospital)
OR many years there has been considerable discussion concerning the incidence of puerperal infect,ion following delivery in the home There have been frequent as contrasted with the lying-in hospital. statements made in the literature to the effect that the average obstetric patient is safer at home than in the hospital, and the following study has been undertaken in an effort to compare the incidence of puerperal infection in institutional and domiciliary practice. At the outset it was felt that there were two factors which had to be considered in order to present comparable figures : first, t,he large number of late admissions of abnormal a.nd neglected patients to a hospital service with its resulting high incidence of operative deliveries and its attendant increase in morbidity; and second, the relative lack of postpartum supervision of patients delivered in the home as compared to those in the hospital. In consideration of the first factor WC have included as a control group the cases of multiparas who were delivered spontaneously of viable children without operative induction by bag or bougie on the Hospital Service of the Johns Hopkins Hospital between May 1, 1932, and April 30, 1934, inclusive, and have compared them to multiparas delivered in like manner by the Outside Service during the same period of time. Concerning the second factor, it has long been noted that mild cases of puerperal infection are demonstrable by fever only in the afternoon and evening, and it has been thought that many of them have been missed on the Outside Service owing to the fact that the nurse in making her postpartum visits was able to record only one temperature reading per day, and this usually between the hours of eight and eleven in thtb morning. Therefore, in order to obtain closer supervision of the cases delivered at home during the years 1933 and 1934, temperatures have been taken every four hours from eight in the morning to eight at. night in t,he following manner: Four thermometers were left at each house in separate envelopes marked with the appropriate hour, The patient was instructed to place each in hrr mouth for five minutes at Ihe proper time and then to replace each in its envelope for the nurse to read on her morning rounds. Patients mere cautioned not to drink hot liquids before taking the temperature and to keep the thermometers 588
STOUT
:
PUERPERAL
589
INFECTION
in a cool place when not in use, If fever was noted by the nurse, t&c externe was immediately notified and the cause investigated. The criterion employed for a febrile pucrperium is that of the Obstetrical Service of the Johns Hopkins Hospital, namely, two elevat’ions of temperature to 100.4” F. or higher on two or more days of the puer. perium not necessarily consecutive, and excluding the first twenty-four hours after delivery. A diagnosis of puerperal infection has only becrr made in those cases in which the fever could not he adequately explained on a basis of pyelitis, upper respiratory infection, mastitis, or other causes, and in whom there was some direct evidence of uterine involvement as shown by abdominal pain and tenderness, foul lochia, and other signs. No patients were included who had been altended during prtrgnancy or labor by midwives or outside physicians. Finally, we wish to state that the patients in t,he series, both hospital and home. comprise material from t.he tenement district, of a large city and are about equally divided between whites and blacks. We, therefore, feel that while this series of cases may not. be comparable to another from a different city or class of individuals, they are certainly cornparable to each ot.hcr. TABLE
I.
HOSPITAL
CASES
May 1, 1932-April Multiparas delivered spontaneously Cases of puerperal infection Incidence of puerperd infection Febrile, other causes
30, 19.73
May 1, 1933-April Multiparas delivered spontaneously Cases of puerperal infection Incidence of puerperal infection Febrile, other causes
30,
340 15 4.4% 10 1934 365 18 4.9% 10
Table I shows the incidence of cases of puerperal infection among 705 normal women delivered at the Johns Hopkins Hospital during a period of two consecutive years, and it should be pointed out that there is only a very slight difference (0.5 per cent) bctwecn one year and the ot hr r. TABLE
II.
OUTSIDE
CASES
May 1, 193%--April Multiparas delivered spontaneously Cases of puerperal infect,ion Incidence of puerperal infection Febrile, other causes
30, 1933
dlay 1, 1933-April Multiparas delivered spontaneously Cases of puerperal infection Incidence of puerperal infection Febrile, other causes
30,
1934 510 43
8.4% 5
Table II shows the incidence of puerpcral infection as recorded on t,h(x Outside Service during the samcb two-year period and includes 989 cases.
590
AMERICAN
JOURNAL
OF
OBSTETRICS
AND
GYNECOLOGY
During the years 1932 and 1933, there was but one temperature reading per day taken by the nurse on her morning rounds, while during 1933 and 1934, temperatures every four hours were obtained as described a.bove. The increase in the incidence of puerperal infection from OS per cent to 8.4 per cent is entirely the result of the closer supervision of cases during the second year, since only the nurses’ record of morning temperatures had been used, there would have been four rather than forty-three cases diagnosed, a figure identical with that of 1932 and 1933. That the general character of puerperal infect,ion did not change in the locality in question from one year to the next is suggested b> the fact that during each year there were three cases on the Outside Service considered sufficiently severe to warrant transfer to the Hospital, and also by the fact that the average duration of fever for both years as well as its maximum height among the Hospital cases was approximately the same. A careful study of the comparative severity of the infections occurring in the hospital and the home revealed nothing of significance. The height of the temperatures and their duration was about the same in both series of cases. Of the cases included in this study, there was one death on the Hospital Service which followed a prolonged labor of forty-five hours and severe perineal lacerations with an ensuing streptococcus septicemia, and one death on the Outside From Servic.e which was the direct result of a fulminating eclampsia. the similarity of the character of the infections occurring in the two series and from the definitely increased frequency of puerperal infection among patients delivered in the home (8.4 per cent as against 4.69 per cent), we believe that hospitalization of the lying-in woman is an important factor toward her well-being. CONCLUSIONS
1. The incidence of puerperal infection was almost twice as great in a series of normal women delivered in the home as in a comparative group delivered in the hospital. 2. No difference in the severity of the infection could be elicited between the two groups. 3. This study would seem to indicate that in the modern maternity hospital the patient has a better chance of escaping infection than in the home.