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 Introduction to
Engineering and Scientific
Computing with Python
As more and more engineering departments and companies choose to use Python,
this book provides an essential introduction to this open-source, free-to-use language.
Expressly designed to support first-year engineering students, this book covers engi-
neering and scientific calculations, Python basics, and structured programming.
Based on extensive teaching experience, the text uses practical problem s­ olving
as a vehicle to teach Python as a programming language. By learning comput-
ing fundamentals in an engaging and hands-on manner, it enables the reader to
apply engineering and scientific methods with Python, focusing this general lan-
guage to the needs of engineers and the problems they are required to solve on
a daily basis. Rather than inundating students with complex terminology, this
book is designed with a leveling approach in mind, enabling students at all levels
to gain experience and understanding of Python. It covers such topics as struc-
tured programming, graphics, matrix operations, algebraic equations, differential
equations, and applied statistics. A comprehensive chapter on working with data
brings this book to a close.
This book is an essential guide to Python, which will be relevant to all
­engineers, particularly undergraduate students in their first year. It will also be of
interest to professionals and graduate students looking to hone their programming
skills, and apply Python to engineering and scientific contexts.
 Introduction to
Engineering and Scientific
Computing with Python

David E. Clough
Steven C. Chapra
MATLAB® is a trademark of The MathWorks, Inc. and is used with permission. The MathWorks
does not warrant the accuracy of the text or exercises in this book. This book’s use or discussion
of MATLAB® software or related products does not constitute endorsement or sponsorship by
The MathWorks of a particular pedagogical approach or particular use of the MATLAB® software.

First edition published 2023

by CRC Press
6000 Broken Sound Parkway NW, Suite 300, Boca Raton, FL 33487-2742
and by CRC Press
4 Park Square, Milton Park, Abingdon, Oxon, OX14 4RN
CRC Press is an imprint of Taylor & Francis Group, LLC
© 2023 David E. Clough and Steven C. Chapra
Reasonable efforts have been made to publish reliable data and information, but the author and
publisher cannot assume responsibility for the validity of all materials or the consequences of
their use. The authors and publishers have attempted to trace the copyright holders of all m
­ aterial
reproduced in this publication and apologize to copyright holders if permission to ­publish in this
form has not been obtained. If any copyright material has not been acknowledged, please write
and let us know so we may rectify in any future reprint.
Except as permitted under U.S. Copyright Law, no part of this book may be reprinted,
­reproduced, transmitted, or utilized in any form by any electronic, mechanical, or other means,
now known or hereafter invented, including photocopying, microfilming, and recording, or in
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For permission to photocopy or use material electronically from this work, access www.­
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­mpkbookspermissions@tandf.co.uk
Trademark notice: Product or corporate names may be trademarks or registered trademarks and
are used only for identification and explanation without intent to infringe.
Library of Congress Cataloging‑in‑Publication Data
Names: Clough, David E., author. | Chapra, Steven C., author.
Title: Introduction to engineering and scientific computing with Python / David
E. Clough, Steven C. Chapra.
Description: First edition. | Boca Raton : CRC Press, 2023. |
Includes bibliographical references and index.
Identifiers: LCCN 2022012776 (print) | LCCN 2022012777 (ebook) |
ISBN 9781032188942 (hardback) | ISBN 9781032188973 (paperback) |
ISBN 9781003256861 (ebook)
Subjects: LCSH: Engineering mathematics—Data processing. |
Science—Mathematics—Data processing. | Python (Computer program language)
Classification: LCC TA345 .C584 2023 (print) | LCC TA345 (ebook) |
DDC 620.001/51—dc23/eng/20220706
LC record available at https://lccn.loc.gov/2022012776
LC ebook record available at https://lccn.loc.gov/2022012777
ISBN: 9781032188942 (hbk)
ISBN: 9781032188973 (pbk)
ISBN: 9781003256861 (ebk)
DOI: 10.1201/9781003256861

Typeset in Times
by codeMantra
 This book is dedicated to the thousands of our former students
at the University of Colorado, Tufts University, and Texas A&M
University. Go Buffs, Go Jumbos, and Gig ‘Em Aggies!
Contents
List of Examples.................................................................................................xiii
Preface................................................................................................................. xv
Acknowledgments...............................................................................................xxi
Authors..............................................................................................................xxiii

Chapter 1 Engineering and Scientific Calculations.......................................... 1

Chapter Objectives........................................................................... 1
1.1 Numerical Quantities............................................................. 3
1.1.1  Positional and Scientific Notation............................ 3
1.1.2  Accuracy and Precision............................................ 4
1.1.3  Significant Figures................................................... 5
1.1.4  Rounding.................................................................. 6
1.2  Mathematical Functions........................................................ 9
1.2.1  Absolute Value and Sign Functions........................ 10
1.2.2  Exponents and Logarithms.................................... 10
1.2.3  Trigonometric Functions........................................ 14
1.2.4  Hyperbolic Functions............................................. 20
1.3  Complex Numbers............................................................... 22
1.4  Engineering Units................................................................ 24
1.5  Organizing and Planning Solutions to Problems................ 28
Problems......................................................................................... 36

Chapter 2 Computer-Based Calculations........................................................ 41

Chapter Objectives......................................................................... 41
2.1  Numerical Quantities as Stored in the Computer................ 43
2.1.1  Integer Numbers..................................................... 43
2.1.2  Real Numbers......................................................... 46
2.2  How the Computer Stores Text............................................ 49
2.3  Boolean True/False Information......................................... 49
2.4  Computer Storage Evolution and Terminology................... 51
Problems......................................................................................... 51

Chapter 3 Python Basics................................................................................. 55

Chapter Objectives......................................................................... 55
3.1  The Spyder/IPython Environment....................................... 56
3.2  Mathematical Functions...................................................... 61
3.3  Variables and Assignment................................................... 64
3.4  Objects, Attributes, Methods, and Data Types.................... 67

vii
viii Contents

3.4.1  Boolean Type.......................................................... 69

3.4.2  Character Type....................................................... 71
3.5  Collections of Data.............................................................. 72
3.6  Creating Plots...................................................................... 76
3.7  The Spyder Editor................................................................ 82
3.8  Input and Output.................................................................. 87
3.8.1  Console Input and Output...................................... 88
3.8.2  File Input and Output............................................. 89
3.8.3  Formatting Output.................................................. 91
3.9  Obtaining Help.................................................................... 93
Problems......................................................................................... 97

Chapter 4 Structured Programming with Python..........................................101

Chapter Objectives........................................................................101
4.1  An Overview of Program Structure.................................. 102
4.2  Implementing Decision Structures with Python............... 104
4.3  Implementing Repetition Structures with Python..............110
4.3.1  The General Loop Structure.................................110
4.3.2  The List-Driven and Count-Controlled
Loop Structures����������������������������������������������������112
4.3.3  The break and Continue Statements with
the for Loop��������������������������������������������������������116
4.4  User-Defined Functions in Python.....................................118
4.4.1  lambda Functions................................................ 120
4.4.2  Function Arguments............................................. 121
4.4.3  Variable Scope...................................................... 127
Problems....................................................................................... 129

