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Oxford Specialist Handbooks in
Anaesthesia

Obstetric Anaesthesia
SECOND EDITION

EDITED BY

Rachel Collis
Consultant Anaesthetist,
University Hospital of Wales,
Cardiff, UK

Sarah Harries
Consultant Anaesthetist,
University Hospital of Wales,
Cardiff, UK

Abrie Theron
Consultant Anaesthetist,
University Hospital of Wales,
Cardiff, UK
Great Clarendon Street, Oxford, OX2 6DP,
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First Edition published in 2008
Second Edition published in 2020
Impression: 1
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 Dedication

Reproduced with the kind permission of the Association of Anaesthetists.

Around the world people are suffering or dying unnecessarily from

the lack of safe anaesthesia in surgery, something that is taken for
granted in the UK.
The situation is critical in Africa, where millions lack access to safe
anaesthesia.
This book is dedicated to patients globally who aspire to receive
the safest possible anaesthesia care.
The authors will donate their royalties to SAFE Africa, which is
the Association of Anaesthetist’s fundraising campaign aiming to:
• Raise at least £100,000.
• Sale-up the delivery of three-day SAFE Obstetrics and SAFE
Paediatrics training courses.
• Sustainably improve anaesthesia education and care in
Africa long term.
 Foreword

The delivery suite can be a very daunting place for the novice, or
even experienced, anaesthetist. Obstetric anaesthesia is both
rewarding and challenging. Helping a mother to give birth and
witness all the joy that unfolds is exhilarating. But childbirth is never
without risk and difficulty and things can go wrong at an alarming
speed, threatening the wellbeing of both mother and baby.
Anticipation, early detection, and efficient management of
complications are key to a successful outcome. What the obstetric
anaesthetist needs is a clear, practical, and easily accessible manual
to assist them. This Oxford Specialist Handbook is such a book.
I am proud to have been involved in the publication of the first
edition in 2008. Since then, however, obstetric anaesthesia practice
has continued to evolve and the publication of an updated second
edition is long overdue and I am sure, eagerly anticipated. Although
some of the editors and authors have changed, it is reassuring to
see that the book continues to be authored by experienced obstetric
anaesthetists who practice in busy units. This ensures that the
guidance given in this book is authoritative, practical, and up to
date.
As part of the updating of this edition there are four new chapters
reflecting the importance of their subject: use of ultrasound, obesity
in pregnancy, the septic mother, and neonatal resuscitation.
Ultrasound is becoming increasingly important to the anaesthetist
and the chapter covers its use to facilitate difficult neuroaxial block,
its use in the increasingly popular transversus abdominis plane block,
and use in assisting central vascular access. The last couple of
decades has seen a rise in the prevalence of obesity in all
populations and a chapter devoted to the management of the
problems of the obese parturient is a welcome addition. Sepsis
remains a major cause of maternal mortality and morbidity and such
an important topic now warrants a chapter devoted to its prompt
recognition and timely treatment, essential to a successful outcome.
Although neonatal resuscitation is usually the responsibility of the
neonatal team, it is important that the obstetric anaesthetist has a
good working knowledge of the subject and the skills to support
paediatric colleagues.
Finally, I’d like to personally thank the editors for donating all
royalties from the sale of this book to the Association of
Anaesthetists’ fundraising campaign for SAFE AFRICA. SAFE (Safe
Anaesthesia From Education) is a ground-breaking project,
supported by the Association of Anaesthetists and the World
Federation of Societies of Anaesthesiology, to roll out educational
anaesthesia courses in low- and middle-income countries,
empowering local educators to educate and train anaesthesia
providers in safe anaesthetic practice.
I also commend the editors for dedicating this book to all patients
worldwide who aspire to receive safe anaesthetic care. This updated
and improved second edition of Obstetric Anaesthesia makes a
significant contribution to that laudable aspiration.

Paul Clyburn
Retired Obstetric Anaesthetist and Past President of the Association
of Anaesthetists of Great Britain and Ireland
 Acknowledgements

This second edition of the Oxford Specialist Handbook of Obstetric

Anaesthesia has been comprehensively revised with updated
information and current evidence to support changes in practice,
since publication of the first edition 10 years ago. We are very
grateful to the authors that have contributed to this edition.
However, this work would not have been possible without the
contribution of the two past editors and all contributors to the first
edition. We wish to sincerely thank and acknowledge the
contribution of Dr Paul Clyburn and Dr Stuart Davies, as past editors,
and the following first edition contributing authors; Drs Korede
Adekanye, Rafal Baraz, Fiona Benjamin, Sue Catling, Monica
Chawthe, Karthikeyan Chelliah, Doddamanegowda Chethan,
Christine Conner, Libby Duff, Kath Eggers, Caroline Evans, Moira
Evans, Claire Farley, Martin Garry, Shubhranshu Gupta, David Hill,
Val Hilton, Felicity Howard, Jon Hughes, Saira Hussain, Aravindh
Jayakumar, Eleanor Lewis, Anthony Murphy, Vinay Ratnalikar, Shilpa
Rawat, Dan Redfern, Alun Rees, Leanne Rees, Hywel Roberts, Anette
Scholz, Raman Sivasankar, Stephen Stamatakis, Gavin Sullivan, Daryl
Thorp-Jones, Matt Turner, Ramesh Vasoya, Viju Varadarajan, Dave
Watkins, Shreekar Yadthore.

Editors—Rachel Collis, Sarah Harries, Abrie Theron

March 2020
 Contents

Contributors
Symbols and abbreviations

1 Thinking about obstetric anaesthesia

Rachel Collis

2 Confidential Enquiries into Maternal Deaths

Nuala Lucas and James Bamber

3 Maternal physiology
Korede Adekanye and Abrie Theron

4 Maternal pathophysiology
Korede Adekanye and Abrie Theron

5 Antenatal assessment and pain management

Rachel Collis, Lucy De Lloyd, and David Hill

6 Non-regional labour analgesia

Matthew Turner and Graeme Lilley

7 Regional techniques in pregnancy

Rachel Collis and Sarah Harries

8 Ultrasound in obstetric practice

Rafal Baraz

9 Regional analgesia for Labour

 Sarah Harries and Rachel Collis
10 Anaesthesia for Caesarean section: Basic principles
Rachel Collis
11 Anaesthesia for Caesarean section: Regional anaesthesia
Sarah Harries and Rachel Collis
12 Anaesthesia for Caesarean section: General anaesthesia
Stephen Morris and Rhidian Jones
13 Post-delivery symptom control
Gemma Keigthley and Sarah Harries
14 Anaesthesia and analgesia for specific obstetric indications
Sarah Harries
15 Postpartum review and problems
Sarah Harries
16 Obesity in pregnancy
Huda Al-Foudri, Stuart Davies, and Abrie Theron
17 The sick and septic mother
Lucy de Lloyd and Sarah Bell
18 Major obstetric haemorrhage
Rachel Collis
19 Hypertensive disease
Eleanor Lewis and Stuart Davies
20 Embolic disease
Abrie Theron
21 The collapsed parturient
Rachel Collis
22 Anaesthesia for non-obstetric surgery
Martin Garry
23 The fetus
Christine Conner
24 Neonatal resuscitation
Angela Hayward
25 A–Z of conditions in obstetric anaesthesia
David Leslie and Rachel Collis

Index
 Contributors

Korede Adekanye
Department of Anaesthetics,
University Hospital of Wales,
Cardiff, UK

Huda Al-Foudri
Department of Anaesthetics,
Al-Adan Hospital, Kuwait

James Bamber
Department of Anaesthetics,
Cambridge University Hospitals
NHS Foundation Trust,
Cambridge, UK

Rafal Baraz
Department of Anaesthetics,
University Hospital of Wales,
Cardiff, UK

Sarah Bell
Department of Anaesthetics,
University Hospital of Wales,
Cardiff, UK

Rachel Collis
Department of Anaesthetics,
University Hospital of Wales,
Cardiff, UK
Christine Conner
Department of Fetal Medicine,
Obstetrics & Gynaecology,
University Hospital of Wales,
Cardiff, UK

