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Business Process Change

A Business Process
Management Guide for
Managers and Process
Professionals

FOURTH EDITION

Paul Harmon
Executive Editor, www.BPTrends.com, Senior Consultant, AI
Technology, Cutter Consortium

Forewords by Michael Rosemann and Thomas Davenport

Table of Contents

Cover image

Title page

Copyright

Dedication

Foreword to fourth edition by Michael Rosemann

Foreword to third edition by Thomas Davenport

Preface to the fourth edition

Introduction

Levels of Concerns

Business Process Change and Management

The Evolution of an Organization’s Understanding of Process

The Variety of Options

The Variety of Solutions

How This Book Is Organized

Notes and References

Chapter 1: Business process change

Abstract

Organizations as Systems

Systems and Value Chains

The Six Sigma Movement

Business Process Change in the 1990s

Lean and the Toyota Production System

Other Process Change Work in the 1990s

A Quick Summary

Business Process Change in the New Millennium

What Drives Business Process Change?

Notes and References

Part I: Organization-wide concerns

Introduction

Chapter 2: Strategy, value chains, business initiatives, and

competitive advantage

Abstract

Defining a Strategy

Porter’s Model of Competition

Industries, Products, and Value Propositions

 Strategies for Competing

Porter’s Theory of Competitive Advantage

Porter’s Strategic Themes

Treacy and Wiersema’s Positioning Strategies

The Balanced Scorecard Approach to Strategy

Business Models

Business Initiatives

Summary

Notes and References

Chapter 3: Understanding your organization

Abstract

A Comprehensive Business Process Method

Strategy and Enterprise BPM

Understand the Enterprise

The Traditional View of an Organization’s Structure

A Case Study of Organization Transformation

The Systems View of an Organization

Models and Diagrams

Organization Diagrams

Organizations and Value Chains

Systems and Processes

 Notes and References

Chapter 4: Business architecture

Abstract

The Supply Chain Council’s Supply Chain Operations

Reference Framework

Business Architecture: The IT Approach

Business Process Architecture

Defining an Architecture Using a Framework

The Supply Chain Council’s SCOR Framework

Developing a Supply Chain Architecture With a SCOR

The Extension of a SCOR

Another Approach

Summary

Notes and References

Chapter 5: Measuring process performance

Abstract

Key Measurement Terms

Developing a Comprehensive Measurement System

Balanced Scorecard and Process Measures

Aligning Process Measures

Deriving Measures From Business Process Frameworks

 A Process-Driven Approach to Defining Measures

Putting It All Together

Notes and References

Chapter 6: Process management

Abstract

The Process Perspective

What Is Management?

Matrix Management

Management of Outsourced Processes

Value Chains and Process Standardization

Management Processes

Documenting Management Processes in an Architecture

Completing the Business Process Architecture Worksheet

Notes and References

Chapter 7: An executive-level business process management

group

Abstract

What Does a BPM Group Do?

Create and Maintain the Enterprise Business Process

Architecture

Identify, Prioritize, and Scope Business Process Change

Projects
 Help Create, Maintain, and Manage the Process Performance
System

Help Create and Support the Process Manager System

Recruit, Train, and Manage Business Process Change

Professionals

Manage Risk/Compliance Reporting and Documentation

A Case Study: Boeing’s GMS Division

Summary

The BPM Group

Notes and References

Part II: Process-level concerns

Introduction

Chapter 8: Understanding and scoping process problems

Abstract

What Is a Process?

Process Levels and Levels of Analysis

Simple and Complex Processes

Business Process Problems

The Initial Cut: What Is the Process?

Refining an Initial Process Description

Creating a Business Case for a Process Change Project

 Notes and References

Chapter 9: Modeling business processes

Abstract

Process Flow and Process Management Problems

Day-to-Day Management Problems

Process Flow Diagrams

Flow Diagramming Basics

More Process Notation

As-Is, Could-Be, and To-Be Process Diagrams

Case Management

Notes and References

Chapter 10: Modeling activities

Abstract

Analyzing a Specific Activity

Analyzing Human Performance

Managing the Performance of Activities

Automating the Enter Expense Reports Activity

Empowering Employees

Analyzing a Completely Automated Activity

Decision Management
 Knowledge Workers, Cognitive Maps, and Decision
Management

Notes and References

Chapter 11: Managing and measuring a specific business process

Abstract

Representing Management Processes

The Management Process

Plan Work

Organize Work

Communicate

Control Work

The Project Management Institute’s Approach

Evaluating the Performance of the Process Manager

Continuous Measurement and Improvement

Management Redesign at Chevron

Notes and References

Chapter 12: Incremental improvement with Lean and Six Sigma

Abstract

Six Sigma

The Six Sigma Concept

The Six Sigma Approach to Process Improvement

 Phases in a Six Sigma Improvement Project

Lean

Summary

Notes and References

Chapter 13: A comprehensive redesign methodology

Abstract

Why Have a Methodology?

How Does It All Begin?

What Happens?

Who Makes It All Happen?