Chapter 5 Graphics—Matplotlib.................................................................. 137

Chapter Objectives....................................................................... 137
5.1  Introduction to Matplotlib................................................. 137
5.2  Customizing Line and Scatter Plots.................................. 140
5.3  Using Figure Window Objects.......................................... 151
5.4  Creating Bar Plots Including Histograms......................... 154
5.5  Creating Other Plots of Interest......................................... 158
5.6  Contour and Surface Plots................................................. 164
Problems........................................................................................170

Chapter 6 Array and Matrix Operations........................................................175

Chapter Objectives........................................................................175
6.1  Creating Arrays in Python..................................................176
6.1.1  Creating Special Arrays........................................178
Contents ix

6.1.2  Combining, Stacking, and Splitting Arrays......... 179

6.1.3  Reshaping Arrays................................................. 180
6.2  Indexing: Array Subscripts.................................................181
6.3  Array Operations............................................................... 184
6.4  Vector/Matrix Operations................................................. 189
6.4.1  Matrix/Vector Multiplication............................... 190
6.4.2  Transpose............................................................. 193
6.4.3  Matrix Inversion................................................... 193
Problems....................................................................................... 196

Chapter 7 Solving Single Algebraic Equations............................................. 199

Chapter Objectives....................................................................... 199
7.1  The Nature of Single, Nonlinear Equations in
One Unknown������������������������������������������������������������������� 200
7.2  Bracketing Methods—Bisection....................................... 202
7.3  Bracketing Methods—False Position................................ 207
7.4  Open Methods—Newton-­Raphson................................... 212
7.5  Open Methods—Modified Secant......................................219
7.6  Circular Methods—Fixed-­Point Iteration......................... 221
7.7  Circular Methods—The Wegstein Method....................... 227
7.8  A Hybrid Approach—Brent’s Method.............................. 230
7.9  Solving for the Roots of Polynomials................................ 233
7.10 Case Study: Trajectories of Projectiles in Air................... 237
Problems....................................................................................... 242

Chapter 8 Solving Sets of Algebraic Equations............................................ 249

Chapter Objectives....................................................................... 249
8.1  Systems of Linear Algebraic Equations............................ 250
8.2  Solving Small Numbers of Linear Algebraic Equations......252
8.2.1  Graphical Method................................................ 252
8.2.2  Determinants and Cramer’s Rule......................... 254
8.2.2.1  Determinants........................................ 254
8.2.2.2  Cramer’s Rule....................................... 256
8.2.3  Elimination of Unknowns.................................... 258
8.3  Gaussian Elimination........................................................ 260
8.3.1  Naive Gaussian Elimination................................. 261
8.3.2  Gaussian Elimination Computer Algorithm........ 265
8.3.2.1  Naive Gaussian Elimination
Algorithm�������������������������������������������� 265
8.3.2.2  Adding Determinant Evaluation���������� 267
8.3.2.3  Partial Pivoting..................................... 268
8.3.2.4  Detecting Singular and
Ill-Conditioned Systems���������������������� 270
x Contents

8.4  Solving Sets of Linear Equations with the NumPy

linalg Module���������������������������������������������������������������� 273
8.5  Solving Sets of Nonlinear Algebraic Equations................ 274
8.5.1  Solution of Nonlinear Algebraic Equations
by Successive Substitution���������������������������������� 275
8.5.2  The Newton-Raphson Method for Nonlinear
Systems of Equations������������������������������������������ 278
8.6  Use of the root Function from the SciPy optimize
Module to Solve Nonlinear Equations����������������������������� 285
Problems....................................................................................... 286

Chapter 9 Solving Differential Equations..................................................... 293

Chapter Objectives....................................................................... 293
9.1  Describing Differential Equations..................................... 294
9.2  Quadrature – Finding the Area under the Curve.............. 298
9.2.1  Pre-computer Methods......................................... 298
9.2.2  Quadrature for Continuous Functions.................. 300
9.2.3  The quad Function from SciPy’s
integrate Module�������������������������������������������� 304
9.2.4  Quadrature for Discrete Data............................... 305
9.3  Solving Differential Equations with Initial Conditions..... 307
9.3.1  Euler’s Method..................................................... 307
9.3.2  Heun’s Method......................................................311
9.3.3  Systems of Differential Equations.........................313
9.4  Solving Differential Equations with the solve _ ivp
Function from SciPy’s integrate Module����������������������319
Problems....................................................................................... 323

Chapter 10 Working with Data....................................................................... 329

Chapter Objectives....................................................................... 329
10.1 Characterizing Data Sets: Initial Observations and
Sample Statistics��������������������������������������������������������������� 330
10.1.1 General Data Concepts......................................... 330
10.1.2 Sample Statistics: Central Tendency and
Dispersion������������������������������������������������������������ 333
10.1.2.1  Central Tendency.................................. 334
10.1.2.2  Spread or Dispersion............................. 336
10.1.3 Using Boxplots to Diagnose Outliers................... 339
10.2 Distributions...................................................................... 342
10.2.1 Several Important Distributions........................... 345
10.2.1.1  Uniform Distribution............................ 345
10.2.1.2  Normal Distribution.............................. 346
10.2.1.3  Weibull Distribution............................. 347
Contents xi

10.2.2  Python and Distributions...................................... 347

10.2.3  Random Numbers................................................. 348
10.3 Making Claims Based on Data.......................................... 352
10.3.1  Comparison of Data with a Standard................... 353
10.3.2  Comparison between Two Samples..................... 356
10.3.3  Determining Whether Data Are Normally
Distributed����������������������������������������������������������� 358
10.4 Fitting Mathematical Models to Data................................ 363
10.4.1  Straight-line Linear Regression............................ 364
10.4.2  Fitting Polynomials.............................................. 368
10.4.3  General Issues and Precautions............................ 370
Problems....................................................................................... 379

References�������������������������������������������������������������������������������������������������������� 385
Index����������������������������������������������������������������������������������������������������������������� 387
Index of Python Terminology������������������������������������������������������������������������ 393
List of Examples
Chapter 1 Engineering and Scientific Calculations
1.1 What is the Volume of the Earth?��������������������������������������������������������������� 1
1.2 Catenary Cable........................................................................................... 21
1.3 Engineering Units in Calculations............................................................. 27
1.4 Engineering and Scientific Problem Solving............................................. 29

Chapter 2 Computer-Based Calculations

2.1 What is the Radius of the Earth—Expressed in Binary?........................... 41
2.2 IEEE 754 Representation of π.................................................................... 48

Chapter 3 Python Basics

3.1 Calculating the Great Circle Distance between Two Points on the Earth........ 62
3.2 Using Variable Names with the Great Circle Formula.............................. 66
3.3 Creating a Script for the Great Circle Calculation..................................... 85

