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Enterprise Systems for Management Instructor’s Manual – Motiwalla & Thompson
Copyright © 2012 Pearson Education, Inc. Publishing as Prentice Hall
1
CHAPTER 6: SOFTWARE AND VENDOR SELECTION
CHAPTER OBJECTIVES
• Understand the initial steps in the process for the successful purchase and implementation
of an ERP system.
• Determine the total cost of ownership and what it is to partner with an ERP vendor.
• Understand why the first steps in the purchase of an ERP are critical to the change
management process.
• Identify the steps involved in negotiating a contract with a vendor.
CHAPTER OUTLINE
I. Opening Case: Oracle wins out over SAP at Welch’s
II. Vendor Research
a) Short List of Vendors
III. Matching User Requirements to Features
IV. Request for Bids
V. Vendor Analysis and Elimination
a) What Does ERP Really Cost?
VI. Contract Management and License Agreements
VII. Implications for Management
VIII. Real World Case: Enterprise Solutions for Fruit & Vegetable Beverage
Manufacturing
CHAPTER SUMMARY
This chapter discusses the process of selecting a vendor for ERP implementation. The chapter
first discusses vendor research and informational gathering. Visiting Internet search engines or
asking department managers are sometimes the best forms of vendor research and information
gathering. It allows the end-user to get involved in the process of ERP implementation. The
chapter then discusses the kind of information a company should be looking for when choosing a
vendor. Vendor financial position, an implementation philosophy, expertise in industry, and
referrals are some key questions companies should investigate.
This chapter also discusses IT infrastructure criteria. This is another important part of the vendor
selection process. As some companies wish to keep their existing platforms, a vendor should be
able to install a “sandbox” application to demonstrate how the company’s infrastructure will
interact with vendor applications.
This chapter then discusses the procedure of identifying and documenting user information and
system requirements for ERP implementation. The chapter discusses the two major documents

2
resulting from selecting functional requirements. The first document, a functional and data flow
chart provides a microscope look at the business process and how a company can make changes
in the process. The second document, the table or description of functions, describes how
important each function is to the company. This information will help a company make an
educated decision about a vendor.
After a company decides on functional requirements, it must then request information from the
vendors. The company makes an RFI (request of information) document and sends it to a long
list of ERP vendors. This will allow the company to review their own functional requirements
along with the ERP vendors’ features and capabilities. This will make it easier for a company to
ultimately determine which vendor to select.
After receiving information from the vendors, a company then sends an RFB or RFP (request for
bid, request for proposal) to a short list of selected vendors. The document includes the
company’s specific hardware and software infrastructure requirements, training requirements,
and the type of ERP system that will need to be implemented. From this the vendor receives a
clear understanding of the needs and desires of the company. The bid itself includes a
breakdown pricing sheet, description of the selection process, and the timeline of how selection
will take place. The point of this is to help the company narrow down the selection of vendors.
After a formal bid is processed the company goes through a stage of analysis and elimination.
This process is divided into three sections, where departments evaluate corresponding functions.
Office staff or end-users evaluate the functionality of the ERP system; IT looks at the technology
requirements; and the contract staff evaluates the contract itself and pricing. This evaluation
process allows the company to eliminate vendors that cannot fulfill their needs for ERP
implementation. Additionally, a company can make an educated decision regarding the cost of
the entire ERP implementation. This is called Total Cost to Ownership (TCO). This cost
analysis takes into account all inductive costs of a full life cycle of ERP implementation. The
majority of TCO costs occur after the ERP implementation. TCO is very difficult to estimate
and deals with the training and upgrade aspect of ERP implementation. This process is
beneficial to the company because it gives an understanding of how the ERP implementation
works with the company’s financial situation.
Chapter six also discusses contract arrangement and license agreement. The primary purpose of
this phase is for both parties to end up with a written monetary agreement and a written plan for
a successful ERP implementation. There should be an appointed contract manager involved in
contract implementation. This liaison monitors both sides to make sure the vendor and the
company uphold their end of the bargain.
From this chapter students learn that selecting an ERP vendor is a matter of problem solving. To
solve a problem one must investigate, brainstorm, evaluate and determine a solution. Selecting
an ERP vendor is the same process, although it can be a difficult choice. There are so many
factors, such as employee satisfaction, business infrastructure, and financial resources, which
affect how a company chooses a vendor.
ADDITIONAL RELATED INFORMATION