Phase 1: Understanding the Project

Phase 2: Analyze Business Process

Phase 3: Redesign Business Process

Phase 4: Implement Redesigned Process

Phase 5: Roll Out the Redesigned Process

Summary

Notes and References

Chapter 14: Rental Cars-R-Us case study

Abstract

Rental Cars-R-Us
 Phase 1: Understand the Project

Phase 2: Analyze the Business Process

Phase 3: Redesigning the Rental Process

Phase 4: Implement the Redesigned Business Process

Phase 5: Roll Out the New Rental Process

Notes and References

Part III: Implementation-level concerns

Introduction

Chapter 15: Software tools for business process work

Abstract

Why Use Business Process Software?

Variety of Business Process Tools

Professional BP Modeling Tools

Modeling and Management Screens

Business Process Management Suites

Process Diagrams and BPMS Engines

What Features Might a BPM Suite Include?

BPMS, SOA, and the Cloud

Choosing a BPMS Product

Some Leading BPMS Vendors

 Creating a BPMS Application

Notes and References

Chapter 16: Enterprise resource planning–driven redesign

Abstract

Processes, Packages, and Best Practices

A Closer Look at SAP

Implementing an ERP-Driven Design

Case Study: Nestlé USA Installs SAP

Using BPMS to Improve ERP Installations

Enterprise Resource Planning and Business Process

Management Suite

Notes and References

Chapter 17: AI-driven process change

Abstract

Artificial Intelligence

AI Technologies

Developing and Deploying AI-Based Processes

Notes and References

Chapter 18: The future of business process management

Abstract
Appendix 1: Business problem analysis checklist

Output Problems

Input Problems

Guide Problems

Enabler Problems

Process Activity and Flow Problems

Problems With the Management of a Process

Appendix 2: Core business process modeling notation

Overview of a BPMN Diagram Used for Business Process

Analysis and Redesign

An Activity

An Event

A Gateway

A Sequence Flow

A Message Flow

A Data Object

An Association

A Pool With Swimlanes

A Few Extensions of the Activity Rectangle

A Few Extensions of the Event Circle

A Few Extensions of the Gateway Diamond

 Some Other Notations That We Occasionally Use

BPTrends Special Notation

Appendix 3: Business process standards

Organization-Level Business Process Standards

Process-Level Business Process Standards

Business Process Standards for Implementation

The Future of Standards

Appendix 4: Processes and capabilities

Some Corollaries

Processes, Capabilities, and Business Architecture

Appendix 5: Process analysis diagrams used in this book

Index
Copyright
Morgan Kaufmann is an imprint of Elsevier
50 Hampshire Street, 5th Floor, Cambridge, MA 02139, United
States

Copyright © 2019 Paul Harmon. Published by Elsevier Inc. All

Rights Reserved.

No part of this publication may be reproduced or transmitted in

any form or by any means, electronic or mechanical, including
photocopying, recording, or any information storage and retrieval
system, without permission in writing from the publisher. Details
on how to seek permission, further information about the
Publisher’s permissions policies and our arrangements with
organizations such as the Copyright Clearance Center and the
Copyright Licensing Agency, can be found at our website:
www.elsevier.com/permissions.

This book and the individual contributions contained in it are

protected under copyright by the Publisher (other than as may be
noted herein).

Notices
Knowledge and best practice in this field are constantly changing.
As new research and experience broaden our understanding,
changes in research methods, professional practices, or medical
treatment may become necessary.

Practitioners and researchers must always rely on their own

experience and knowledge in evaluating and using any
information, methods, compounds, or experiments described
herein. In using such information or methods they should be
mindful of their own safety and the safety of others, including
parties for whom they have a professional responsibility.

To the fullest extent of the law, neither the Publisher nor the
authors, contributors, or editors, assume any liability for any injury
and/or damage to persons or property as a matter of products
liability, negligence or otherwise, or from any use or operation of
any methods, products, instructions, or ideas contained in the
material herein.

Library of Congress Cataloging-in-Publication Data

A catalog record for this book is available from the Library of
Congress

British Library Cataloguing-in-Publication Data

A catalogue record for this book is available from the British
Library
ISBN: 978-0-12-815847-0

For information on all Morgan Kaufmann publications visit our

website at https://www.elsevier.com/books-and-journals

Publisher: Katey Birtcher

Acquisition Editor: Katey Birtcher
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Cover Designer: Mark Rogers

Typeset by SPi Global, India

Dedication

To my friends who have made my life so much more enjoyable:

Roger Addison, Michael Cullen, Jim Eilers, Fred Goldsmith, Bob
and Ana Harmon, Paul Heidt, Remco Kobus, Garfield Moore,
Cheri Murrell, Willem Smit, and David Sutton
Foreword to fourth edition by
Michael Rosemann
Michael Rosemann, Professor, School of Management, Queensland
University of Technology, Brisbane, QLD, Australia