Chapter 4 Structured Programming with Python

4.1 Converting Thermocouple Millivolt Readings to Temperature............... 107
4.2 Using the while Structure for Input Validation......................................111
4.3 Using a for Loop to Limit Iterations.......................................................113
4.4 Using a for Loop to Vary Subscripts of an Array...................................114
4.5 Carrying Out a Set of Calculations Based on a Sequence of Values........115

Chapter 5 Graphics—Matplotlib
5.1 Freezing Point of Aqueous Ethylene Glycol Solutions............................ 138
5.2 Sunspot Observations............................................................................... 139
5.3 Plotting the Densities of Salt and Mag Chloride Solutions...................... 145
5.4 Plotting Weather Data—Temperature and Relative Humidity................. 148
5.5 Worldwide Wind Power Generation......................................................... 156
5.6 Plotting the Vapor Pressure of Water versus Temperature....................... 160
5.7 Creating a Pie Chart for World Energy Production by Source................ 163
5.8 Contour Plot from Data of Salt Solution Density..................................... 167

Chapter 6 Array and Matrix Operations

6.1 Using Arrays in a Case Study.................................................................. 186
6.2 Solving a Set of Linear Equations with Vector/Matrix Operations......... 195

Chapter 7 Solving Single Algebraic Equations

7.1 Finding the Depth of Liquid in a Spherical Tank Given the Volume...... 205
7.2 Calibrating the Depth/Volume Relationship of Liquid in a Spherical Tank......217
7.3 Solving the van der Waals Equation for Volume with Brent’s Method..... 232

xiii
xiv List of Examples

Chapter 8 Solving Sets of Algebraic Equations

8.1 Linear Equations and Engineering/Science Problem Solving................. 250
8.2 Determinants............................................................................................ 255
8.3 Cramer’s Rule........................................................................................... 256
8.4 Elimination of Unknowns........................................................................ 259
8.5 Naive Gaussian Elimination..................................................................... 261
8.6 Construction Materials: A Blending Problem with Linear Equations..... 272
8.7 Equilibrium between Water Liquid and Vapor in a Boiler Vessel........... 283

Chapter 9 Solving Differential Equations

9.1 Computing Probability for the Gaussian Distribution............................. 303
9.2 Trajectory of a Projectile with Air Resistance..........................................316

Chapter 10 Working with Data

10.1 Simulating a Noisy Signal with Random Number Generation................ 350
10.2 Fitting a Straight Line to U.S. CO2 Emissions from Fossil Fuels............ 366
10.3 
Fitting a Polynomial to Data on the Density of Water versus
Temperature.............................................................................................. 374
Discovering Diverse Content Through
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with chin resting upon chest; arms crossed upon chest below chin;
thighs flexed upon abdomen and knees bent.

Fig. 51.—Illustrations
from the first textbook
on obstetrics, Roesslin’s
“Rosengarten,” 1513,
which gives an amusing
impression of early ideas
of the position of the
fetus in utero.

With a few exceptions the long axis of the fetus is parallel to the
long axis of the mother, and most frequently the head is downward.
It was formerly believed that the child stood upright in the uterus
until toward the end of pregnancy and then somersaulted to the
position it occupied immediately before birth. (Fig. 51.) But it is now
known that though the fetus may move about and change its position
during the early part of pregnancy, it is not likely greatly to alter its
relation to the mother’s body during the tenth lunar month.
 Fig. 52.—Attitude of fetus in
breech presentation.

It seems advisable to define here certain terms which are in

common use in discussing patients in labor, and which will be
employed in the following pages.
A nullipara (0–para) is a woman who has not had children.
A primigravida is a woman who is pregnant for the first time.
A primipara (1–para) applies to a woman during her first labor
and until the beginning of her second labor.
2–para, 3–para and 4–para apply to women in succeeding labors
which correspond to the numerals used.
A multipara is a woman who has had more than one child.
There is also a terminology, with abbreviations, which is fairly
generally used in this country and England to designate the position
which the child, about to be born, occupies in relation to its mother’s
body. A diagnosis of this position is, of course, absolutely necessary
to a skilful management of labor, and the nurse should understand
the meanings of the terms used, and also their distinctions and
subdivisions.
 Fig. 53.—Attitude of fetus in
vertex presentation.

The presentation of the fetus is the term which is employed to

indicate the part of the baby’s body which is at the brim of the
mother’s pelvis. Thus the part of the fetus which is lowermost is
designated as the presenting part and gives the presentation its
name. If the breech is downward, therefore, it is a breech
presentation (Fig. 52), and if the head is the lower pole it is termed a
head, or cephalic presentation. (Fig. 53.) The head presentations are
divided into two main groups, which are designated, respectively, as
face and vertex presentations. For example, if the baby’s neck is so
arched that the chin rests upon the chest, the crown of its head, or
the vertex, is the part that is lowest in the birth canal and is the part
that will be seen first at the vaginal outlet. Therefore, this is called a
vertex, or occipital presentation. But if the neck is bent sharply
backward, the face becomes the presenting part and we have a face
presentation.
The breech, face and vertex presentations are sometimes referred
to as longitudinal presentations since in these instances the long
axes of the bodies of mother and child are parallel. In transverse
presentations, however, the child lies across the uterus, with one side
or the other at the pelvic brim.
 The transverse presentations are infrequent, occurring once in
about 250 cases, and are regarded as abnormal because spontaneous
delivery under such circumstances is extremely rare. They are more
likely to be seen, when they do occur, among multiparæ and women
who have contracted pelves.
The longitudinal presentations, however, constitute something
over 99 per cent. of all cases and are regarded as normal, since the
child occupying this relationship may be born spontaneously. In
about 3 per cent. of the longitudinal presentation the breech is the
presenting part and in about 97 per cent. it is the head. Of these, the
vertex presentation is the one most commonly seen and is the one in
which the child is most easily delivered. Face presentations are very
rare, occurring in only a fraction of 1 per cent. of all cases.
In addition to the child’s presentation, there is also its position,
which is an entirely different matter, for in each longitudinal
presentation the presenting part may occupy any one of six positions.
By position is meant the relation of some arbitrarily chosen point
on the presenting part of the fetus, to the right or left side of the
mother, and to the front (anterior), side (transverse) or back
(posterior) segment of that side.
Taking these up in turn, we find, that in transverse presentations
the shoulder, acromion process, is the point on the baby’s body
which is chosen, to give the four possible positions their names.
In breech presentations the sacrum is the arbitrarily chosen point.
In face presentations it is the chin, or mentum, while in vertex
presentations the occiput is the point chosen.
Presentation, then, describes the relation of the long axis of the
entire fetal body to the mother’s body, while position describes the
relation between the baby’s shoulder, sacrum, face or occiput to the
mother’s pelvis.
If the child is so placed in the uterus that the head is the
presenting part; the neck arched with chin on chest, and the occiput
directed toward the mother’s left side, and more to the front than to
the side, the presentation would be longitudinal, of the vertex
variety, and the position would be a left-occipito-anterior. The
arbitrarily chosen point on the child’s body (the occiput) would be
directed toward the left, anterior segment of the mother’s pelvis. This
is the situation most commonly seen and the description of this
presentation and position are abbreviated, by taking the first letter of
each word, into L. O. A.