3
1. ERP consulting companies
a. http://www.panorama-consulting.com/erpsoftwareselection.html
b. http://zenobia-associates.com/vendor_selection_process.html
2. A functional requirement proposal written by the state of Connecticut
a. http://www.osc.state.ct.us/vendor/rfps/2000/osc0012000/scope.htm
ANSWERS TO END-OF-CHAPTER REVIEW QUESTIONS
1. What are the steps in purchasing an ERP?
The steps are as follows:
• Vendor research and informational gathering
• Decide on functional requirements and IT criteria
• Request information from vendor on features
• Review information with company’s functional requirements
• Request bid from vendor
• Review and Eliminate vendors not suitable
• Negotiate with selected vendor on price and functional requirements
• Come to an agreement and prepare licensing agreement
2. Who generally needs to be involved in the ERP selection process and why?
Everyone in the organization needs to be part of ERP implementation. ERP
implementation affects everyone and by keeping an open line of communication it will
help everything run as smooth as it possibly can.
3. What is total cost of ownership (TCO) and why should it be a part of the ERP
selection process?
TCO is the total cost associated with ERP implementation, including training, software
implementation, and upgrades to the system. It is an important part of the selection
process because it gives a company an overall look at how much an ERP system will
actually cost.
4. What are the key components in contract negotiation and licensing?
The key components in contract negotiation are to evaluate the company’s functional
requirement and financial resources with the vendor’s features and price. Then
formulate a plan to make a successful ERP implementation.
5. Why is it important in the request for bid process to make the vendors reply in a
specified format?

4
By formatting the request for bid the vendor understands directly what the company
wants and needs for ERP implementation. They also understand the who, what, why,
and when of the selection process.
6. Why is communication important in this phase?
Communication is important because vendor selection involves negotiation and
informational gathering. Without clear and periodic communication there is no way
ERP system implementation will work. Without clear communication the vendor can
misinterpret requirements and not provide the client with the business process software to
meet their needs.
7. What is the difference between an RFI and RFB?
RFI is a formal request of information made by a company to a vendor. The information
should include both the vendor’s features and the compatibility of these features with
user requirements. RFB is a formal request of bid which explains who, what, where,
when, and how a vendor will be selected and the ERP system will be implemented.
8. What are the benefits of a bidding process to purchase of an ERP?
The bidding process allows vendors to compete for the best price, producing a more
affordable ERP system implementation and more flexible vendor to the functional
requirements of the company.
DISCUSSION QUESTIONS
DISCUSSION QUESTIONS
1. As Welch Foods narrowed down the vendors in their quest to purchase an ERP,
discuss the steps Welch Foods took to get the best price.
1. Vendor research and information gathering.
2. Needs/requirement assessment after determining what their current
infrastructure was using
3. Internal selection team creation and involvement.
4. Vendor elimination process, to top two choices.
5. Vendor selection, determined by which would be easier to implement after fully
understanding current and future infrastructure
6. Customer referrals
7. Price negotiation
By narrowing the ERP decision down to two providers, Welch Foods was able to create a
competitive situation, using each provider as leverage against the other. Not only did SAP
and Oracle both want the business, but they also wanted to make sure that their competitor

5
did not have the upper hand during the negotiation period. Once SAP and Oracle became
aggressive with their pricing, Welch took other outlying factors into account, such as
functionality and ease of flexibility and implementation. The strategy SAP and Oracle both
used for pricing also factored into the decision making process. Oracle was very aggressive
early on in the negotiations and SAP only seemed to become aggressive as a "last ditch
effort". By the time SAP offered an aggressive bid, Oracle had won the order.
2. Describe the components of TCO and why it is difficult to use in comparing ERP
systems.
TCO can be difficult to use when comparing ERP systems, because it is difficult to
estimate. This makes it hard to anticipate the benefits of the investment. One way to look at
TCO, which could make it easier to compare ERP systems, is by deciphering between
Direct and Indirect Cost:
Direct Costs: the obvious hardware, software, and mainframe; in addition, annual licensing
and ongoing support.
Indirect Costs: less articulated; included the costs of staff tasked with supporting and
developing the ERP and the costs for ongoing training.
As would be expected, indirect costs are a mere fraction of the cost to acquire and
implement the system, yet they are curial when it comes to the appeal of choosing an ERP
system
Components of TCO include
- costs of purchase
- networking costs
- costs of ensuring security
- costs of training
- repairs and upgrades
- maintenance and service support
There are also many intangible costs such as opportunity cost of removing employees from
there daily jobs as part of project team and training, and potential costs of lost sales and
waste if implementation is not successful.
TCO is difficult to determine, but once an estimate is reached, it should be compared to the
TBO (total benefits of ownership) which can include just as many intangible benefits as the
costs.
3. Defined and documented functional requirements is a part of the bid process.
Discuss why this would be beneficial in the selection of an ERP system even if a bid
is not required.