Business processes continue to be one of the most important assets

of an organization. Like blood vessels, they fill it with life and
determine its way and speed of value creation as well as the cost
to serve its customer base. Thus processes reflect not only
organizational productivity, effectiveness, and efficiency, but also
its reliability, complexity, and ultimately its culture. Internally,
processes orchestrate the internal system of value creation and,
externally, they are an important source of competitive advantage.
A well-designed process is the runway for new products and
services, but equally process innovation can be a source of new
revenue potential when products and services have plateaued.
Processes put work, man, and machine into context.
Traditionally, this meant that roles and resources are guided to
ultimately arrive at a valuable contribution as the overall process
outcome. As such, processes are the recipe for converting
organizational resources into guided action. Ensuring compliant
process executions is essential to organizations, and the lack
thereof has had dramatic consequences for a number of
corporations over recent years.
Over time processes have expanded beyond the boundaries of a
firm, and we have witnessed the emergence of entire value chains
and networks leading to complex, multistakeholder process
interdependencies. Fueled by increased digital literacy of our
society and ubiquitous computing capabilities, this has allowed
citizens to become process participants leading to what could be
labeled the democratization of processes.
Nowadays and into the future, processes play an essential role
in considering and positioning the possible impact of quickly
emerging digital technologies. No longer is the narrative of
Business Process Management purely driven by reactively
analyzing those parts of a process that are broken (pain points).
Rather, technologies such as Artificial Intelligence, advanced data
analytics, robotics, or blockchain have expanded the set of process
design options and provided companies with new opportunity
points. Instead of focusing on optimized processes, economics of
scale, and mass production, processes are increasingly aiming
toward mass personalization and change more frequently leading
to the notion of minimum viable processes.
For all these reasons it is impossible to consider organizations,
their operations, the change they undergo, and their ultimate
well-being without their processes. In light of this, it is surprising
to witness that organizations vary substantially in the extent to
which they manage their processes explicitly and with priority.
The ongoing and increasing significance of business processes
requires related organizational and technical capabilities and an
overall process mindset. This is exactly where this book by Paul
Harmon continues to make its significant contribution. In times of
rapid technological changes, demographic shifts, and new
business model opportunities, this book provides a stable point of
reference to comprehend, appreciate, and benefit from the
importance of business processes. The breadth and depth of this
book has provided a variety of stakeholders, executives,
academics, project managers, and process analysts, across the
globe and in all industries with the essential frameworks and
architectures, life cycles, guidelines, best practices, and case
studies needed to approach their very own process challenges and
opportunities.
I have no doubt that this fourth edition of Business Process
Change will again guide countless architects of value and remain a
long-lasting source of process knowledge in a fast-changing
environment.
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or without a sense of cold. These are supposed to arise in
consequence of the system rallying its energies to concentrate them
upon one important object, namely, that of effecting the dilatation of
the uterus and the expulsion of the fetus. They are evidently not
attended with any danger, and should therefore give the patient no
alarm.
State of the Bowels.—It is not uncommon for patients to have one
or more loose discharges from the bowels at the beginning of or
during labor. This symptom occurs in consequence of the sympathy
that exists between the womb and the lower part of the alimentary
tract. There appears to be in the minds of most women a great
prejudice against bowel complaints through the different stages of
pregnancy, and at the time of labor, and, as a consequence, there is a
willingness, and often anxiety, on their part to use such means as are
supposed to have an effect in suppressing them. But in most cases of
diarrhea under these circumstances, the patient is relieved by it
rather than made worse, and should therefore take no special means
of counteracting it, unless, indeed, under the guidance of a medical
attendant who should deem such a course necessary.
Nature of the Pains.—It is an object to know how you may
distinguish between the true pains of labor and those which are false.
The true pains of labor usually begin in the back and loins, and
shoot round to the upper part of the thighs; or they may commence
first in the lower part of the abdomen, as if in the region of the
bladder, passing backward toward the spine. Some women
commence being sick, as if they had eaten something that disagreed
with them; and I have repeatedly known them to attribute the pains
of the commencement of labor to this cause. A little time in such
cases is sufficient to convince them of their error.
Periodicity is, in most cases, a symptom showing that the pains are
not false. The interval between them may vary in different cases from
one minute to thirty, forty, or more, according to the action of the
uterus, on which they depend. The more the pains are multiplied the
better it is to be regarded for the patient, and for the reason, that if
an effort of great importance to the constitution is to be produced,
the more slowly and gradually it is done the better, if the slowness is
not the effect of disease. A sudden and violent labor is never to be
looked upon as being so safe as one which happens in a more gradual
manner. “It is an old observation,” says Dr. Denman, “confirmed by
daily experience, that after the completion of slow or lingering
labors, patients usually recover better than after those which are
quick; not to mention that they are less liable to the untoward
accidents which precipitation may immediately produce.”
A considerable difference exists in the character of the pains,
according to the stage of labor in which they occur. The earlier pains
are termed cutting or grinding, from the fact that uterine fibers alone
are principally concerned in them. Afterward the pains get to be
lower down, and are of a more bearing-down nature. When these
pains exist, the woman is instinctively led to bring her abdominal
muscles into powerful action, causing her, at the same time, to hold
in her breath, so that after the pain has ceased, or partially so, she