Fig. 54.—Diagram showing the six possible

positions in a vertex presentation.

If the occiput were turned directly toward the mother’s left side,
neither to the front nor the back, we should have a left-occipito-
transverse, L. O. T., and if it were directed toward the left posterior
segment of the pelvis the position would be left-occipito-posterior, or
L. O. P. As there are three corresponding positions on the right side,
anterior, transverse and posterior, there are six possible positions for
the child to occupy in the vertex, or occipital presentations, as
follows:

Left-occipito-anterior, abbreviated to L.O.A.

Left-occipito-transverse, abbreviated to L.O.T.
Right-occipito-posterior, abbreviated to L.O.P.
Right-occipito-anterior, abbreviated to R.O.A.
Right-occipito-transverse, abbreviated to R.O.T.
Right-occipito-posterior, abbreviated to R.O.P. (Fig. 54.)

Similarly there are six face (Fig. 55) and six breech (Fig. 56)
presentations. Thus, if the chin (mentum) is resting in the left
anterior segment of the mother’s pelvis, the position would be left-
mento-anterior, or L. M. A. If the breech presents and the sacrum is
in that relation the position is left-sacro-anterior, or L. S. A.

Fig. 55.—Diagram showing the six possible

positions in a face presentation.

In describing the transverse presentations, four words, instead of

three are used; thus, left-acromio-dorso-anterior, or L. A. D. A.
There are but four varieties of transverse presentations, since the
shoulder is either anterior or posterior: thus left-acromio-dorso-
anterior, left-acromio-dorso-posterior and the two corresponding
positions on the right side.

Fig. 56.—Diagram showing the six possible

positions in a breech presentation.
 During the last two to four weeks of pregnancy, particularly among
the primiparæ, the top of the fundus settles to the level which it
reached at about the eighth month, and the lower part of the
abdomen becomes more pendulous than formerly. The patient
usually breathes much more comfortably after this change in contour
takes place, but, at the same time, she may have cramps in her legs as
a result of the increased pressure; more difficulty in walking;
frequent micturition and desire to empty her bowels, while the
vaginal discharge may be considerably increased. It is at this time
that the presenting part enters the superior strait and is spoken of as
being “engaged.”
The time at which engagement takes place depends upon three
factors: Whether the patient is a multipara or a primipara; the size
and normality of the pelvis; the size and position of the fetus. It is
often helpful to the obstetrician in planning for the delivery to know
whether or not the presenting part is engaged, particularly in
primiparæ.
Although in primiparæ engagement usually occurs about four
weeks before labor begins, it does not normally take place in
multiparæ until immediately before labor. This difference is
accounted for in the increased tonicity of the uterine and abdominal
muscles of primiparous women. In certain abnormalities, or marked
disproportion between the diameters of the child’s head and
mother’s pelvis, engagement may not take place until labor is well
advanced, or possibly not at all.
The presentation and position of the fetus are ascertained by
means of abdominal palpation, vaginal examination, rectal
examination and auscultation of the fetal heart.
Palpation of the child’s body through the mother’s abdominal wall
is possible under ordinary conditions, because the uterine and
abdominal muscles are so stretched and thinned that the various
parts may be made out through them. But it is sometimes difficult in
hydramnios and is practically impossible in very fat patients or in the
case of a ruptured uterus when the fetal outline is obscured by
hemorrhage. This procedure has been practiced only during
comparatively recent years, and is regarded by many obstetricians as
one of the most important factors in reducing the frequency of
puerperal infections and thus in decreasing maternal deaths. The
explanation is that in general the dangers of puerperal infection are
believed to increase in direct proportion to the number of times a
patient is examined vaginally; and since it has been known how to
diagnose the child’s position by means of abdominal palpation, the
necessity for vaginal examinations is not so great and they are
accordingly made less frequently.

Fig. 57.—First maneuver in

abdominal palpation to discover
position of fetus.

Rectal examinations may also be regarded as a factor in preventing

infection, for, since much the same information may be obtained by
means of them as by vaginal examinations, after the onset of labor,
they often replace direct exploration of the easily infected birth canal.
Abdominal palpation, as usually practiced, consists of four
maneuvers, with the patient lying flat and squarely on her back with
the abdomen exposed. The nurse should bear in mind that successful
palpation requires even pressure. Cold hands applied to the
abdomen or quick, jabbing motions with the fingers will usually
stimulate the muscles lying beneath them to contract, thus somewhat
obscuring the outline of the child. Such palpation is also very
uncomfortable for the patient; but firm, even pressure, started
gently, with warm hands, does not hurt.
 Fig. 58.—Second maneuver in
abdominal palpation.

First Maneuver. The purpose of the first maneuver is to ascertain

what is in the fundus; this is usually either the head or the breech.
The nurse should stand facing the patient and gently apply the entire
tactile surface of the fingers of both hands to the upper part of the
abdomen, on opposite sides and somewhat curved about the fundus.
(Fig. 57.) In this way the outline of the pole of the fetus which
occupies the fundus may be made out. If the head is uppermost, it
will be felt as a hard, round object which is movable or ballottable
between the two hands, and if the breech, it will be felt as a softer,
less movable, less regularly shaped body.

Fig. 59.—Third maneuver in

abdominal palpation.
 Second Maneuver. Having determined whether the head or the
breech is in the fundus, the next step is to locate the child’s back and
the small parts in their relation to the right and left sides of the
mother. This is accomplished by slipping the hands down to a
slightly lower position on the sides of the abdomen than they occupy
in the first maneuver, and making firm, even pressure with the entire
palmar surface of both hands. The back is felt as a smooth, hard
surface under the palm and fingers of one hand, and the small parts,
or hands, feet and knees, as irregular knobs or lumps, under the
hand on the opposite side. (Fig. 58.)

Fig. 60.—Fourth maneuver in

abdominal palpation. (This
series of pictures is from
photographs taken at Johns
Hopkins Hospital.)

Third Maneuver. Unless the presenting part is engaged, the third

maneuver virtually amounts to a confirmation of the impression
gained by the first maneuver, by showing which pole is directed
toward the pelvis. The thumb and fingers of one hand are spread as
widely apart as possible, applied to the abdomen just above the
symphysis and then brought together to grasp the part of the fetus
which lies between them. If not engaged, the head will be felt as
hard, round and movable, while the breech will be less clearly
defined. (Fig. 59.)
 Fig. 61.—Diagrams showing
relation of nurse’s hands to fetus
in the four maneuvers of
abdominal palpation.