6
When a company is evaluating an ERP system, they have to prioritize certain criteria. By
reviewing the documented functional requirements, there is a comfort level that the
organization can reach with the software. If it is documented, you can have your contract
state that the software must function according to it; you then have some leverage if you
find out later that the software does not do behave as it is documented that it should.
Defined and documented functional requirements are the result of the staff/team
documenting current legacy system functionality or using business process re-
engineering to address 'best practices' in the industry. Going through this process will
provide the company with well-defined functional requirements; information on which to
select an ERP system. Also, a key component of the document is how the integrated ERP
system cross-functional data flow affect departments within the company.
CASE QUESTIONS: FRUIT AND VEGETABLE MANUFACTURER
1. What are some of the tracking issues a fruit and vegetable manufacturer must
utilize in an ERP to better ensure success?
• Characteristics of the lot such as brix and acidity
• Specifications of customers (i.e. for juices percentage of solids)
• Accounting and settlement process
• Quality control for sterilization of equipment
• Order of processing (i.e. apples before blueberries)
• Kosher or Halal certifications
• Expiry and sell by dates
• Shipping timing and costs
2. What is an “organic system plan” and what are some of the key features an ERP
must include?
Shoppers often want to purchase products that are organically grown and products that
only use an organic process to produce the product. This requires elaborate tracking of
how the product was grown the ingredients in growing the product and the practices of
how it was picked, stored and manufactured in order to assure it complies with organic
guidelines.
3. Why are some manufacturing systems specific to a product?
• Lot tracking for ingredients to manufacture a consistent product.
• Expiration of tracking to ensure freshness.
• Equipment usage tracking to ensure the equipment was properly sterilized and
used.

Other documents randomly have
different content

Fig. 62.—The breech.
Left-sacro-posterior
position. (Lenoir and
Tarnier.)
Externally the palpating fingers at the pelvic brim will note the
absence of the hard, round head, and feel a mass, softer, quite
irregular in shape, and less defined than customary. Movements also
may be appreciated that would be too far down in the uterus if the
head was presenting.
Next the hard, spherical tumor of the head can be outlined
somewhere in the fundus, and the heart tones, instead of being below
the umbilicus will be on the same level or even higher.
Vaginally the cervix is not filled out, the presenting part does not
come down, but after labor has begun the distinctive features of the
breech gradually become more evident, as they are driven into the
pelvis.
One or both feet, or the buttocks, may be recognized. The
examining finger may possibly enter the anus and be stained with
meconium or pinched by the sphincter, which differentiates this
orifice from the mouth.
One after another the characteristic landmarks appear until the
diagnosis can not be doubtful. As soon as the sacrum is found or the
legs definitely placed, the position can be named.
Mechanism.—The hips always enter the inlet in one of the oblique
diameters and the back is turned to the same part of the uterine wall
as in the corresponding vertex positions.