utters a deep groan. In the earlier part of the labor, the cries are more
shrill, so that an experienced observer will often be able to judge of
the stage of the labor merely by hearing the manifestations made. In
some cases, however, the patient does not exhibit any of the
aforementioned signs of distress, until the moment when the child is
about to pass into the world. She is then obliged to put forth an
expression of agony, which proves but too well how much it is her lot
to endure.
 THE LIQUOR AMNII, OR WATERS.
In order that you may the better understand the first stage of
labor, I will here make some remarks on the nature and office of the
fluid above-named. By liquor amnii, or waters, is meant that fluid
which is contained within the membranes surrounding the child.
The quantity of the waters, when compared with the size of the
child, is greater in the earlier parts of pregnancy. At the time of labor
it is found to vary a good deal in different cases, amounting in some
to four or five pints, and in others to scarcely as many ounces. It is
thought to be largest in case the child has been for some time dead,
as also when it is very feeble.
In regard to the office of this fluid, some have imagined that the
fetus is nourished by it, the liquor being swallowed into the stomach.
But in answer to this doctrine, it is to be remarked, that there are
many examples of children having been born without any passage to
this organ. There have also been born children of a full size and well-
formed shape, all except the head, which was wanting. These facts
make it clear that the child must be nourished in some other way
than by the waters surrounding it.
Some also have supposed this fluid to be an excrementitious
substance; but this belief is not now generally adopted, or rather, no
physiologist of any eminence regards it as such at the present day.
The liquor amnii “is generally transparent, often milky, and
sometimes of a yellow or light-brown color, and very different in
consistence; and these alterations seem to depend upon the state of
the constitution of the parent. It does not coagulate with heat, like
the serum of the blood; and chemically examined, it is found to be
composed of phlegm, earthy matter, and sea-salt, in different
proportions in different subjects, by which the varieties in its
appearance and consistence are produced.”
It has been supposed that the liquor amnii may, all of it, be
discharged as early as the sixth month of pregnancy, without
producing injury to either mother or child; but this cannot be true, it
would appear, since it is well known, that when the membranes are
broken intentionally, so that all of the waters are discharged, the
uterus never fails to contract itself until abortion or the birth comes
on. A discharge from the vagina, somewhat resembling the waters,
however, may appear for weeks, and even months, before the
delivery takes place; but in such cases it has been observed, that no
diminution in the size of the abdomen occurs, from which
circumstance it is known that the real liquor amnii does not pass off.
The normal purposes of this fluid in the system appear to be to
afford the fetus a safe and easy lodgment in the uterus. If it were not
there to protect the embryo, it would constantly be in danger of being
destroyed by mechanical violence; besides which, it would be almost
certain of adhering to the inner surface of the womb in such a way
that the birth could not possibly take place. At the time of labor, too,
we see the advantages of the “bag of waters,” for as it is protruded in
advance of the child, it forms a soft, yielding wedge, as it were, which
gradually dilates the soft parts, without overstretching or tearing
them, which would not be the case if the comparatively hard head of
the child was the first to present itself.
The rupture of the membranes, which ends the first stage of labor,
may take place a very short time before the expulsion of the child, or
it may happen prematurely, as it were; that is, many hours, or even
days or weeks before the child is born. In such cases the occurrence
is to be considered as an accident or exception to the general rule. It
does happen, however, every now and then, and in many cases it
seems to make no difference whatever in regard to the future
progress and safety of the delivery.
The greatest agony, as I have remarked, is experienced at the time
the child is brought into the world; but if I could make plain to you
the mechanism of labor, you would be struck with admiration, I am
sure, at the wonderful marks of benevolence and design which are
exhibited in the manner in which a child is expelled from the uterine
cavity.
You may ask why it is that a woman should be made to suffer pain
at all in bringing forth a child, and why did not the Creator form the
system of woman in such a way that a child could be expelled without
causing any of that agony which is well known to be a natural
circumstance of childbirth. I answer, it was not possible for God to
create woman in such a way. Suppose He had made her pelvis larger,
and the soft parts more yielding; she would have been constantly
subject to the misfortune of miscarriage; or rather, it would not have
been possible for her to carry a child at all.
But see the beautiful, and at the same time wonderful operation of
nature in the mechanism of parturition. At first, some days before
labor is to come on, the abdomen begins to subside, showing that the
uterus, with its contents, is gradually sinking downward in
preparation for the greater struggle that is to take place at the birth.
Probably, too, the womb at the same time begins to contract itself
more firmly upon the child, and, as it were, begins to gather strength
for the contest which it is about to engage in, namely, that of forcing
the child into the world. After this there appears a greater discharge
of mucous than ordinary from the womb and vagina, which serves to
soften and lubricate the parts in preparation for the terrible
distension which is to take place. Gradually, also, in the first stage of
labor, the womb dilates, for too sudden a distention of this important
part would be very apt to cause a fatal rupture of the organ. In the
second stage, the head of the child is driven through the os uteri into
the vagina. As the pains continue, the face of the child is turned into
the hollow of the sacrum; that is, toward the back of the mother, the
wider part of the head being in the wider part of the pelvis, just as a
wise mechanician would naturally place it; but in the beginning of
labor, when the child’s head is at the upper part of the pelvis, it lies
more to the side of the mother, corresponding to the wider diameter
of this upper strait.
Look at a skeleton, I repeat, that bugbear of our childhood, that
grim yet beautiful remnant of our mortality; and when you see and
understand how admirably adapted the form and shape of the pelvis
is to the ends for which it was created, tell me if you do not recognize
in this adaptation the most unmistakable evidences of the work of an
Almighty hand.