Fourth Maneuver. The fourth maneuver is of particular value after

the presenting part has become engaged. The nurse faces the
patient’s feet in this position, and directs the first three fingers of
each hand down into the pelvis, on either side of the fetus, to
ascertain whether it is a face or vertex presentation, by discovering
whether chin or occiput is the higher cephalic prominence in the
mother’s pelvis. (Fig. 60.) If it is a vertex presentation, the neck will
be flexed, with the chin on the chest and consequently higher in the
pelvis than the occiput. The nurse’s fingers of one hand will
accordingly come in contact with the chin on the side opposite to the
child’s back, before the fingers of the other hand reach the occiput.
If, however, it is a face presentation, the neck will be bent sharply
backward and the nurse’s fingers will feel the occiput first, and on
the same side as the baby’s back. This maneuver tells, also, how far
into the pelvis the presenting part has descended.
 Fig. 62.—Diagram showing method of
ascertaining position of fetus by means of rectal
examination. Examining finger palpates head
through recto-vaginal septum.

Vaginal Examination. The information obtained by vaginal

examination, before the cervix is dilated, is rather uncertain since the
child’s presenting part must be palpated through the fornix. But after
complete, or even partial dilatation, the exploring finger is able to
feel the sagittal suture and one fontanelle, in a vertex presentation,
and diagnose the position by discovering the direction of the suture
and whether it is the anterior or posterior fontanelle that is felt. The
anterior fontanelle, it will be remembered, is relatively large and
four-sided, while the posterior is small and more nearly triangular in
shape. In a face presentation, the features may be felt; in a breech the
examining finger can palpate the buttocks and genital crease.
Because of the possible danger of introducing infective material
into the birth canal, the tendency is to make fewer and fewer vaginal
examinations, and then only after the most painstaking preparation
which will be described presently. Needless to state, vaginal
examinations are not within the province of the nurse.
Rectal Examinations. More and more frequently rectal
examinations are being employed to obtain information about the
child’s position, as the examining finger is able to feel the surface of
the presenting part through the recto-vaginal septum, after the
cervix is dilated, and there is no danger of infecting the birth canal
while so doing. For this reason nurses are frequently taught to make
rectal examinations, thereby increasing the value of their assistance
to the doctor in watching the progress of labor. (Fig. 62.)
Auscultation of the fetal heart is valuable in confirming the
diagnosis of presentation and position which has been made by
palpation. In vertex and breech presentations the heartbeat is best
heard through the baby’s back and in face presentations it is
transmitted through the chest, which presents a convex surface in
this case and fits into the curve of the uterine wall. In anterior vertex
presentations the heart is heard a little to the side and below the
umbilicus; in transverse, further to the side, and in posterior, well
toward the back.
 CHAPTER XI
SYMPTOMS, COURSE AND MECHANISM OF
NORMAL LABOR

Labor may be defined as the process by means of which the

product of conception is separated and expelled from the mother’s
body. It ordinarily occurs about 280 days from the beginning of the
last menstrual period. (See p. 93.)
The cause of labor is not known. Many theories have been
advanced to explain why the uterine contractions, which have
occurred painlessly throughout pregnancy, and without expulsive
force, finally become painful at the end of the tenth month and so
changed in character as to extrude the uterine contents; but as yet,
none is wholly satisfactory nor generally accepted. Nor is it known
why some labors are premature and some delayed.
The onset of labor is usually marked by the patient’s becoming
conscious of the uterine contractions through dragging pains which
may be felt first in the back and then in the lower part of the
abdomen and the thighs. At first the pains are feeble and infrequent,
but they gradually grow more severe and more frequent. Intestinal
colic is sometimes mistaken for labor pains, but when the paroxysms
are rhythmical and the uterus is felt, through the abdominal wall, to
grow hard as the pain increases and soft as it subsides, there can be
no doubt but that the patient is in labor. The first signs of labor may
be a gush of amniotic fluid, caused by the rupture of the membranes,
or of blood, but these are not typical.
For purposes of convenience, labor is usually described as
consisting of three periods or stages. The first stage begins with the
onset of labor and lasts until the cervix is completely dilated; the
second stage begins with the complete dilatation of the cervix and
lasts until the child is born; the third stage begins with the birth of
the child and lasts until the placenta is expelled.
The entire duration of labor may vary from a few moments,
comprising a few pains, to several days of severe and exhausting
pain, but the average length of the first labor is 18 hours and of
subsequent labors about 12 hours, divided respectively into the three
periods as follows:
1st stage. 2nd stage. 3rd stage. Total.
Primipara 16 hours 1¾ hours 15 minutes 18 hours.
Multipara 11 hours 45 minutes 15 minutes 12 hours.
The longer labor in primiparous women is due to the greater tone,
and thus the greater resistance offered by the muscles of the cervix
and perineum. Elderly primiparæ are likely to have longer labors
than young primiparæ.
First Stage. This is frequently called the stage of dilatation.
During this period the contractions of the uterine muscles make
pressure upon the amniotic sac of fluid, forcing it gradually down
and into the cervix as a water wedge, widening the internal os first,
then the external os, until the entire canal is fully dilated (thinned
out); shortened to about one-half inch in length and finally
obliterated so that it is uninterruptedly continuous with the lower
uterine segment. (Figs. 63, 64, 65, 66.)
The first stage pains begin by being mild and occurring at intervals
of from 15 to 30 minutes, but they gradually increase in frequency
and intensity until at the end of 14 to 16 hours they are very severe
and recur every three or four minutes, each pain lasting about one
minute. The pains begin in the back, pass slowly forward to the
abdomen and down into the thighs.
The patient is entirely comfortable, as a rule, between pains and
until they become very frequent will usually feel able, in fact prefer,
to be up and about, but if she is on her feet when a contraction
begins she will usually seek relief by assuming a characteristic
leaning position (Fig. 67) or by sitting down, until the pain subsides.
As dilatation advances, the patient has an increasing, sometimes
persistent, desire to empty the bowels and bladder because of
encroachment upon these two organs by the descending head. She
may vomit, also, when the cervix becomes nearly or quite dilated.
Fig. 63.

Fig. 64.

Fig. 65.
 Fig. 66.

Figs. 63, 64, 65, and 66 are diagrams showing stages of dilatation and obliteration
of cervix during labor.

In the course of this stretching process, the cervix sustains many

tiny lesions, from which blood oozes and tinges the vaginal
discharge. This blood-stained secretion is often called the “show” and
usually appears toward the end of the first stage.

Fig. 67.—Characteristic
position which patient
often assumes during
pains in first stage.
 As a rule, when the cervix is fully dilated the membranes rupture
and there is a sudden gush of that part of the fluid which was below
the fetus in the amniotic sac, but the rupture of the membranes does
not necessarily mark the end of the first stage. In some instances
they rupture before the cervix is fully dilated; in others, though not
often, before the patient goes into labor, thus producing what is
known as a “dry” labor.
The abdominal muscles do not contract very forcibly during the
first stage, the expulsive force in this period coming almost entirely
from the uterine contractions. The patient’s cries at this time are
sharp and complaining in contrast to the groans and grunts which
accompany the second stage.
Complete dilatation of the cervix marks the termination of the first
stage.