The acts described in the mechanism for vertex deliveries show a
somewhat different order. Descent is first, then comes internal
anterior rotation, which brings the anterior hip under the symphysis
and its delivery is quickly followed by the posterior hip, which rolls
out over the perineum.
The body advances, as a rule, with the back toward the front of the
mother. The shoulders with arms folded move under the pubic arch
and then the head delivers in a state of flexion. The head, of course,
has no caput and it is not moulded.
This mechanism may be greatly impeded or complicated at any
stage of the movement. The advance may be retarded to a
pathological degree, the belly may be large and as it passes along the
canal one or both arms may be stripped up alongside the head or
even into the back of the neck. The head may be arrested at the inlet
by the arms, by its degree of deflexion, or by pelvic contraction.
The rotation may not take place, or it may be abnormal, and the
belly of the child look forward toward the mother’s. Any of these
variations adds further to the difficulty of the labor and to the danger
of the partners in the event.
Artificial aid may be required which brings with it the possibility of
sepsis.
The fœtal mortality which averages five per cent is due mostly to
asphyxiation. Interference with the supply of oxygen begins as soon
as the cord passes the vulva and the child must be delivered in eight
minutes from that time, or perish. Partial detachment of the placenta
may also cut off the oxygen to a fatal degree, and the child may be
unable to breathe when born on account of mucus sucked into the
trachea by premature efforts at respiration.
Minor accidents also occur, such as fractures, dislocations, and
paralysis from injury to the nerve trunks.
Management.—In the interest of the child, this presentation is
occasionally converted into a vertex by external version during the
last weeks of pregnancy or in labor before the membranes have
ruptured. It is difficult, however, to maintain the vertex over the
inlet. The woman must be kept quiet in a horizontal posture and long
roller splints applied to the side of the child in utero and bound on.

In primiparas, this is nearly impossible, and it is wiser, in the
absence of some great necessity to warn the parents of the conditions
and dangers and let them share in the responsibility.
Fig. 63.—Extraction of the breech. Traction on
one leg. (Hammerschlag.)
When the labor begins, the bag of waters must be kept from
rupture as long as possible and when it finally breaks, an internal
examination should be made to see if the cord has come down. If this
happens it may be necessary to expedite the delivery by external
assistance.

Fig. 64.—Breech delivery. Extraction of the trunk
by pulling on the hips. (Hammerschlag.)
The doctor brings down a foot, if it is not already down, or pulls on
the breech until the feet drop out. Compression of the cord must be
always in mind. It is always compressed after the umbilicus has
passed the navel. The shoulders are delivered by seizing the feet with
the operating hand and swinging the body out of the way. This brings
the posterior shoulder, which should be first, into the hollow of the
pelvis. Extraction is then completed by what is called the Smellie-
Veit maneuver. The child is put astride one arm, the first finger of
which is hooked into the child’s mouth to maintain flexion. The
fingers of the other hand then grasp the shoulders of the child astride
the back of the neck and traction is made downward in the axis of the
inlet until the head slips into the excavation.

Fig. 65.—Breech delivery. Delivering the
shoulder. The body is swung strongly upward and
outward to bring posterior shoulder into the
pelvis. (Hammerschlag.)
Fig. 66.—The delivery of the after-coming head
by the Smellie-Veit maneuver. (Hammerschlag.)
If the head is delayed at the inlet, it may be necessary to put the
woman in the Walcher position (q. v.) and for the nurse to use the

Wiegand compression (q. v.). The feet must not be fastened in
stirrups for breech cases.
Fig. 67.—Shoulder
presentation. Left-
scapulo-anterior
position. (Lenoir and
Tarnier.)
Forceps are not recommended for application to the breech as they
do not fit and are liable to slip off and injure both child and mother.
The fingers are best.
Forceps are not recommended for the after-coming head unless
the child is dead. If the child lives, the Smellie-Veit is more-
successful; and if the child dies, the cranioclast, if possible, will save
the mother much suffering and avoid some injury to the tissues.
Transverse or Shoulder Presentations.—These are cases in
which the long axis of the child lies directly across or obliquely across
the long axis of the uterus.
The shoulder (scapula) is the bony landmark, and the part which
most frequently impends over the inlet. This presentation probably
occurs once in two hundred labors.
It is due to the same conditions that were given for breech cases;
namely, weak abdominal or uterine muscles, pelvic contraction,
placenta previa, hydramnios, and twins.
It is easily recognized in pregnancy, and must not be neglected, for
it is impossible of delivery without first changing it into a
longitudinal presentation. If this correction is not done, rupture of