Stuart Davies
Department of Anaesthetics,
Singleton Hospital, Swansea, UK

Martin Garry
Department of Anaesthetics,
Singleton Hospital, Swansea, UK

Sarah Harries
Department of Anaesthetics,
University Hospital of Wales,
Cardiff, UK

Angela Hayward
Department of Neonatology,
University Hospital of Wales,
Cardiff, UK

David Hill
Department of Anaesthetics,
Ulster Hospital, Belfast, UK

Rhidian Jones
Department of Anaesthetics,
Princess of Wales Hospital,
Bridgend, UK

Gemma Keigthley
Department of Anaesthetics,
University Hospital of Wales,
Cardiff, UK
David Leslie
Department of Anaesthetics,
University Hospital of Wales,
Cardiff, UK

Eleanor Lewis
Department of Anaesthetics,
Singleton Hospital, Swansea, UK

Graeme Lilley
Department of Anaesthetics,
Nevill Hall Hospital,
Abergavenny, UK

Lucy De Lloyd
Department of Anaesthetics,
University Hospital of Wales,
Cardiff, UK

Nuala Lucas
Department of Anaesthetics,
Northwick Park Hospital,
Harrow, UK

Stephen Morris
Department of Anaesthetics,
University Hospital of Wales,
Cardiff, UK

Abrie Theron
Department of Anaesthetics,
University Hospital of Wales,
Cardiff, UK

Matthew Turner
Department of Anaesthetics,
Royal Gwent Hospital,
Newport, UK
 Symbols and abbreviations

5-HT 5-hydroxytryptamine
A&E Accident and Emergency
ABG arterial blood gas
AC abdominal circumference
ACE angiotensin-converting enzyme
ACTH adrenocorticotrophic hormone
ADP accidental dural puncture
AF atrial fibrillation
AFE amniotic fluid embolus
AFI amniotic fluid index
AFLP acute fatty liver of pregnancy
AFV amniotic fluid volume
AITP autoimmune thrombocytopenia purpura
AKI acute kidney injury
ALS advanced life support
ALT alanine aminotransferase
AoDP aortic diastolic pressure
APTT activated partial thromboplastin time
ARDS adult respiratory distress syndrome
ARF acute renal failure
ARM artificial rupture of membranes
AS aortic stenosis
ASD atrial septal defect
AST aspartate aminotransferase
AVA aortic valve area
AVM arteriovenous malformation
BD twice a day
BMI body mass index
BMR basal metabolic rate
BP blood pressure
bpm beats per minute
CDP computerized dynamic posturography
CEMACH Confidential Enquiry into Maternal and Child Health
CEMD Confidential Enquiry into Maternal Deaths
CHD congenital heart defect
CKD chronic kidney disease
cLMA classic laryngeal mask airway
CNS central nervous system
CO cardiac output
COP colloid oncotic pressure
CP cerebral palsy
CPAP continuous positive airway pressure
CPP coronary perfusion pressure
CPR cardiopulmonary resuscitation
CS caesarean section
CSE combined spinal–epidural
CSF cerebrospinal fluid
CSM Committee on the Safety of Medicines
CT computed tomography
CTG cardiotochograph
CTPA CT pulmonary angiography
CVP central venous pressure
DDAVP 1-desamino-8D-arginine vasopressin
DIC disseminated intravascular coagulation
DVT deep vein thrombosis
EBP epidural blood patch
ECG electrocardiograph
ECV external cephalic version
EDF end-diastolic flow
EEG electroencephalograph
EF ejection fraction
EFL epidural for labour
EFM electronic fetal monitoring
EFW estimated fetal weight
ENT ear, nose and throat
EXIT ex utero intrapartum treatment
FBC full blood count
FBS fetal blood sample
FFP fresh frozen plasma
FHR fetal heart rate
FRC functional residual capacity
FSE fetal scalp electrode
FSH follicle-stimulating hormone
GA general anaesthesia
GAS Group A Streptococcus
GCS Glasgow Coma Score
GFR glomerular filtration rate
GIT gastrointestinal tract
GTN glyceryl trinitrate
GTP gestational thrombocytopenia of pregnancy
Hb haemoglobin
HbF fetal haemoglobin
HC head circumference
hCG human chorionic gonadotrophin
HDU high dependency unit
HELLP haemolytic anaemia, elevated liver enzymes and low platelets
HHT hereditary haemorrhagic telangiectasia
HIT heparin-induced thrombocytopenia
HIV human immunodeficiency virus
HPV human papillomavirus
HR heart rate
ICP intracranial pressure
ICU intensive care unit
IDDM insulin-dependent diabetes mellitus
Ig immunoglobulin
IGP intragastric pressure
IM intramuscular
INR international normalized ratio
IPPV intermittent positive pressure ventilation
ITP idiopathic thrombocytopenia purpura
ITU intensive therapy unit
IUGR intrauterine growth restriction/retardation
IV intravenous
IVC inferior vena cava
IVF in vitro fertilization
JVP jugular venous pressure
kPa kilopascal
LA local anaesthesia
LAP left atrial pressure
LBP low back pain
LDF leucocyte depletion filter
LEHPZ lower oesophageal high pressure zone
LFT liver function test
LH luteinizing hormone
LMA laryngeal mask airway
LMWH low molecular weight heparin
LSCS lower segment caesarean section
LV left ventricle
LVEDP left ventricular end-diastolic pressure
LVF left ventricular failure
MAC minimum alveolar concentration
MAP mean arterial pressure
MAS meconium aspiration syndrome
MBRRACE- Mothers and Babies: Reducing Risk through Audits and Confidential
UK Enquiries across the UK
MCQ multiple choice questions
MEOWS Modified Early Obstetric Warning Score
MMR Maternal Mortality Ratio
MPAP mean pulmonary arterial pressure
MR mitral regurgitation
MRI magnetic resonance imaging
MSL meconium-stained liquor
MVP mitral vein prolapse
NeP neuropathic pain
NICE National Institute for Health and Clinical Excellence
NIDDM Non-insulin dependent diabetes mellitus
NIPP non-invasive positive pressure ventilation
NMDA N-methyl-D-aspartate
NNT number needed to treat
NOAD National Obstetric Anaesthetic Database
NSAID non-steroidal anti-inflammatory drug
NYHA New York Heart Association
OAA Obstetric Anaesthetists’ Association
ODP operating department practitioner
OSA obstructive sleep apnoea
Pa pascal
PCA patient-controlled analgesia
PCEA patient-controlled epidural analgesia
PCR protein:creatinine ratio
PCWP pulmonary capillary wedge pressure
PDA patent ductus arteriosus
PDPH postdural puncture headache
PDSA Plan Do Study Act
PE pulmonary embolism
PEA pulseless electrical activity
PEEP positive end-expiratory pressure
PET pre-eclampsia toxaemia
PFO patent foramen ovale
PG prostaglandin
PIH pregnancy-induced hypertension
PMCS peri-mortum caesarean section
PO per os (orally)
PPH postpartum haemorrhage
PR per rectum
PT prothrombin time
PTH parathyroid hormone
PVR pulmonary vascular resistance
QDS four times a day
QI Quality Improvement
RBBB right bundle branch block
RBC red blood cell
RCT randomized controlled trial
RR respiratory rate
RRT renal replacement therapy
RV right ventricle
RVF right ventricular failure
SADS sudden adult death syndrome or sudden arrhythmic death
syndrome
SC subcutaneous
SEP somatosensory evoked potential
SFG small for gestational age
SFH symphyseal fundal height
SIRS systemic inflammatory response syndrome
SLE systemic lupus erythematosus
SNP sodium nitroprusside
STAN ST analysis of the fetal ECG
SV stroke volume
SVD spontaneous vaginal delivery
SVR systemic vascular resistance
T3 tri-iodothyronine
T4 thyroxine
TB tuberculosis
TBG thyroxine-binding globulin
TDS three times a day
TED thromboembolism deterrent
TEG thromboelastography
TENS transcutaneous electrical nerve stimulation
THRIVE transnasal humidified rapid-insufflation ventilatory exchange
TIBC total iron binding capacity
TORCH toxoplasmosis, rubella, cytomegalovirus and herpes simplex
TSH thyroid-stimulating hormone
TTP thrombotic thrombocytopenia purpura
TV tidal volume
U&E urea and electrolytes
UA umbilical artery
UFH unfractionated heparin
UO urine output
URTI upper respiratory tract infection
UTI urinary tract infection
V/Q ventilation/perfusion
VAE vascular air embolism
VBAC vaginal delivery after caesarean section
VHA viscoelastometric haemostatic assay
VR venous return
VSD ventricular septal defect
VTE venous thrombo-embolism
vWF von Willebrand factor
WCC white cell count
WHO World Health Organization
 Chapter 1