Fig. 68.—Diagram indicating the rotation and

pivoting of baby’s head during birth.

Second Stage. The second stage is sometimes called the stage of

descent, or expulsion, of the fetus. The patient should and is usually
quite willing to be in bed throughout the second stage, during which
she should not be left alone. The pains are now regular, occurring at
intervals of about two minutes from the beginning of one to the
beginning of the pain following, and as the contractions last about
one minute and are excruciatingly painful, the patient has very little
respite from her suffering. Her face is flushed and she may perspire
freely.
The abdominal and respiratory muscles are brought into active use
during the second stage, contracting simultaneously with the uterine
muscles and increasing their expulsive force. These are apparently
controlled by the patient’s will at first, and she is able somewhat to
increase their power by taking a deep breath, closing her lips, bracing
her feet, pulling against something with her hands, straining with all
her might and “bearing down.” Finally, however, the whole bearing
down process becomes involuntary, is accompanied by intense pain
and the deep grunting sound, which is characteristic of the well-
advanced second stage. Under normal conditions, the child descends
a little farther into the pelvis with each contraction, and finally the
presenting part begins to distend the perineum and to separate the
labia advancing at the height of each pain and slipping back a little as
it subsides.

Fig. 69.—Anterior shoulder

being slipped from under
symphysis to facilitate birth of
posterior shoulder.

The baby descends into and through the mother’s pelvis by means
of a series of twisting and curving motions, accommodating the long
axes of its head to the long diameters of the pelvis. The head being
somewhat compressible and mouldable, because of imperfect
ossification, is capable of a good deal of accommodation to the
mother’s pelvis.
The mechanism of labor, therefore, is virtually a series of
adaptations of the size, shape and mouldability of the baby’s head to
the size and shape of the mother’s pelvis. If the head passes through
the inlet satisfactorily, the rest of the labor will usually be
accomplished with comparative safety. But a marked disproportion
between the diameters of the head and pelvis may interfere with the
engagement or descent of the head and produce a serious
complication.

Fig. 70.—Delivery of posterior

shoulder.

The long diameter of the head must first conform to one of the
long diameters of the inlet, usually oblique, and then turn so that the
length of the head is lying antero-posterior in conformity to the long
diameter of the outlet through which it next passes. As the head
descends and rotates it also describes an arc because the posterior
wall of the pelvis, consisting of the sacrum and coccyx, is about three
times as deep as the anterior wall formed by the symphysis. That
part of the baby’s head which passes down the posterior wall of the
pelvis must therefore travel three times as far in a given time as the
part which simply slips under the short symphysis pubis.
 Fig. 71.—Diagrams showing Duncan and Schultze
mechanisms of placental separation.

In a vertex presentation, left-occipito-anterior position, while the

occiput passes under the symphysis and appears at the distending
vaginal outlet, the face passes down the posterior wall and along the
floor of the pelvis. As pressure is exerted by the rapidly succeeding
contractions, the head pivots about the pubis, thus extending the
neck and pushing the face farther downward and forward. After
emergence of the back and top of the head below the symphysis, the
forehead appears over the posterior margin of the vagina, then the
brow, eyes, nose, mouth and chin in turn, and the entire head is
born. (Fig. 68.) The baby’s head then drops forward, in relation to its
own body, with its face toward the mother’s rectum and the occiput
in front of the pubis, but soon the occiput rotates toward the
mother’s left side, resuming the relation that it bore to the inner
aspect of her pelvis before expulsion. The undelivered shoulders are
now antero-posterior, one under the pubis and the other resting on
the perineum. (Fig. 69.) The lower, or posterior shoulder is born first
(Fig. 70), followed quickly by the anterior shoulder and the rest of
the body, and the amniotic fluid which was behind the child’s body.
Thus is the second stage completed.
 Fig. 72.—Longitudinal
section through uterus
showing thinness of
uterine wall before
expulsion of fetus,
contrasting sharply with
thickened wall in Fig.
73. (From photograph of
specimen, to which twin
placentæ are still
adherent in upper
segment, in the
obstetrical laboratory,
Johns Hopkins
Hospital.)

Third Stage. The third stage, sometimes termed the placental

stage, is that period following the birth of the child, during which the
placenta is delivered. For a few moments after the baby is born the
tired mother lies quietly and free from pain, as there is a temporary
cessation of the uterine contractions, and she often sleeps as a result
of the anesthetic given during the second stage.
The uterus has greatly decreased in size, the fundus now lying
below the umbilicus where it may be felt as a firm, solid mass. The
uterine contractions are resumed in the course of a few moments and
as they persist, the uterus grows smaller, thereby greatly decreasing
the area of placental attachment. As the placenta
is non-contractile it cannot accommodate itself to
this decreased area of attachment, and so is
literally squeezed from its moorings. It is then
gradually forced down into the lower uterine
segment where it may be located by the
distension of the abdominal wall which it
produces just above the symphysis. After the
separation of the placenta is complete the uterus
rises in the abdominal cavity until the fundus is
felt above the umbilicus. The placenta, finally,
may be completely expelled spontaneously, or
expressed by slight pressure made upon the
fundus by the accoucheur. Fig. 73.—
The placental detachment may begin at the Longitudinal
centre, the area of separation spreading to the section through
margin, or the detachment may start at the uterus,
margin of the placenta and extend toward the immediately
centre. Either is normal. These two modes of after labor,
placental separation are named the Schultze and showing marked
the Duncan, respectively, from the men who first thickening of
described them. (Fig. 71.) wall as a result of
muscular
In the Schultze mechanism, which occurs most contraction.
frequently, the separating process begins at the (From
centre of the placenta and the glistening fetal photograph of
surface appears at the vaginal outlet. In this case specimen in the
there is practically no bleeding during the third obstetrical
stage as the inverted placenta blocks the vagina laboratory,
and holds back the blood. Johns Hopkins
In Duncan’s mechanism the detachment Hospital.)
begins at the margin, the placenta rolls upon
itself and presents at the outlet by its roughened
maternal surface and there is usually slight but continuous bleeding
from the time the separation begins. When the placenta is delivered,
the collapsed membranes trail after it like a tapering cord. A good
deal of blood is lost at the time of the placental expulsion and
immediately afterwards, but this profuse bleeding usually subsides in
a few moments. Although the loss of blood may be as much as 500
cubic centimetres without its being regarded as serious, the average
amount is about 350 cubic centimetres.
The patient has been through a severe ordeal and at the end of the
third stage of labor she is usually tired out and cold.
 CHAPTER XII
THE NURSE’S DUTIES DURING LABOR