the uterus is liable to occur, with the consequent death of both
mother and child.
The treatment is invariably version.
Face and Brow Presentations.—The face presents once in
about three hundred labors. In this case, the head is completely
extended so that the occiput rests against the back of the neck. The
trunk and spine are straightened out while the legs and arms remain
in the normal attitude of flexion.
The causes of these anomalies must be sought in those conditions
which bring about the deflexion of the chin. The most common are
pelvic contraction, large child, placenta previa, hydramnios, goiter,
anencephalus and multiparity.
Fig. 68.—Face
presentation. (Bumm.)
Face positions take their names from the location of the chin
(mentum—Latin). Thus the most frequent face position is the right-
mento-posterior.
The diagnosis is not easy and may not be conclusive until the bony
prominences of the face, such as the nose and orbital ridges can be
distinguished by vaginal examination.

Fig. 69.—Descent of the chin in face presentation.
(Bumm.)
The delivery is protracted from three to five hours beyond the
average by this complication, and the mortality is higher both for
mother and child. The face is badly swollen and disfigured, but the
normal condition of the tissues will be restored by the end of a week.
Most face cases terminate spontaneously, but operative interference
is not infrequent on account of danger to mother or child.
Version or manual correction of the presentation may be done
before engagement.
Forceps is the operation of choice after the head is fixed in the
pelvis, but it may be necessary to precede the delivery by a
preparatory pubiotomy, or in case of failure, to do a craniotomy on
the dead child.
If the chin does not rotate forward under the symphysis, the labor
is impossible without pubiotomy or the destruction of the child. In
general, the case should be left to nature unless some definite
indication to interfere develops.

Fig. 70.—Delivery in face
presentation. (Bumm.)
The brow presents much more rarely than the face, possibly once
in a thousand labors. It is due to the same conditions as bring about
the presentation of the face. The mortality for both mother and child
is higher than in face cases. The whole labor is harder and longer,
besides being more dangerous to life and to tissues.
This presentation, if recognized before the head is fixed, should be
converted into a breech by version, but after the head comes down, it
may be possible by hand or forceps to deliver either as a face or as an
occipito-posterior, but otherwise the cranioclast must be considered.
Occipito-posterior position is the name given to vertex cases
wherein the occiput lies in one or the other of the two posterior
quadrants of the pelvic inlet.
These labors are necessarily prolonged, both in the first and
second stages, because the mechanism of delivery is deranged by the
larger diameters brought into relation with the bony canal and by the
ineffectiveness of the contractions.
The pains in the second stage may become violent and extremely
painful, but the labor does not advance appreciably. After a little
experience, mere observation of the course of the labor will cause the
suspicion to arise in the mind of a competent nurse that the occiput
is posterior. The diagnosis will be cleared up by the doctor’s internal
examination, which shows the large fontanelle anterior and the
sagittal suture running backward.
The head is partially deflexed and it may not be possible at first to
find the small fontanelle.

The position terminates by delivery uncorrected, by spontaneous
rotation into an anterior position, or is corrected by the doctor.
Correction should not be attempted until it is apparent that the
anomaly will not right itself, which it will do in four cases out of five.

CHAPTER XII
OPERATIONS
Complications during labor may arise from abnormal positions of
the head, such as face or brow; from abnormal presentations of the
child, such as breech, transverse or shoulder; from twin labors; or
from prolapse of a part like the foot, arm or cord.
The mother may be responsible for some of these abnormalities
through having a contracted pelvis, a rigid os, or a rigid pelvic floor.
The uterus, too, may functionate abnormally by acting too
vigorously, as in precipitate labor, or too slowly, as in uterine inertia.
The membranes may rupture prematurely and produce a dry birth.
There may be hæmorrhages before labor (ante partum
hæmorrhage) during labor (intra partum), and after labor (post
partum hæmorrhage), or the labor may be preceded, accompanied,
or followed by that extreme example of toxæmia known as
eclampsia.
Face and brow presentations are rare and come to the attention of
the nurse only when an operation is required for their relief. Further
conditions may arise, such as danger to mother or child, which
demand an acceleration of the labor.
If the head is engaged, forceps is the operation most commonly
undertaken, and if not engaged, the problem may be solved either by
an early version and extraction or by forceps later. The dangers to
the mother are not usually difficult to diagnose if the case has been
followed carefully.
Signs of danger to child must be looked for constantly. Such are:
(a) Alteration of the heart tones.
(b) Retardation of pulse in cord between pains.