In cases of first children, the first or dilating stage usually occupies

from six to thirty or more hours. It is natural to expect that a woman
must suffer greater pain, and bear a more tedious labor with her first
child than with the subsequent ones. “I have heard a voice as of a
woman in travail, and the anguish as of her that bringeth forth her
first child,” saith the prophet Jeremiah. The difference in the length
of the first and subsequent labors, however, is not usually in
proportion to the number of children that have been borne. If a
woman be twenty-four or thirty-six hours in labor with her first
child, she may be only six or eight with her second, and in the
subsequent labors only three or four hours. There will, of course, be
many deviations from any calculation of this kind that can be made,
but the practitioner will, however, often be able to form a tolerably
accurate opinion of the probable duration of a labor, if the woman
have had a number of children previously. But even here there will
be a good deal of liability to error, since the fifth, sixth, or tenth labor
may prove a very tedious and difficult one, because of some mal-
position of the child. I had an example of this kind in my own
practice some months ago, in which a lady suffered incomparably
more with the birth of her third child than with both of the former
together, and the labor was protracted to thirty hours, which was a
much longer period than either of the former had been. This
happened in consequence of the face of the child, that is, the wider
part of the head, presenting forward in the narrower part of the
outlet of the pelvis, whereas in almost all cases the reverse of this
takes place, as I before remarked. Such cases are, however,
fortunately very rare, the exception only to the general rule.
You will readily understand why the first labor is apt to be
somewhat more difficult than subsequent ones, when you recollect
that all the soft parts, such as the womb, vagina, the external organs,
etc., are more rigid and unyielding in the first labor than they
afterward are. The bones, recollect, are the same at all times; they do
not give or separate, as many of you have supposed; they are bound
so firmly together that it is not possible for them to be separated, in
their natural and healthful state, by any such force as that which is
exerted in the birth of a child, although this force is a great one. It is
necessary that the bones of the pelvis should be thus strongly bound
together, otherwise they would not be sufficiently firm to answer the
purposes for which they are intended.
 THE AGE AS AFFECTING LABOR.
If the patient be considerably advanced in years at the time of her
first pregnancy, the labor is apt to be, or rather, must necessarily be,
a more difficult one than would occur earlier in life.
In the life of any woman there is a period at which her system has
become, as we say, matured, or, in other words, capable of child-
bearing. After the system has become thus matured, it is evidently
more natural, and consequently more healthful to bear children than
not to do so. We are to suppose, then, that if a woman follows the
order of nature, it will be better for her, in regard to the easiness of
childbirth, than if she becomes old before this function is brought
into action. Nature, however, is not so closely bound down to
arbitrary rules as we might at first conclude. Indeed, we could not
reasonably suppose that the Creator would form woman’s system in
such a way that she could not safely bear children, even if the child-
bearing function were not brought into action until some years after
puberty. I knew a lady whose marriage took place quite late in life,
and whose first child was born when she was forty-two; and although
her labor was a severe one, lasting seventy-two hours and upward,
yet she recovered remarkably well, as much so as almost any one I
ever knew. Her child, too, was a fine, healthy one, and throve well.
Another lady, whom I attended about one year since, who was thirty-
eight years old at the time, it being her first labor, felt some pains for
two days and nights previously to the one on which I was called to
visit her. It could hardly be said, however, that labor had fully set in
before ten o’clock of the day on which the child was born at four in
the afternoon, making the real labor only about six hours. Thus we
see that, although the age of the individual has generally more or less
influence in regard to the painfulness and length of labor, yet a
woman who is far advanced in the child-bearing part of her life,
when she bears her first child, has apparently as good a chance for a
speedy and favorable recovery as a younger one has. In this
circumstance, too, we have still another among the many proofs of
the benevolence of the Creator of all things. He, in His wisdom,
foreknew that it would not be proper for every woman to marry
precisely at that age in which it is most natural for her to become
pregnant, and consequently her system was formed with a reference
to that circumstance, although it is admitted that labor is somewhat
more difficult and protracted if it occur for the first time late in the
fruitful period.
It is an unwise procedure to tell a woman, as has been sometimes
done, that because she is somewhat advanced in years, and must
consequently expect to have a difficult labor, she should be bled
frequently toward the close of her period, have purgative medicines
given her, etc., with the view of helping nature, as it is said. But it
were far better, more honest, as well as more truly philosophic, to tell
her that, in order to get along the best that may be under the
circumstances, she should do every thing in her power to improve
her general health; for always the more strong and vigorous the
patient at the time of labor, the better is her prospect in every
respect. Suppose, too, it were deemed necessary to reduce her system
somewhat toward the close of pregnancy, how much better are
abstinence and fasting for that purpose than bleeding and cathartics?
It is a foolish practice to bleed or drug the system when we have
always at hand so much better means.
 LETTER XXVI.
MANAGEMENT OF LABOR.