Thinking about obstetric

anaesthesia
Rachel Collis

Surviving the labour ward A–Z

Asking the right questions OR where do you look for the
answers?
Dealing with difficult behaviour
Dealing with malformation and death
The mother who does not speak English
Audit and quality improvement in obstetric anaesthesia

Surviving the labour ward A–Z

The labour ward can be a stressful and demanding experience for all
anaesthetists, junior and senior alike. Start off by seeing yourself as
part of a team comprising anaesthetists, midwives, and
obstetricians. Your level of seniority will often determine how you are
viewed within that team, but the principles of team-working are
always the same.
Obstetricians and midwives may need an anaesthetist to aid in the
safe delivery of mother and baby, as well the multidisciplinary
management of a whole host of complications associated with
childbirth such as postpartum haemorrhage and sepsis. The
anaesthetist, however, cannot work effectively, dealing with the
multitude of problems on the delivery suite, without the skills of both
midwives and obstetricians. No one is better or more important than
anyone else; only experience should change how you function within
the team.
When the anaesthetist starts working on the delivery suite for the
first time, it can feel like one of the most frightening and out of
control places in the hospital. The anaesthetist can feel they are
working to their maximum capability, at flat out pace with
heightened emotion in nearly every setting. By the end of a shift it
can be natural to feel exhausted, and perhaps grateful that no major
mistakes have been made and both mothers and babies are safe.
Before you start, think how you can function optimally. The best
way to start is to think ahead. This means not only familiarizing
yourself with local protocols and the layout of the maternity unit
before your first shift but also constantly thinking ahead as each
situation arises. You need to minimize the tendency to react to a
situation and start to learn to anticipate potential problems. You will
feel more in control, and that control will enable you to work in a
calmer and more effective manner.

The A–Z layout sets out ways that can help you cope without
emphasizing one point above others. No single suggestion is more
important than another and no single action will help without
taking into account many of the others.

A–Z of survival

A
• Advice: ask for advice if you are not sure. Never be afraid to
ask. It may be a very simple question but, if you don’t know the
answer, it can lead to problems later on.
• Anaesthetic alert: has the patient been to an anaesthetic
antenatal clinic? If so, what are the likely anaesthetic problems
and what is the plan? Familiarize yourself with the local
mechanism of alert; there may be clinic letters, special
anaesthetic alert pages in the maternity notes, or a separate
folder kept on the labour ward.
• Anticipate: almost all problems on the labour ward can be
anticipated. The ‘crash section’ is rarely so—it’s that you only
just found out about it and now everything has to be done
immediately in a hurry.
• Assessment: before you perform any general or regional
anaesthetic, always assess the patient. It is routine practice in
all other fields of anaesthesia but can be overlooked on the
labour ward. Learn to do it the same on every occasion so
nothing is missed, even if time is of the essence. Many units
have assessment proformas—use them.

B
• Bleeps: give your bleep number to the midwife who is
coordinating the labour ward. Make sure that the bleep numbers
of consultants, operating department practitioners (ODPs), and
senior cover are known to you and clearly displayed on a
contact information board. Most units have one. If you have
duties away from the labour ward, inform the senior midwife
how best to get hold of you.
• Blood: blood loss can be rapid. Find out local blood policy: how
to get hold of it in a hurry, who to ask, and what forms need to
be filled out. Most hospitals will provide O negative blood,
group-specific blood, and full cross-match depending on the
urgency. Give a clear account to the blood bank of how urgent
the situation is and find out how long the blood will take to
reach the labour ward. If the situation changes and becomes
more or less urgent, inform the blood bank.
• Board: all labour wards have a board with details of patients,
current obstetric progress, and management. Abbreviations are
nearly always used and there could be over 30 different ones.
Some are universal such as P for parity or a number for
centimetres of cervical dilatation. Some others can be unique to
an individual unit. Make sure you know what everyone means,
otherwise you could be missing an essential piece of
information. If you don’t know, ask. The information on the
board can change rapidly. Review it regularly.
• Breaks: it is important to sit down and have a drink and
something to eat as often as you can, even if it is only for a few
minutes. When the delivery suite is busy, it can be difficult to
get to the hospital canteen, so bring some snacks to work.
Don’t spend long periods of time away from a busy unit during a
break as you can be caught unawares regarding pending
problems.
• Busy: if the labour ward is very busy, let another anaesthetist in
the hospital know if possible, so help can be quickly summoned
if required.

C
• Calm: if you stay outwardly calm, even if inwardly you feel the
opposite, the people around you will trust you and stay calmer
themselves, thus making a difficult situation easier to handle.
• Caesarean section (CS): find out the urgency for surgery. This
can be categorized into:
1. Threat to life of mother or baby that requires immediate delivery.
2. Compromise to mother or baby that requires early delivery.
3. Early delivery where neither the baby nor mother is compromised.
4. Elective CS.
This classification does not dictate the type of anaesthetic you
should give, but provides an approximate time frame for you to give
a safe anaesthetic in the situation.
• Check your epidurals: see all the women with an epidural at the
beginning of your shift. Examine and document the block. See
them again even if not called by the midwife when you have
time.
• Communicate: clear and concise communication with the ODP,
midwife, and other members of the labour ward team is crucial.
Take adequate time to communicate with the mother and her
birthing partner. Taking a little time early on can save time later.
Inadequate communication is the basis for many complaints and
legal claims.
• Confrontation: this can quickly arise, especially in a stressful
situation. It never helps, so take a deep breath and don’t get
 involved. If there is a point you feel strongly about, be polite or
get someone more senior to deal with it. Sort out ongoing
confrontation later and away from the clinical setting when
there is plenty of time for a long discussion.
• Consultant: know who the consultant anaesthetist is and how to
call them in an emergency.
• CTG: the cardiotochograph is a printed or electronic record of
the fetal heart rate (FHR) with a pressure gauge reading of the
mother’s contractions which is below the FH reading. Knowing
the basic patterns associated with fetal well-being and
impending fetal compromise will allow you to think ahead as
you provide epidural analgesia or anaesthesia for CS.
• Consent: this should be obtained before all anaesthetic
procedures, either written or verbal informed consent. There is
much debate regarding the capacity of a labouring woman to
give informed consent; therefore it is good practice to ensure
that consent is witnessed by her birthing partner, if present, and
the attending midwife.

D
• Debrief: things do go wrong. Sometimes you may feel
responsible and sometimes you are an onlooker. In all
situations, talk to someone senior about it.
• Drugs: draw up all drugs that may be required in an emergency.
Label each syringe with content, concentration, and the time
and date that the drug was drawn up; remember that a
different anaesthetist may have to use them. Store them in a
drug fridge.
Find out where non-anaesthetic emergency drugs are kept,
particularly those used for eclampsia.
Familiarize yourself with the entire content of the drug cupboard.
Know what is routinely kept on delivery suite and how they are
stored, e.g. alphabetically or groups of drugs by function.
E
• Emotions: happiness, sadness, fear, aggression, and
helplessness are all normal and commonly encountered
emotions on the labour ward. You will feel them in yourself and
see them in others. Work out how you can cope with them
before they happen, and stay focused. If you become
distracted, you can miss something important.
• Epidural: almost every labour ward will have an epidural policy.
Follow it, even if you have used something different elsewhere.
All the other staff will be used to it and it is dangerous to do
your own thing. If you want to make changes, talk to the policy
makers.
• Equipment: always check all anaesthetic equipment at the
beginning of the shift. This must include the anaesthetic
machine, monitoring, and airway equipment. You may need to
use them in a hurry later.
• Experience: appreciate the limitations of your expertise. When
you reach your limit, ask for help.