The extent of the nurse’s helpfulness during labor, both to the

patient and to the doctor, will depend very largely upon the
intelligence with which she grasps what is taking place and upon her
own attitude, as an individual, toward the patient and the miraculous
event which approaches. Important as is the preparation of the room
and dressings, this other factor is almost equally influential.
It will be wiser, therefore, for the nurse to try to picture the process
of labor in each instance, and to be guided by a few broad principles
that apply to all cases under all conditions, rather than to try to
memorize the details of her duties and of the desirable equipment
and preparation.
The process of labor we have just described.
As to the general principles: If there is any time in a nurse’s career
when she should give scrupulous attention to establishing and
maintaining asepsis, it is during labor, for the patient’s life may, and
often does depend upon it. If there is any time when she should be
watchful for developments and for symptoms of complications, it is
during labor, for again the patient’s life may depend upon this.
Her powers of adaptability to doctor, patient and surroundings
may be severely tried, for though they all may be infinitely varied, the
nurse must invariably be clear-headed and efficient and the
adequacy of her service must never fail.
The sympathetic insight, which should constantly underlie the
work of the obstetrical nurse, will be needed at this crucial time of
labor in the fullest and finest and completest sense. This is almost
her test as a nurse and as a womanly woman, for she needs to be
both, supremely.
 Perhaps she had better imagine for a moment what this
occurrence, that we baldly term labor, may mean to the patient and
look at it as nearly as possible from the standpoint of the patient
herself. It is one of the most stirring and momentous experiences of
her life, particularly if the expected baby is her first child. She is
about to realize the sweetest and tenderest of dreams—that of
motherhood—cherished throughout nine long months. She is also
approaching a period of excruciating pain, and knows it, with her
eyes wide open to the possibility of not surviving it; and an event so
amazing in its mystery and wonder that to only the most stolid can it
fail to be a deeply emotional experience.
And so, the young woman, to whom we refer so impersonally as
“the patient,” is an intensely personal being at this time,
experiencing a number of the most poignant of the human emotions:
awe, expectancy, doubt, uncertainty, dread and in some cases fear
amounting almost to terror. And through it all her body is being
racked and exhausted with pain that grows harder and harder to
bear.
It is known that the ravaging effects of pain, coupled with great
emotional stress, such as fear, worry, doubt, anger or apprehension,
upon the physical well-being of surgical patients, is such that death
itself may be caused by excessive fear and suffering. Accordingly,
many careful surgeons take elaborate precautions to tranquillize a
patient who is about to be operated upon, if for no other reason than
to increase his chance for recovery.
There can be no doubt that nervous and emotional disturbances
are detrimental to the physical well-being of the patient in labor,
also, and this fact alone is enough to warrant an effort to avert them.
If the nurse appreciates the significance of the emotional influence
and shapes her attitude and conduct accordingly, she will thereby
help to increase the ease and safety of the actual delivery. Just what
that attitude shall be, no one can say, for it must be developed, in
each case, in such a way as to win the confidence and meet the needs
of that particular patient.
But in all cases the nurse should impress her patient with her
sincere sympathy and appreciation of the fact that she, the patient, is
going through a difficult time. Through it all the nurse must be
cheerful, encouraging and optimistic; very gentle; very calm and
reassuring in all that she does in preparing for the delivery. She must
steadily increase the patient’s realization of the part which she
herself must play in the effort which is being made to carry the event
through to a happy issue.
The occasion need not, should not, be a mournful one but it is
often a very sacred one to the patient, and the nurse should be
dignified, almost reverential in her bearing.
If the patient feels secure in the belief that her ordeal is not being
taken lightly; that it is being regarded seriously, as it merits, and that
every known precaution is being taken, and taken confidently, to
safeguard her and her baby’s welfare, her actual physical condition
will be favorably affected by the condition of mind thus produced.
And her patience and courage will often be strengthened if the nurse
will explain, from time to time, the cause of certain conditions that
normally arise, and which otherwise might give her alarm. It is the
mysterious events, the unexpected and unexplained that so often
terrify.
This giving of comfort and strength to the variety of temperaments
and mentalities which the nurse meets among her patients will
involve a very sensitive adjustment of manner on her part, but it is
one aspect of her duty, none the less, and one which will give her
great satisfaction.