The Placenta, or After-Birth—The Membranes—Management of the After-Birth—

Rules for Extracting it—Of Flooding after Delivery.

In the preceding letter, I spoke of the first two stages of labor. The
last, which refers to the birth, or expulsion of the placenta and
membranes, I now propose considering.
First, I must say something of the nature and office of what is
termed the after-birth.
 THE PLACENTA AND UMBILICAL CORD.

The placenta, or after-birth, is of different forms in different

animals. In the human subject, “it is a flat, circular body, about six
inches in diameter, and about one inch and a half in thickness at the
center, becoming thinner toward the circumference. Usually in the
center, but sometimes at or near the edge, we find the insertion of
the funis, or umbilical cord, the vessels of which immediately ramify
in a divergent manner upon the surface of the organ.”
From Dr. Maunsel, of Dublin, I make the following quotation, in
regard to the office of this viscus:
“The uses of the placenta appear to be in some degree analogous to
those of the lungs and stomach of the breathing animal. The blood
passes into it from the hypogastric arteries, and after a very free
circulation through it, returns by the umbilical vein directly to the
heart. The circulation continues until respiration is established,
when it ceases spontaneously, and any interruption of it, before the
latter process has commenced, is immediately fatal. From these facts
we are warranted in inferring that a change necessary to life
(probably oxygenation) is produced in the placenta, although the
nature of that change is obscure, and the relative properties of the
blood in the umbilical arteries and veins not at all known. That the
organ in question not only revivifies the blood, but also elaborates
new vital fluid, thus performing a function analogous to that of the
stomach, can only be inferred from the absence of any other source
from whence the fetus could obtain materials for growth and
support.”
 THE MEMBRANES.
These are expanded from the edge of the placenta, in connection
with which they form a complete involucrum of the fetus and waters,
and at the same time a lining for the uterus. The membranes grow
and expand in the same proportion as the fetus, and when expelled
after the birth has taken place, are, in connection with the placenta,
termed the secundines.
There are three of these membranes, which are found surrounding
the fetus. “There is first the outer, or connecting membrane, which is
flocculent, spongy, and extremely vascular, completely investing the
whole ovum, and lining the uterus; secondly, the middle membrane,
which is nearly pellucid, with a very few small blood-vessels
scattered over it, and which form a covering to the placenta and
funis, but does not pass between the placenta and uterus; thirdly, the
inner membrane, which is transparent, of a firmer texture than the
others, and lines the whole ovum, making, like the middle
membrane, a covering for the placenta and funis. With the two last
the ovum is clothed when it passes from the ovarium into the uterus,
where the first is provided for its reception. These membranes, in the
advanced state of pregnancy, cohere slightly to each other, though in
some ova there is a considerable quantity of fluid collected between
them, which being discharged when one of the outer membranes is
broken, forms one of the circumstances which has been
distinguished by the name of by, or false waters.”
It seemed necessary that I should make these preliminary remarks
concerning the physiology of the placenta and the membranes, in
order that you might the better understand the third process of
labor, or that which consists in the expulsion of these growths, the
secundines, as they are called.
I have now some practical remarks to make, which I hope you will
study faithfully, for it not unfrequently happens that a child is born
before you can obtain the assistance of a physician; and after the
child has been expelled, what to do in reference to the after-birth;
that is a question which, under such circumstances, puzzles your sex
more a great deal than it need or ought to do.
Suppose, then, that a child is born suddenly, or at least before the
medical man or woman whom you would employ, comes to your aid,
and the placenta remains undelivered.
I shall tell you, in another place, not to be in such a flurry, as
women too often are, in regard to separating the umbilical cord. So,
too, I say in regard to the after-birth; be in no hurry.
Have you not often heard people say that the after-birth has grown
fast and sticks? Women sometimes say this, and so do the doctors,
some of them; such, for example, as are not honest enough to tell the
truth, if they know it, and would make you believe that they are
doing a great thing when they get away the after-birth, if it sticks.
Now please remember that it is right that the placenta should grow
fast to the womb; that is, to its inner surface. It is always grown fast,
and should be; but it is possible for it to adhere more firmly in some
cases than in others; and in some cases, too, the uterus seems to be
so weak that it has not power sufficient to expel it.
In cases when the womb is very active after the birth of the child,
the placenta may be expelled very quickly.
But it is more commonly the case that after the uterine
contractions have forced the child into the world, the womb reposes
itself for a half hour, less or more. After this, periodical pains begin
to occur, so that the after-birth may be completely thrown forth into
the world; but far oftener it is either wholly, or in part only, into the
vagina, where it remains for a time at least.
At what time, and under what rules, should manual aid be
administered in helping away the after-birth? By different
practitioners different rules have been instituted. A rule of Dr.