F
• Fear: this is a normal reaction to a situation that you don’t
understand, is happening too quickly, or is outside your control
or competence. Recognize the signs early and ask for help
before it gets the better of you.
• Flag issues: if you are concerned about a particular problem,
flag it up early with a senior midwife, obstetrician, or a senior
anaesthetist.
• Fluids: know where they are kept, what to give, and when. Fluid
requirements can be difficult to estimate in a labouring mother.
• Forceps delivery: find out the local policy on where they should
be carried out—delivery room or operating theatre. Always get
involved, even if the mother does not want or already has an
epidural. You can at least make an assessment of the situation
so you are not completely caught out when a forceps delivery
turns into a ‘crash section’. If the mother has an epidural, assess
 the adequacy of her analgesia, give an appropriate top-up, and
stay with her to monitor her and the situation until the baby is
delivered, and the risk of haemorrhage has passed.
G
• Guidelines: most delivery suites have them. Find out where they
are kept, read them before you start, and refer back to them
regularly.
H
• Handovers: usually happen at the beginning of the morning
shift, at and at the start of the night shift. They should involve
midwives, obstetricians, and anaesthetists, and will provide
useful information about women who have not required
anaesthetic intervention at that time. You may also find out
about potential problems that are on the ante- or postnatal
wards, medical wards, or A&E.

Within your shift pattern there should be adequate time for

anaesthetic handover. Make full use of it. A useful mnemonic is
SAFE handover: S-mothers who are Sick; A-Anticipated problems;
F-who needs Follow-up; E-who has an epidural and is it working
well.
• Help: where is it? Who is it? How long will it take to get to you?
• Helpful: if what you have been asked to do is within your
competence, be helpful when you have time, even if you think it
is not your direct responsibility. A common example is being
asked to site IV access. If you genuinely don’t have time to
help, be polite.

I
• Information: labour is a dynamic process. Situations progress
and change rapidly. Stay well informed about all mothers in
labour, not just the ones with an epidural.
• Intravenous access: make sure you use a 14G or 16G drip in all
mothers who have an epidural or need an obstetric anaesthetic.
J
• Jehovah’s Witness: there are Association of Anaesthetists of
Great Britain and Ireland (AAGBI) and local guidelines for the
management of a Jehovah’s Witness. You should be informed
when a Jehovah’s Witness is admitted, and have a management
plan. Most Jehovah’s Witnesses will have signed an advanced
directive in the antenatal clinic with a list of blood products and
procedures they will accept.

K
• Knowledge: keep up to date and discuss controversial issues
surrounding patient management.

L
• Labels: label all syringes and infusions with the drug name and
concentration.
• Labour: understand the normal and abnormal patterns of labour.
Abnormally prolonged labour very frequently requires
anaesthetic intervention at some time.

M
• Meetings: attend the multidisciplinary labour ward meeting or
organize one if you don’t happen. It is a forum to raise concerns
and issues.
• “My name is. ….” There is no more important place to do this—
even if the mother is distressed.
• Multidisciplinary team: you are a member of a team. Don’t work
in isolation. Understand what you are expected to do during a
major obstetric emergency.
N
• Notes: legible notes are very important. Discuss and document
plans, procedures, and advice received. ‘If you have not written
it down, you have not done it’. Every entry should be timed and
dated with a legible signature. If notes are written in retrospect,
make that clear.
Read the patients notes, especially if there is additional medical
information and a high risk obstetric plan.

O
• Obstetric emergencies: there are a number of obstetric
emergencies including antenatal and postpartum haemorrhage,
shoulder dystocia, and eclampsia which you may see and will be
expected to be involved with. Find out what you need to do in
each and ask about teaching or ‘obstetric fire drills’ when it is
quiet.
• Organize: Organize your workload for the shift by prioritizing
and delegating to others if appropriate. If a mother is thinking
about an epidural, it is usually possible to tell her and her
midwife whether you anticipate other more pressing anaesthetic
procedures. Remember you can only be in one place at a time.
• Oxytocics and prostaglandins: give these drugs slowly. Find out
how the different drugs should be given and diluted. Be aware
as you step up the therapeutic ladder from oxytocin bolus to
oxytocin infusion to prostaglandin that blood loss can be
considerable and difficult to estimate. An obstetric patient will
appear to be cardiovascularly stable until she has lost 25–30%
of her blood volume, and blood loss can be insidious.

P
• Passwords: in many hospitals, blood results and X-rays can only
be accessed electronically. Familiarize yourself with the
computerized system and have an up-to-date access code and
password.
• Position: make sure the mother is in the ideal position for your
regional technique. Taking your time and being patient,
especially if she is in a lot of pain, will save time later. When
sitting or lying a mother down, take great care to avoid aorto-
caval compression. Explain to the mother why this is important.
• Problem epidural: work out what you are going to do if an
epidural for labour is not working well. Replace it early if you
 have got time, or recognize that you may need to do a spinal
anaesthetic should the mother need a CS.

Q
• Questions: there must be time for patients to raise concerns.
Always ask mothers if they have any questions.
R
• Rapport: build a rapport with the midwives. They can help you a
lot.
• Resuscitaire: this is where a baby that requires resuscitation is
placed. They can be complex to use, but find out how to
operate the basic functions. Babies are frequently born
unexpectedly requiring help, and with good airway skills the
anaesthetist is ideally placed to give initial resuscitation until a
paediatrician can attend. Find out about the basic principles of
neonatal resuscitation and how they differ from other life
support algorithms.
• Risk management: this is a part of clinical governance and is
important for patient safety. Raise any concerns and report
them to the appropriate person, who is frequently one of the
senior midwives.

S
• Smile: it may seem a small thing but to appear relaxed and
friendly will go a long way on a labour ward.
• STAN: Stands for ST analysis and is a sophisticated form of fetal
scalp monitoring. If your labour ward uses this form of
monitoring in high risk labours, find out about it, as
interpretation is different to usual CTG analysis.
• Stress: the labour ward can be a very stressful place to work
and fear can be a normal response. Accept it and have a way of
coping with it.
T
• Teach: teaching and training—get involved and show initiative.
Valuable informal teaching should take place with midwives
looking after a mother with an epidural and with midwifery and
medical students. A midwife who understands more about an
epidural will call you to troubleshoot less often.
• Time: there is a tendency for the obstetrician to demand a
general anaesthetic when time is short. The question in reply
should be ‘how quickly does the baby need to be delivered?’
U
• Use: use quiet time to practice difficult scenarios or learn about
equipment you are less familiar with.
• Utilize: utilize all your resources. The haematologist, general
physicians, and surgeons can all be invaluable in an emergency
or when there are complex management issues with a sick
mother.

V
• Value: value the opinion of midwives and others in the team.
Many will be more experienced than you and can offer an
opinion that, although different from yours, can be equally valid
and helpful in the long run.
• Vulnerable: the patient can feel vulnerable, which can come
across as rude and aggressive behaviour. Put yourself in her
place.

W
• Ward rounds: all mothers who have had an obstetric anaesthetic
should be followed-up. Feedback is important and you will learn
a lot from listening to her.

X
• (E)Xpectations: it is easy to underestimate the mother’s
expectations in a stressful environment like the labour ward.
She may not be able to differentiate one doctor from the other.
 Introduce yourself, be courteous and be clear. For the doctors,
one situation can merge into the next. For the mother, she will
remember her personal experiences for many years.

Y
• Y: why are you doing what you are doing? Watch and learn
from others to improve your own practice.

Z
• Plan Z: always have one before things go wrong.