FIRST STAGE

Happily, the onset of labor is usually gradual, as has been

described, and there is accordingly ample time during the first stage
for deliberate and unhurried preparation for the birth of the baby.
The character of the preparation and of the nurse’s assistance will
vary greatly according to the wishes of the attending doctor; the
duration of labor; the circumstances and condition of the patient,
and whether she is at home or in a hospital.
It is a fairly general routine, at present, both in hospitals and in the
home, to give the patient a soap-suds enema and a shower or sponge
bath, at the onset of labor; to braid her hair in two braids and dress
her in freshly laundered stockings and nightgown and a dressing
gown. The enema is given to empty the rectum of material which
might be expelled during labor and contaminate the field. For this
reason, enemata are often given until the fluid returns clear, virtually
irrigating the rectum, and are repeated every six or eight hours
during the first stage. The enema should be given to the patient in
bed and expelled into a bed-pan, as it is not wise for her to use the
toilet after labor has begun. Sometimes the vulva and perineal region
are shaved and scrubbed at the onset of labor, either before or
immediately after the bath and enema. But the time and sequence of
the different steps in the preparation for labor are governed entirely
by the wishes of the individual doctor, to which the nurse may very
easily adjust herself.
The patient should be given a bed-pan and encouraged to void
every four hours. If she is unable to do so, and the bladder becomes
distended, the doctor will usually wish to have her catheterized, and
with a rubber catheter. This distension is not uncommon, and in
extreme cases the bladder may reach to the umbilicus. The nurse
should therefore observe the amount of urine which the patient voids
and also watch the lower abdomen for bladder distension, which may
be observed easily, excepting in very fat patients.
The seriousness of a distended bladder lies in the fact that it may
markedly retard labor, partly by interfering with the descent of the
baby’s head and partly through reflex inhibition of the uterine
contractions. The prevention of a distended bladder during labor,
therefore, is of considerable importance.
As the pains are infrequent and not severe at first, the patient will
usually prefer to be up and about, most of the time during the first
stage, when it occurs in the daytime, and many doctors think it
important that she should be. They feel that patients tend to stay in
bed too much during the first stage, since being on their feet would
really promote their comfort and also have a tendency to make the
pains more regular and efficient. But, on the other hand, the patient
must be cautioned against tiring herself, and should, therefore, lie
down often enough and long enough to avert fatigue. When labor
begins at night, it is well to advise the patient to stay in bed and to
sleep as much as possible until morning. Even though her sleep be
disturbed and broken by the labor pains, she will be much less tired
in the morning than if she had gotten up and had no sleep at all.
 The patient should also be advised against trying to hasten labor
by bearing down during first stage pains, since the only result at this
time will be to waste her strength which will be needed later. This is
one of the points that the nurse will do well to explain; that no
voluntary effort on the patient’s part, during the first stage, will
advance labor and if she tires herself by making such efforts before
the second stage pains begin she will not be able to use them as
effectively as she would were she in a rested condition.
Bearing in mind the importance of conserving all of her forces, it is
usually advisable for a patient in labor to have no visitors,
particularly the type of person who would be likely to offer advice
and gratuitous information.
She should drink water freely and take some kind of light
nourishment about every four hours. As pain of any kind tends to
retard digestion, the diet during labor is usually restricted to fluids,
such as broths, weak tea or coffee and sometimes milk or cocoa;
while occasionally crackers and crisp toast are allowed. Whatever
nourishment is given must be very light because of the probability of
the patient’s vomiting and the possibility of her having to be given
complete anesthesia before the termination of labor.
The maternal temperature, pulse and respirations should be taken
every two or four hours and the fetal heart rate from every hour to
every two hours, according to the wishes of the doctor.
The time at which the nurse should call the doctor is the subject of
considerable discussion. Doctors never want to be called too late,
neither do they wish to be called unnecessarily early, though they
prefer to have the nurse err on that side, if at all. On general
principles the doctor should be notified as soon as the patient goes
into labor, in order that he may make his various plans with the
pending delivery in mind. But if the nurse remembers that in
primiparæ the first stage of labor usually lasts about sixteen hours
and in multiparæ about eleven hours, she will realize that if the pains
begin between the hours of eleven p.m. and seven a.m., and are of
average character, mild and infrequent, she is not warranted in
disturbing the doctor’s much needed sleep, unless he has explicitly
requested her to do so. But under average conditions he should be
notified by seven o’clock in the morning that the patient is in labor;
at what hour the pains began; their character and frequency at the
time of the report; the patient’s temperature, pulse and respirations
and general condition and the fetal heart rate.
During the early hours of the first stage the nurse should begin to
arrange the room and bed for delivery. She will need two, or
preferably, three tables, though the top of a bureau may be used in
place of one table. A washstand or the bathroom should be equipped
for the doctor with soap; two sterile brushes; nail scissors or clippers
and file or orange stick; hot water; alcohol and a solution of bichlorid
1–1000, biniodid 1–5000, lysol 2 per cent. or any solution that he
may wish; sterile gloves and sterile vaseline or albolene to lubricate
his hands. In short, an equipment which will enable him to prepare
his hands exactly as he would for performing a major operation.
A large receptacle of water may be boiled, covered and set aside to
cool; a boiler or large kettle placed in readiness for boiling
instruments or other appliances that the doctor may bring; the room
may be given a final cleaning: floor wiped up, furniture and all small
articles wiped with a damp cloth; the unopened packages of
dressings, sterile douche pan, irrigation-bag and basins may be
placed on the tables, ready to be opened when needed, together with
the other articles which have been prepared.
In preparing the bed in a patient’s home, it is practically always
advisable to make it firm by slipping a board, or the leaves from a
dining-table, between the mattress and springs. The bed should be
made up with three freshly laundered sheets, the entire mattress
being protected by means of a rubber placed under the lower sheet;
next a rubber draw sheet, covered by one of muslin, while the top
sheet, light blanket and counterpane should be left free at the foot. A
flat hair pillow is better than one of feathers.
If the doctor wishes to make a vaginal examination, it devolves
upon the nurse to prepare the patient with the most scrupulous care,
as it is by means of vaginal examinations, made without careful
preparation, that so many parturient women are infected. In fact,
even the most conscientious preparation sometimes seems to be an
inadequate safeguard, for infection has been known to follow in its
wake. For this reason, some obstetricians prefer to make no vaginal
examination during labor, when previous inspection has indicated
that the case is normal, depending rather upon rectal examinations
for guiding information.
 The patient should be placed in bed, on a douche pan, with knees
flexed and well separated; gown tucked up under her arms; draped
with a sheet or the bedding folded down to her knees according to
the extent of the area to be prepared; and the articles needed for the
preparation arranged on a table at the bedside. The nurse should
trim her nails, scrub her hands with soap and hot water; shave the
vulva, supra-pubic region and inner surface of the thighs and rinse
with sterile water. In shaving the vulva, the strokes should be from
above downward, greatest care being taken not to allow hair, soap or
water to enter the vaginal opening. She should then scrub her hands
vigorously for three minutes, scrubbing about the nails with especial
thoroughness. Some obstetricians have the entire area from the
umbilicus to the knees prepared as for an operation, while others
prepare only the supra-pubic region, inner surface of the thighs and
the vulva. The number and kind of solutions which are used in this
preparation also vary greatly, but in general the shaving is followed
by a thorough scrubbing, by clean hands, with green soap and sterile
water, then iodin, lysol or alcohol and bichlorid or biniodid solution,
according to the custom of the doctor. (Fig. 74.)
But the kind and number of the solutions are probably not so
important as the nurse’s technique. Throughout the entire course of
the preparation she must apply the principles of what she was taught
about the technique of preparing the skin for an operation and
regard the perineal region in the same light as she would the field
which was being prepared for a major operation; scrubbing from the
centre toward the periphery, always, in order not to carry infective
material from an unclean to a clean area, which in this case is the
vaginal outlet.
 Fig. 74.—Bathing the vulva preparatory to vaginal
examination or delivery. (From photograph taken
at Johns Hopkins Hospital.)

The supra-pubic region and abdomen are scrubbed across, back

and forth, working up from the symphysis; the strokes on the thighs
are up and down; in the groin, down toward the rectum, and away
from the vagina, never toward it, and fluids poured upon the vulval
region must never run into the vagina from over surrounding skin. A
sponge or scrub ball must be discarded after approaching the
rectum, or stroking away from the vagina in any direction. Some
obstetricians instruct the nurse to place a firm, sterile cotton pad or
scrub ball between the labia, against the vaginal opening while
scrubbing and flushing the adjacent areas, to preclude the possibility
of introducing fluids. But with a painstaking nurse this is scarcely
necessary.
 Fig. 75.—Patient draped for vaginal examination;
vulva covered with sterile towel. (From
photograph taken at Johns Hopkins Hospital.)

After the surrounding areas have been prepared, the labia are
separated and the inner surfaces scrubbed, first across, then from
above downward, and flushed by pouring the solution directly
between the folds. After the patient has been given this preparation,
a dry sterile towel or pad is placed over the vulva; the douche pan is
removed, the back and hips are dried, after which the patient is so
draped with a clean sheet that only the perineal region is exposed,
and a sterile towel is slipped under the buttocks. (Fig. 75.)
To summarize the preparation for vaginal examination or delivery:

1. Trim nails and scrub hands with soap and hot water.
2. Shave vulva.
3. Scrub and soak hands.
4. Scrub vulva, inner surface of thighs and lower abdomen with
green soap and sterile water, alcohol, 70%, and lastly
bichloride 1–1000 or lysol 1% or 2%, using sterile sponges
and taking care not to contaminate vulva from surrounding
fields.
5. Cover vulva with sterile towel or pad.