Hunter’s was to wait till four hours after the birth of the child. If the
placenta come away of itself, before this time have elapsed, it is well;
but if, on the other hand, it still remain in the cavity of the uterus,
manual aid may become necessary.
Another rule is, to judge by the pains, without any regard to the
length of time that has elapsed since the delivery of the child; pains,
it is said, accompany the contractions; the contractions expel the
placenta; the pains, therefore, indicate the time at which artificial
assistance should be interposed.
Another rule is, first to determine the situation of the womb before
any manual attempt is made for helping away the after-birth. If, on
examination, the placenta is found lying in the upper part of the
vagina, and through the os uteri, and more especially if the union of
the umbilical cord with the placenta can be felt, it is considered
proper to remove it. But if the umbilical cord ascend high into the
womb, and no part of the placenta can be felt, it is considered best to
wait.
Still another rule is, to act according to the feeling and condition of
the uterus, without any regard to the length of time after the birth,
the pains, or the situation of the placenta. If, on examination
externally, it is found that the womb is yet large, uncontracted, and
pulpy, the placenta should not, according to this rule, be interfered
with. But if, on the other hand, there is an opposite state of things—
that is, if the uterus is found hard and contracted, feeling like a
child’s head in the abdomen, and if it remain so for some time
permanently, it is considered safe and best at once, in a proper
manner, to remove the viscus. A skillful practitioner will bear in
mind all these circumstances, and form a rule out of all of them, as it
were, to guide him in each individual case; and I wish you to
remember, that although you may consider the principal part of
delivery is accomplished at the time when the child comes into the
world, it is to be remembered that its real danger has not yet
commenced, and that the birth of the placenta is a most important
part of the process.
Into all the niceties and difficulties of this part of the accoucheur’s
art, I do not, you will remember, attempt to induct you. It is my
object to give you some general ideas of the matter, such as may be of
use to you in an emergency, and prevent a great deal of unnecessary
anxiety and alarm in some cases. My remarks will also, I trust, go to
impress upon your minds how very necessary it is, under such
circumstances, to have the aid of a physician—a man or woman, I
care not which—who understands well the art. You may say that
nature is sufficient in most cases to perform her own tasks unaided
and alone. That, I admit, may all be true, especially with those who
have good constitutions, and who observe well the laws of life. But
remember that these circumstances do not always exist. Any one of
you would rather incur the expense of having a physician a thousand
times, when he is not needed, than to suffer danger for his want in a
single instance.
 OF FLOODING AFTER DELIVERY.
Hemorrhage is one of the most dangerous of all circumstances
connected with labor. Fortunately, however, this does not often
happen; and in those cases when it does occur, it may generally be
very soon arrested, provided the proper means are adopted.
This form of uterine hemorrhage not unfrequently occurs when
the physician is absent. For this reason, it is necessary that I should
make some remarks on the subject.
Flooding may be either external or internal. When the blood
passes from the vagina, we call it external; when it does not thus pass
off, but remains within the cavity of the uterus, causing the abdomen
to swell and the patient to faint, we call it internal.
Here is a remarkable fact in nature. Women, in consequence of
possessing the menstrual function, and being exposed to the
accidents of childbirth, are more subject to hemorrhage than men. In
striking accordance with this fact, it appears to have been a
benevolent intention of the Creator to form the female system in
such a manner that it more readily recovers from profuse loss of
blood than that of the opposite sex. Under the effects of severe loss of
blood, the system of a man remains pale and enfeebled for months,
perhaps, while that of a woman regains its strength and color in half
the time. Many a time, before I was aware of these facts, I have been
fearful, and sometimes greatly alarmed at the amount of blood lost at
the birth of a child, and when, to my great surprise, in a day or two
the patient was up, and apparently almost as well as ever. This, then,
is an important practical fact, and one well worth remembering.
In regard to the treatment of flooding after delivery, I refer you to
what I have already said under the head of uterine hemorrhage. Cold,
remember, is the great agent here, as all acknowledge.
If the woman faints from loss of blood—and she may also faint
from mere debility—you should not be alarmed at the circumstance.
People generally make a great deal too much ado when a patient
faints. It should be remembered that the object nature has in causing
a person to faint from loss of blood, is to arrest the heart’s action, for
the most part, so that the blood may, as it were, cease its movement
in the uterus, and a coagulum or plug be formed in the orifice of the
bleeding vessel or vessels. This is nature’s method of arresting an
hemorrhage. This being so, it is no doubt often the case that bringing
a person to, is the cause of more harm than good. There should be no
hurry; give the patient good air to breathe, and nature will, as a
general thing, do her own work better than we can do it for her in
these cases.
 LETTER XXVII.
ADVICE CONCERNING LABOR.

The Medical Attendant—State of Mind—The Room—State of the Bowels—The

Dress—The Bed—The Position, Exercise, Food, and Drink.