Asking the right questions OR where do you

look for the answers?
There are different questions that should be directed to the patient,
obstetrician, and midwife. The questions you ask will depend upon
the time you have, but most of the information below will need to be
obtained, even if time is very short. Directing your questions to the
right person can save time.

The midwife
Has the pregnancy and labour been normal? The midwife will have
carefully reviewed the mother’s notes and will be aware of problems
that may alter your anaesthetic management:
• History of blood pressure (BP) problems or pre-eclampsia, which
could cause clotting or platelet abnormalities.
• History of low platelets (ITP).
• History of thrombosis. Is the mother on heparin?

The midwife will also be able to tell you if the pattern of labour up
to that point has been normal or abnormal and if the CTG has
been reassuring or suggestive of fetal compromise.

• Is this a first or subsequent labour? A mother who has laboured

before is more likely to deliver quickly, and this may alter your
 anaesthetic management.
• Is this a spontaneous or induced labour? An induced labour is
more likely to be slow and complicated.
• How many centimetres of cervical dilatation has the labour
progressed to? An early request for an epidural may already
indicate a slow labour with excessive pain from an occipito-
posterior presentation of the fetal head. An epidural will need to
be effective for many hours. You may consider late requests for
an epidural to be inappropriate as delivery is possibly imminent.
However, it may reflect major obstetric difficulties in the latter
stages of labour, when epidural analgesia can be difficult to
achieve and operative delivery is likely.
• Has the mother had a previous CS? If so, she is more likely to
have another one.
• Is this labour slow and is augmentation with oxytocin likely? If
so, an epidural may to be required for many hours and needs to
be effective.
• Is the CTG normal or abnormal? If it is abnormal, is fetal scalp
blood sampling or early operative delivery anticipated?

The obstetrician
There will be overlap between the questions you can direct towards
the midwife and obstetrician, especially about the obstetric history,
but a clearer overview of the labour and likelihood of operative
delivery can usually be obtained from the obstetrician.
• How long do I have to do this anaesthetic? Is the anaesthetic
urgent for fetal blood sampling or operative delivery, or can I
take more time?
• When do you anticipate obstetric intervention? This may be in
the next few minutes or in several hours if there has been
inadequate progress in labour.
• Is it likely the baby will be delivered by forceps or need a
caesarean delivery? If an operative vaginal delivery is likely, is
there a high risk of proceeding to CS? In which case the
 anaesthetic needs to be effective for both procedures before the
obstetrician starts.

The mother
The mother will be able to tell you if she has any past medical
complications. There is usually a tick box questionnaire in her notes
that will have been filled out in early pregnancy, but there may be a
need for clarification. The mother should also tell you what she
understands about the procedure you have been asked to carry out.
• What do you know about epidurals? There are issues about
consent in labour, but it is important that the mother
understands the major issues. If she tells you that she has read
the information from a well-recognized source and discussed it
with a midwife or anaesthetist in the antenatal period, the
information you need to give her is brief. If she says she knows
nothing, you must spend some time in giving her a good
explanation.
• What are your expectations? The mother may have very high or
unrealistic expectations. Listen carefully and give good
information back. If she has low expectations, be reassuring.

A systematic review of questions

Many obstetric units have a dedicated obstetric anaesthetic chart
because the information that needs to be documented is different
from other theatre work. It is helpful if the chart is subdivided into
systems and has some tick boxes so a history and examination can
be carried out quickly without overlooking important factors.

Past medical history

• Medical problems: systems review.
• Previous surgery: what?
• Anaesthesia: any previous problems with regional or general
anaesthetic?
Another random document with
no related content on Scribd:
 LIST OF ILLUSTRATIONS
MISS NIGHTINGALE (From a photograph) Frontispiece
PAGE
LEA HURST, DERBYSHIRE 16
EMBLEY PARK, HAMPSHIRE 32
MISS NIGHTINGALE (From a drawing) 48
PASTOR FLIEDNER 55
MISS NIGHTINGALE (From a bust at Claydon) 61
SIR WILLIAM HOWARD RUSSELL 80
SIDNEY, LORD HERBERT OF LEA 96
MR. PUNCH’S CARTOON OF “THE LADY-BIRDS” 113
THE BARRACK HOSPITAL AT SCUTARI 125
BOULOGNE FISHERWOMEN CARRYING THE LUGGAGE OF
MISS NIGHTINGALE AND HER NURSES 128
THE LADY-IN-CHIEF IN HER QUARTERS AT THE BARRACK
HOSPITAL 133
MISS NIGHTINGALE IN THE HOSPITAL AT SCUTARI 144
MISS NIGHTINGALE AND THE DYING SOLDIER—A SCENE AT
SCUTARI HOSPITAL WITNESSED BY M. SOYER 176
LADY HERBERT OF LEA 192
FLORENCE NIGHTINGALE AS A GIRL 208
THE NIGHTINGALE JEWEL 237
THE CARRIAGE USED BY MISS NIGHTINGALE IN THE CRIMEA 240
MISS NIGHTINGALE AFTER HER RETURN FROM THE CRIMEA 272
PARTHENOPE, LADY VERNEY 288
MRS. DACRE CRAVEN (née FLORENCE LEES) 304
CLAYDON HOUSE, THE SEAT OF SIR EDMUND VERNEY, 320
 WHERE THE “FLORENCE NIGHTINGALE” ROOMS ARE
PRESERVED
SPECIMEN OF MISS NIGHTINGALE’S HANDWRITING 335
MISS NIGHTINGALE’S OLD ROOM AT CLAYDON 336
MISS NIGHTINGALE 340
 THE LIFE OF
FLORENCE NIGHTINGALE
 CHAPTER I
BIRTH AND ANCESTRY

Birth at Florence—Shore Ancestry—Peter Nightingale of Lea—

Florence Nightingale’s Parents.

We are born into life—it is sweet, it is strange,

We lie still on the knee of a mild mystery
Which smiles with a change;
But we doubt not of changes, we know not of spaces,
The heavens seem as near as our own mother’s face is,
And we think we could touch all the stars that we see.
Elizabeth Barrett Browning.

Thought and deed, not pedigree, are the passports to

enduring fame.—General Skobeleff.

A T a dinner given to the military and naval officers who had

served in the Crimean War, it was suggested that each guest
should write on a slip of paper the name of the person whose
services during the late campaign would be longest remembered by
posterity. When the papers were examined, each bore the same
name—“Florence Nightingale.”
The prophecy is fulfilled to-day, for though little more than fifty
years have passed since the joy-bells throughout the land
proclaimed the fall of Sebastopol, the majority of people would
hesitate if asked to name the generals of the Allied Armies, while no
one would be at a loss to tell who was the heroine of the Crimea. Her
deeds of love and sacrifice sank deep into the nation’s heart, for they
were above the strife of party and the clash of arms. While Death
has struck name after name from the nation’s roll of the great and
famous, our heroine lives in venerated age to shed the lustre of her
name upon a new century.
Florence Nightingale was born on May 12th, 1820, at the Villa
Colombaia near Florence, where her parents, Mr. and Mrs. William
Shore Nightingale, of Lea, Derbyshire, were staying.
“What name should be given to the baby girl born so far away
from her English home?” queried her parents, and with mutual
consent they decided to call her “Florence,” after that fair city of
flowers on the banks of the Arno where she first saw the light. Little
did Mr. and Mrs. Nightingale then think that the name thus chosen
was destined to become one of the most popular throughout the
British Empire. Every “Florence” practically owes her name to the
circumstances of Miss Nightingale’s birth.
It seemed as though the fates were determined to give an
attractive designation to our heroine. While “Florence” suggested the
goddess of flowers, “Nightingale” spoke of sweet melody. What could
be more beautiful and euphonious than a name suggesting a song-
bird from the land of flowers? The combination proved a special joy
to Mr. Punch and his fellow-humorists when the bearer of the name
rose to fame.
However, Miss Nightingale’s real family name was Shore. Her
father was William Edward Shore, the only son of William Shore of
Tapton, Derbyshire, and he assumed the name of Nightingale, by the
sign manual of the Prince Regent, when he succeeded in 1815 to
the estates of his mother’s uncle, Peter Nightingale of Lea. This
change took place three years before his marriage, and five before
the birth of his illustrious daughter.
Through her Shore ancestry Miss Nightingale is connected with
the family of Baron Teignmouth. Sir John Shore, Governor-General
of India, was created a baron in 1797 and took the title of
Teignmouth. Another John Shore was an eminent physician at Derby
in the reign of Charles II., and a Samuel Shore married the heiress of
the Offleys, a Sheffield family.
 It is through her paternal grandmother, Mary, daughter of John
Evans of Cromford, the niece and sole heir of Peter Nightingale, that
Florence Nightingale is connected with the family whose name she
bears. Her great-great-uncle, Peter Nightingale, was a typical
Derbyshire squire who more than a century ago lived in good style at
the fine old mansion of Lea Hall. Those were rough and roystering
days in such isolated villages as Lea, and “old Peter” had his share
of the vices then deemed gentlemanly. He could swear with the best,
and his drinking feats might have served Burns for a similar theme to
The Whistle. His excesses gained for him the nickname of “Madman
Nightingale,” and accounts of his doings still form the subject of local
gossip. When in his cups, he would raid the kitchen, take the
puddings from the pots and fling them on the dust-heap, and cause
the maids to fly in terror. Nevertheless, “old Peter” was not
unpopular; he was good-natured and easy going with his people,
and if he drank hard, well, so did his neighbours. He was no better
and little worse than the average country squire, and parson too, of
the “good old times.” His landed possessions extended from Lea
straight away to the old market town of Cromford, and beyond
towards Matlock. It is of special interest to note that he sold a portion
of his Cromford property to Sir Richard Arkwright, who erected there
his famous cotton mills. The beautiful mansion of Willersley Castle,
which the ingenious cotton-spinner built, and where he ended his
days as the great Sir Richard, stands on a part of the original
Nightingale property. When “old Peter” of jovial memory passed to
his account, his estates and name descended to his grand-nephew,
William Edward Shore.
The new squire, Florence Nightingale’s father, was a marked
contrast to his predecessor. He is described by those who remember
him as a tall, slim, gentlemanly man of irreproachable character. He
had been educated at Edinburgh and Trinity College, Cambridge,
and had broadened his mind by foreign travel at a time when the
average English squire, still mindful of the once terrifying name of
“Boney,” looked upon all foreigners as his natural enemies, and
entrenched himself on his ancestral acres with a supreme contempt
for lands beyond the Channel. Mr. Nightingale was far in advance of
the county gentry of his time in matters of education and culture.
Sport had no special attraction for him, but he was a student, a lover
of books and a connoisseur in art. He was not without a good deal of
pride of birth, for the Shores were a very ancient family.
As a landlord he had a sincere desire to benefit the people on
his estates, although not perhaps in the way they most appreciated.
“Well, you see, I was not born generous,” is still remembered as Mr.
Nightingale’s answer when solicited for various local charities.
However, he never begrudged money for the support of rural
education, and, to quote the saying of one of his old tenants, “Many
poor people in Lea would not be able to read and write to-day, if it
had not been for ‘Miss Florence’s’ father.” He was the chief supporter
of what was then called the “cheap school,” where the boys and
girls, if they did not go through the higher standards of the present-
day schools, at least learned the three R’s for the sum of twopence a
week. There was, of course, no compulsory education then, but the
displeasure of the squire with people who neglected to send their
children to school was a useful incentive to parents. Mr. Nightingale
was a zealous Churchman, and did much to further Christian work in
his district.
Florence Nightingale’s mother was Miss Frances Smith,
daughter of William Smith, Esq., of Parndon in Essex, who for fifty
years was M.P. for Norwich. He was a pronounced Abolitionist, took
wide and liberal views on the questions of the time, and was noted
for his interest in various branches of philanthropy. Mrs. Nightingale
was imbued with her father’s spirit, and is remembered for her great
kindness and benevolence to the poor. She was a stately and
beautiful woman in her prime and one of the fast-dying-out race of
gentlewomen who were at once notable house-keepers and
charming and cultured ladies. Her name is still mentioned with
gratitude and affection by the old people of her husband’s estates.
It was from her mother, whom she greatly resembles, that
Florence Nightingale inherited the spirit of wide philanthropy and the
desire to break away, in some measure, from the bonds of caste
which warped the county gentry in her early days and devote herself
to humanitarian work. She was also fortunate in having a father who
believed that a girl’s head could carry something more than elegant
accomplishments and a knowledge of cross-stitch. While our
heroine’s mother trained her in deeds of benevolence, her father
inspired her with a love for knowledge and guided her studies on
lines much in advance of the usual education given to young ladies
at that period.
Mr. and Mrs. Nightingale had only two children—Frances
Parthenope, afterwards Lady Verney, and Florence, about a year
younger. Both sisters were named after the Italian towns where they
were born, the elder receiving the name of Parthenope, the classic
form of Naples, and was always known as “Parthe,” while our
heroine was Florence.
 CHAPTER II
EARLIEST ASSOCIATIONS

Lea Hall first English Home—Neighbourhood of Babington Plot

—Dethick Church.

... Those first affections,

Those shadowy recollections,
Which be they what they may,
Are yet the fountain light of all our day,
Are yet a master light of all our seeing.
Wordsworth.