It will be inferred, from what I have already said in these letters,

that I am in favor of employing a physician, male or female, in all
cases of parturition. Most cases, I admit, will get along well without
any medical aid whatever; but, as you are well aware, there are
exceptions to all rules; and it is for these exceptions that a physician
is needed.
In the first place, then, it is always advisable in labor that you call
your medical attendant early. If it is worth your while to have aid at
all, it is best to have it in good season. The physician himself always
prefers to be called early.
Once you have fixed upon your medical attendant, resolve to be
guided by him in every particular, and follow his directions faithfully.
If you have, from necessity or otherwise, chosen a man-midwife, you
need have none of those foolish whims which some among the so-
called reformers of the present day would have you to believe.
It is always an unpleasant duty for one to attend a woman in
childbed; and be assured that, of all places in the world, a delivery is
the last one in which lascivious or lustful excitement is experienced. I
wish you, then, one and all, to remember that if it is unpleasant for
you to be attended by a man under such circumstances, it is equally
so to him. If he is a conscientious and benevolent physician, he will
cheerfully do that which he considers his duty to do; but as far as his
own personal self is concerned, he would much rather be at home,
enjoying its quiet and its sleep, if need be.
 In regard to your preparation for labor, I will suppose that you
have done all in your power to maintain an equable and healthful
state of both mind and body, and that you are resigned to encounter
whatever God in His mercy may see fit to bring upon you. If you have
done all that you could for yourself, and are still willing and
determined to do so, surely you should feel contented; you can do no
more.
The Room.—As to the apartment in which you are to be confined,
you should take the best one in the house. If possible, you should
have one which is well lighted and aired, and which can be readily
warmed, if there is need of raising the temperature. If it is in a city, a
back room should be preferred in preference to one in front, on
account of the noise of the street.
If the labor is to be a tedious one, it is particularly necessary that
the air of the apartment be kept as pure as possible. Not only should
the strictest attention be paid to ventilation, but all odors and
perfumes should be dispensed with. These do no good, for mere
hiding the bad air is not destroying it, and they always do more or
less harm.
There should not be too many persons in the room when the
woman is to be confined. In the country it is by far too much the
fashion for a large company of women to get together on such
occasions. This always renders the air of the apartment more foul
than it otherwise would be, and for other reasons it ought not to be
permitted.
I have many a time pitied the condition of women whom I have
attended, who had but one room to live in, cook, wash, iron, and at
last to be confined in; and yet those women have in general got along
better than such as live in a more sumptuous way. Such women are,
in fact, workers, and employment, as I have before remarked, is a
most blessed thing in regard to preparing the system for the
important function of labor.
The Bowels.—If the bowels should be constipated at the time when
labor is about to come on—and such is likely to be the case—the
woman should use clysters freely. This practice is, in fact, advisable
in all cases, inasmuch as it can do no harm. If there is fecal matter in
the colon, it is better that it be removed before the birth is about to
take place. Hardened excrementitious matters in the lower bowel are
always a hindrance to labor.
The Dress.—Formerly it was considered a matter of importance as
to how a woman was dressed in labor. Different countries and
provinces had their particular forms of gowns, jackets, chemises, and
head-dresses. The great thing, however, to be observed, is simplicity;
that is, nothing should be worn which at all interferes with the body
in any of its functions or parts. If the dress is such as causes no
constriction of the abdomen, the chest, or the neck, such as gives free
motion to the limbs, and is of such material that it makes the body
neither too hot nor too cold, it is all that is required. Generally too
much clothing is worn at the time of labor. It is safer to be on the side
of too great coolness than of the opposite extreme.
The Bed.—This has been called by different names; the lying-in
bed, bed of labor, bed of pain, bed of misery, little bed, etc.
Some women will not make use of any sort of couch whatever. I
know a lady in this city who has borne a pretty large family of
children, who affirms that she gets along much better upon her
hands and knees on the floor than in any other way. Some are
delivered standing up, the elbows resting on some object, as the
mantle-piece, bureau, the back of a chair, or some other piece of
furniture, or perhaps upon the shoulders of a friend. “A strong and
well-formed woman,” says Velpeau, “may be delivered in any
posture, on a chair, on the floor, a bundle of straw, on foot, and on all
the kinds of beds that have been proposed; so that it is only in the
cases where nothing interferes with the accoucheur’s doing just what
he thinks best, that he ought to attach some value to the composition
of the lying-in bed; further, the only essential matter is, that the
woman should lie as comfortable as possible, that she should not be
incommoded, neither during the pains nor the intervals between
them, and that the perineum may have room to dilate.”
Oftener than otherwise in this country, the woman is delivered on
the same bed on which she sleeps. Sometimes, also, a cot is used,
which also is a very convenient contrivance, since it allows of the free
passing of the physician and others about it. It is, likewise, a
healthful plan to move from one bed to another after labor; but this
is by no means strictly necessary. Cleanliness, comfort, and good air
—these are the great requisites in regard to the bed.
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