W HEN Mr. and Mrs. Nightingale returned from abroad with

their two little daughters, they lived for a time at the old
family seat of Lea Hall, which therefore has the distinction of being
the first English home of Florence Nightingale, an honour generally
attributed to her parents’ subsequent residence of Lea Hurst.
Lea Hall is beautifully situated high up amongst the hills above
the valley of the Derwent. I visited it in early summer when the
meadows around were golden with buttercups and scented with
clover, and the long grass stood ready for the scythe. Wild roses
decked the hedgerows, and the elder-bushes, which grow to a great
size in this part of Derbyshire, made a fine show with their white
blossoms. Seen then, the old grey Hall seemed a pleasant country
residence; but when the north wind blows and snow covers the
hillsides, it must be a bleak and lonely abode. It is plainly and solidly
built of grey limestone from the Derbyshire quarries, and is of good
proportions. From its elevated position it has an imposing look, and
forms a landmark in the open country. Leading from it, the funny old
village street of Lea, with its low stone houses, some of them very
ancient, curls round the hillside downwards to the valley. The butcher
proudly displays a ledger with entries for the Nightingale family since
1835.
The Hall stands on the ancient Manor of Lea, which includes the
villages of Lea, Dethick, and Holloway, and which passed through
several families before it became the property of the Nightingales.
The De Alveleys owned the manor in the reign of John and erected a
chapel there. One portion of the manor passed through the families
of Ferrar, Dethwick, and Babington, and another portion through the
families of De la Lea, Frecheville, Rollestone, Pershall, and
Spateman to that of the Nightingales.
The house stands a little back from the Lea road in its own
grounds, and is approached by a gate from the front garden. Stone
steps lead up to the front door, which opens into an old-fashioned
flag-paved hall. Facing the door is an oak staircase of exceptional
beauty. It gives distinction to the house and proclaims its ancient
dignity. The balustrade has finely turned spiral rails, the steps are of
solid oak, and the sides of the staircase panelled in oak. One may
imagine the little Florence making her first efforts at climbing up this
handsome old staircase.
In a room to the left the date 1799 has been scratched upon one
of the window-panes, but the erection of the Hall must have been
long before that time. For the rest, it is a rambling old house with
thick walls and deep window embrasures. The ceilings are
moderately high. There is an old-fashioned garden at the back, with
fruit and shady trees and a particularly handsome copper beech.
The Hall has long been used as a farmhouse, and scarcely one
out of the hundreds of visitors to the Matlock district who go on
pilgrimages to Lea Hurst knows of its interesting association. The old
lady who occupied it at the time of my visit was not a little proud of
the fact that for forty-four years she had lived in the first English
home of Florence Nightingale.
The casual visitor might think the district amid which our
heroine’s early years were spent was a pleasant Derbyshire wild and
nothing more, but it has also much historic interest. Across the
meadows from Lea Hall are the remains of the stately mansion of
Dethick, where dwelt young Anthony Babington when he conspired
to release Mary Queen of Scots from her imprisonment at Wingfield
Manor, a few miles away. Over these same meadows and winding
lanes Queen Elizabeth’s officers searched for the conspirators and
apprehended one at Dethick. The mansion where the plot was
hatched has been largely destroyed, and what remains is used for
farm purposes. Part of the old wall which enclosed the original
handsome building still stands, and beside it is an underground
cellar which according to tradition leads into a secret passage to
Wingfield Manor. The farm bailiff who stores his potatoes in the cellar
has not been able to find the entrance to the secret passage, though
at one side of the wall there is a suspicious hollow sound when it is
hammered.
The original kitchen of the mansion remains intact in the bailiff’s
farmhouse. There is the heavy oak-beamed ceiling, black with age,
the ponderous oak doors, the great open fireplace, desecrated by a
modern cooking range in the centre, but which still retains in the
overhanging beam the ancient roasting jack which possibly cooked
venison for Master Anthony and the other gallant young gentlemen
who had sworn to liberate the captive Queen. In the roof of the
ceiling is an innocent-looking little trap-door which, when opened,
reveals a secret chamber of some size. This delightful old kitchen,
with its mysterious memories, was a place of great fascination to
Florence Nightingale and her sister in their childhood, and many
stories did they weave about the scenes which transpired long ago in
the old mansion, so near their own home. It was a source of peculiar
interest to have the scenes of a real Queen Mary romance close at
hand, and gave zest to the subject when the sisters read about the
Babington plot in their history books.
Dethick Church, where our heroine attended her first public
service, and continued to frequently worship so long as she lived in
Derbyshire, formed a part of the Babingtons’ domain. It was
originally the private chapel of the mansion, but gradually was
converted to the uses of a parish church. Its tall tower forms a
picturesque object from the windows of Lea Hall. The church must
be one of the smallest in the kingdom. Fifty persons would prove an
overflowing congregation even now that modern seating has utilised
space, but in Florence Nightingale’s girlhood, when the quality sat in
their high-backed pews and the rustics on benches at the farther end
of the church, the sitting room was still more limited. The interior of
the church is still plain and rustic, with bare stone walls, and the bell
ropes hanging in view of the congregation. The service was quaint in
Miss Nightingale’s youth, when the old clerk made the responses to
the parson, and the preaching sometimes took an original turn. The
story is still repeated in the district that the old parson, preaching one
Sunday on the subject of lying, made the consoling remark that “a lie
is sometimes a very useful thing in trade.” The saying was often
repeated by the farmers of Lea and Dethick in the market square of
Derby.
Owing to the fact that Dethick Church was originally a private
chapel, there is no graveyard. It stands in a pretty green enclosure
on the top of a hill. An old yew-tree shades the door, and near by are
two enormous elder-bushes, which have twined their great branches
together until they fall down to the ground like a drooping ash,
forming an absolutely secluded bower, very popular with lovers and
truants from church.
The palmy days of old Dethick Church are past. No longer do the
people from the surrounding villages and hamlets climb its steep
hillside, Sunday by Sunday, for, farther down in the vale, a new
church has recently been built at Holloway, which, if less
picturesque, is certainly more convenient for the population. On the
first Sunday in each month, however, a service is still held in the old
church where, in days long ago, Florence Nightingale sat in the
squire’s pew, looking in her Leghorn hat and sandal shoes a very
bonny little maiden indeed.
 CHAPTER III
LEA HURST

Removal to Lea Hurst—Description of the House—Florence

Nightingale’s Crimean Carriage preserved there.

L o! in the midst of Nature’s choicest scenes,

E mbosomed ’mid tall trees, and towering hills,
A gem, in Nature’s setting, rests Lea Hurst.

H ome of the good, the pure at heart and beautiful,

U ndying is the fame which, like a halo’s light,
R ound thee is cast by the bright presence of the holy Florence
S aint-like and heavenly. Thou hast indeed a glorious fame
T ime cannot change, but which will be eternal.
Llewellyn Jewett.

W HEN Florence Nightingale was between five and six years

old, the family removed from Lea Hall to Lea Hurst, a house
which Mr. Nightingale had been rebuilding on a site about a mile
distant, and immediately above the hamlet of Lea Mills. This delightful
new home is the one most widely associated with the life of our
heroine. To quote the words of the old lady at the lodge, “It was from
Lea Hurst as Miss Florence set out for the Crimea, and it was to Lea
Hurst as Miss Florence returned from the Crimea.” For many years
after the war it was a place of pilgrimage, and is mentioned in almost
every guidebook as one of the attractions of the Matlock district. It
has never been in any sense a show house, and the park is private,
but in days gone by thousands of people came to the vicinity, happy if
they could see its picturesque gables from the hillside, and always
with the hope that a glimpse might be caught of the famous lady who
lived within its walls. Miss Nightingale remains tenderly attached to
Lea Hurst, although it is eighteen years since she last stayed there.
After the death of her parents it passed to the next male heir, Mr.
Shore Smith, who later assumed the name of Nightingale.

LEA HURST, DERBYSHIRE.

(Photo by Keene, Derby.)
[To face p. 16.

Lea Hurst is only fourteen miles from Derby, but the following
incident would lead one to suppose that the house is not as familiar in
the county town as might be expected. Not long ago a lady asked at
a fancy stationer’s shop for a photograph of Lea Hurst.
“Lea Hurst?” pondered the young saleswoman, and turning to her
companion behind the counter, she inquired, “Have we a photograph
of Lea Hurst?”
“Yes, I think so,” was the reply.
 “Who is Lea Hurst?” asked the first girl.
“Why, an actor of course,” replied the second.
There was an amusing tableau when the truth was made known.
Miss Nightingale’s father displayed a fine discrimination when he
selected the position for his new house. One might search even the
romantic Peak country in vain for a more ideal site than Lea Hurst. It
stands on a broad plateau looking across to the sharp, bold
promontory of limestone rock known as Crich Stand. Soft green hills
and wooded heights stud the landscape, while deep down in the
green valley the silvery Derwent—or “Darent,” as the natives call it—
makes music as it dashes over its rocky bed. The outlook is one of
perfect repose and beauty away to Dove’s romantic dale, and the
aspect is balmy and sunny, forming in this respect a contrast to the
exposed and bleak situation of Lea Hall.
The house is in the style of an old Elizabethan mansion, and now
that time has mellowed the stone and clothed the walls with greenery,
one might imagine that it really dated from the Tudor period. Mr.
Nightingale was a man of artistic tastes, and every detail of the house
was carefully planned for picturesque effect. The mansion is built in
the form of a cross with jutting wings, and presents a picture of
clustering chimneys, pointed gables, stone mullioned windows and
latticed panes. The fine oriel window of the drawing-room forms a
projecting wing at one end of the house. The rounded balcony above
the window has become historic. It is pointed out to visitors as the
place where “Miss Florence used to come out and speak to the
people.” Miss Nightingale’s room opened on to this balcony, and after
her return from the Crimea, when she was confined to the house with
delicate health, she would occasionally step from her room on to the
balcony to speak to the people, who had come as deputations, while
they stood in the park below. Facing the oriel balcony is a gateway,
shadowed by yew-trees, which forms one of the entrances from the
park to the garden.
In front of the house is a circular lawn with gravel path and flower-
beds, and above the hall door is inscribed N. and the date 1825, the
year in which Lea Hurst was completed. The principal rooms open on
to the garden or south front, and have a delightfully sunny aspect and
a commanding view over the vale. From the library a flight of stone
steps leads down to the lawn. The old schoolroom and nursery where
our heroine passed her early years are in the upper part of the house
and have lovely views over the hills.
In the centre of the garden front of the mansion is a curious little
projecting building which goes by the name of “the chapel.” It is
evidently an ancient building effectively incorporated into Lea Hurst.
There are several such little oratories of Norman date about the
district, and the old lady at Lea Hurst lodge shows a stone window in
the side of her cottage which is said to be seven hundred years old. A
stone cross surmounts the roof of the chapel, and outside on the end
wall is an inscription in curious characters. This ancient little building
has, however, a special interest for our narrative, as Miss Nightingale
used it for many years as the meeting place for the Sunday afternoon
Bible-class which she held for the girls of the district. In those days
there was a large bed of one of Miss Nightingale’s favourite flowers,
the fuchsia, outside the chapel, but that has been replaced by a
fountain and basin, and the historic building itself, with its thick stone
walls, now makes an excellent larder.
The gardens at Lea Hurst slope down from the back of the house
in a series of grassy terraces connected by stone steps, and are still
preserved in all their old-fashioned charm and beauty. There in spring
and early summer one sees wallflowers, peonies, pansies, forget-me-
nots, and many-coloured primulas in delightful profusion, while the
apple trellises which skirt the terraces make a pretty show with their
pink blossoms, and the long border of lavender-bushes is bursting
into bloom. In a secluded corner of the garden is an old summer-
house with pointed roof of thatch which must have been a delightful
playhouse for little Florence and her sister.
The park slopes down on either side the plateau on which the
house stands. The entrance to the drive is in the pleasant country
road which leads to the village of Whatstandwell and on to Derby.
This very modest park entrance, consisting of an ordinary wooden
gate supported by stone pillars with globes on the top, has been
described by an enthusiastic chronicler as a “stately gateway” with
“an air of mediæval grandeur.” There is certainly no grandeur about
Lea Hurst, either mediæval or modern. It is just one of those pleasant
and picturesque country mansions which are characteristic of rural
England, and no grandeur is needed to give distinction to a house
which the name of Florence Nightingale has hallowed.
Beyond the park the Lea woods cover the hillside for some
distance, and in spring are thickly carpeted with bluebells. A long
winding avenue, from which magnificent views are obtained over the
hills and woodland glades for many miles, skirts the top of the woods,
and is still remembered as “Miss Florence’s favourite walk.”
The chief relic preserved at Lea Hurst is the curious old carriage
used by Miss Nightingale in the Crimea. What memories does it not
suggest of her journeys from one hospital to another over the heights
of Balaclava, when its utmost carrying capacity was filled with
comforts for the sick and wounded! The body of the carriage is of
basket-work, and it has special springs made to suit the rough
Crimean roads. There is a hood which can be half or fully drawn over
the entire vehicle. The carriage was driven by a mounted man acting
as postilion.
It seems as though such a unique object ought to have a
permanent place in one of our public museums, for its interest is
national. A native of the district, who a short time ago chanced to see
the carriage, caught the national idea and returned home lamenting
that he could not put the old carriage on wheels and take it from town
to town. “There’s a fortune in the old thing,” said he, “for most folks
would pay a shilling or a sixpence to see the very identical carriage in
which Miss Florence took the wounded about in those Crimean times.
It’s astonishing what little things please people in the way of a show.
Why, that carriage would earn money enough to build a hospital!”
 CHAPTER IV
THE DAYS OF CHILDHOOD

Romantic Journeys from Lea Hurst to Embley Park—George

Eliot Associations—First Patient—Love of Animals and Flowers
—Early Education.

The childhood shows the man,

As morning shows the day.
Milton.

There is a lesson in each flower;

A story in each stream and bower;
On every herb o’er which you tread
Are written words which, rightly read,
Will lead you from earth’s fragrant sod,
To hope and holiness and God.
Allan Cunningham.

T HE childhood of Florence Nightingale, begun, as we have

seen, in the sunny land of Italy, was subsequently passed in
the beautiful surroundings of her Derbyshire home, and at Embley
Park, Hampshire, a fine old Elizabethan mansion, which Mr.
Nightingale purchased when Florence was about six years old.
The custom was for the family to pass the summer at Lea Hurst,
going in the autumn to Embley for the winter and early spring. And
what an exciting and delightful time Florence and her sister Parthe
had on the occasions of these alternative “flittings” between
Derbyshire and Hampshire in the days before railroads had
destroyed the romance of travelling! Then the now quiet little town of
Cromford, two miles from Lea Hurst, was a busy coaching centre,
and the stage coaches also stopped for passengers at the village inn
of Whatstandwell, just below Lea Hurst Park. In those times the
Derby road was alive with the pleasurable excitements of the
prancing of horses, the crack of the coach-driver’s whip, the shouts
of the post-boys, and the sound of the horn—certainly more inspiring
and romantic sights and sounds than the present toot-toot of the
motor-car, and the billows of dust-clouds which follow in its rear.
Sometimes the journey from Lea Hurst was made by coach, but
more frequently Mr. and Mrs. Nightingale with their two little girls
drove in their own carriage, proceeding by easy stages and putting
up at inns en route, while the servants went before with the luggage
to prepare Embley for the reception of the family.
How glorious it was in those bright October days to drive through
the country, just assuming its dress of red and gold, or again in the
return journey in the spring, when the hills and dales of Derbyshire
were bursting into fresh green beauty. The passionate love for nature
and the sights and sounds of rural life which has always
characterised Miss Nightingale was implanted in these happy days
of childhood. And so, too, were the homely wit and piquant sayings
which distinguish her writings and mark her more intimate
conversation. She acquired them unconsciously, as she encountered
the country people.
In her Derbyshire home she lived in touch with the life which at
the same period was weaving its spell about Marian Evans, when
she visited her kinspeople, and was destined to be immortalised in
Adam Bede and The Mill on the Floss. Amongst her father’s tenants
Florence Nightingale knew farmers’ wives who had a touch of Mrs.
Poyser’s caustic wit, and was familiar with the “Yea” and “Nay” and
other quaint forms of Derbyshire speech, such as Mr. Tulliver used
when he talked to “the little wench” in the house-place of the ill-fated
Mill on the Floss. She met, too, many of “the people called
Methodists,” who in her girlhood were establishing their preaching-
places in the country around Lea Hurst, and she heard of the fame of
the woman preacher, then exercising her marvellous gifts in the
Derby district, who was to become immortal as Dinah Morris. In
Florence Nightingale’s early womanhood, Adam Bede lived in his
thatched cottage by Wirksworth Tape Mills, a few miles from Lea
Hurst, and the Poysers’ farm stood across the meadows.
The childhood of our heroine was passed amid surroundings
which proved a singularly interesting environment. Steam power had
not then revolutionised rural England: the counties retained their
distinctive speech and customs, the young people remained on the
soil where they were born, and the rich and the poor were thrown
more intimately together. The effect of the greater personal
intercourse then existing between the squire’s family and his people
had an important influence on the character of Florence Nightingale
in her Derbyshire and Hampshire homes. She learned sympathy with
the poor and afflicted, and gained an understanding of the workings
and prejudices of the uneducated mind, which enabled her in after
years to be a real friend to those poor fellows fresh from the
battlefields of the Crimea, many of whom had enlisted from the class
of rural homes which she knew so well.
When quite a child, Florence Nightingale showed characteristics
which pointed to her vocation in life. Her dolls were always in a
delicate state of health and required the utmost care. Florence would
undress and put them to bed with many cautions to her sister not to
disturb them. She soothed their pillows, tempted them with imaginary
delicacies from toy cups and plates, and nursed them to
convalescence, only to consign them to a sick bed the next day.
Happily, Parthe did not exhibit the same tender consideration for her
waxen favourites, who frequently suffered the loss of a limb or got
burnt at the nursery fire. Then of course Florence’s superior skill was
needed, and she neatly bandaged poor dolly and “set” her arms and
legs with a facility which might be the envy of the modern miraculous
bone-setter.
The first “real live patient” of the future Queen of Nurses was
Cap, the dog of an old Scotch shepherd, and although the story has
been many times repeated since Florence Nightingale’s name
became a household word, no account of her childhood would be
complete without it. One day Florence was having a delightful ride
over the Hampshire downs near Embley along with the vicar, for
whom she had a warm affection. He took great interest in the little