(c) Escape of meconium is not significant unless occurring in the
pain-free interval, when it may signify hypercarbonization of blood
and a threat of asphyxiation.
The preliminaries for the performance of these operations may
now be described, and the indications and conditions briefly
tabulated.
The preparation should be standardized so that the same set-up of
the room will do for all of the major obstetrical operations, except
Cæsarean section.
The kitchen table is generally regarded as a satisfactory operating
table. Its length is sufficient for delivery when the legs are doubled
up. The table should be covered with a blanket or comfort on which it
laid a clean sheet. A rubber blanket or piece of oil cloth is put on, so
folded above the place for the patient’s hips, and so pinned at the
sides, that all drainage will flow off into a bucket or jar at the foot.
In front of the table is placed a straight-backed chair with flat seat.
To the right of the operator, as he faces the table, stands a bench, or
two chairs, side by side; or, if possible, another table. This is covered
with a clean sheet for the reception of the instruments. To the
operator’s left, another table similarly prepared carries the solutions,
sponges, etc. Every operation for delivery should have tape and cord
scissors within easy reach, as well as facilities for the resuscitation of
the child.
The light should come from behind the operator and fall full upon
the field of operation. The room should be warm.
The patient is laid upon the table and her knees elevated in the
exaggerated lithotomy position. If there are assistants enough, one
can stand on either side and hold a knee, if not, a sheet sling can be
made and slung round the patient’s shoulders and tied to the knees
as previously described.

Fig. 71.—Exaggerated lithotomy position. The legs
are held by a sheet sling. The vulva should be
shaved. (Williams.)
An anæsthetic will be required. If a doctor can not be had, this
duty will fall to the nurse.
A sterile douche bag hangs near the table. A bath tub of hot water
must be provided and a tracheal catheter must be ready for the
removal of mucus from the child’s windpipe. An abundance of hot
and cold sterile water must not be overlooked. In the hospital the
following synopsis for the placing of the linen may be found useful:
Sterile Linen for Operative Case.—
Bring patient to foot of bed.
Put in the stirrups. (For breech deliveries do not use stirrups.)
Same order as for normal case except that feet are put in stirrups instead of on
bed.

Fig. 72.—Dorsal position when assistants are
available. (Hammerschlag.)
Sterile sheet under patient extends now from basin under bed to buttocks.
Combination pad over field of operation.
Sterile sheet over abdomen.
The genitals of the patient are now cleansed with all care and
attention described for labor. If this has been done within an hour,
she need only be sponged off thoroughly with lysol solution (1 per
cent). The feet and legs are covered with stockings, the body kept
warm, and protected by sheets and blankets, if necessary.
Every operative delivery is preceded by catheterization.
All instruments are boiled for thirty minutes and brought to the
table in the same container in which they are sterilized. The hot
water has been poured off and a cool, weak solution of lysol (0.5 per
cent) added.

Fig. 73.—Instruments for artificial delivery of the
head. A, Braun’s blunt hook; B, Cranioclast
(Auvard); C, Axis traction forceps (Webster); D,
Low forceps (Simpson).
Forceps.—Before using forceps it should be determined that the
woman can not deliver the child unaided, or can not be permitted to
do so without too great expenditure of physical and nervous energy.
The exact conditions must be recognized as to the location and
position of the head, the condition of the fœtal heart tones and the
size of the pelvis. When the head is high up, the axis traction
instrument is employed and patient put in Walcher’s position for the
traction.
Axis traction forceps are extremely dangerous to mother and child,
and should be avoided wherever possible.
The following instruments are required:

The obstetric forceps.
2 eight-inch forceps.
6 artery forceps.
1 vulsellum forceps.
1 tissue forceps.
1 needle forceps and 6 needles.
2 vaginal retractors.
1 pair dressing forceps.
1 douche point.
1 silver catheter.
Suture material—both catgut and silkworm gut.
Besides these instruments, the nurse will also have solution basins
as described for normal labor. For operations outside of hospitals,
the nurse need not be clean, as her duties will consist for the most
part in changing solutions, refilling basins, handing towels, etc., all of
which can be done with sterile forceps.
The following summary may be serviceable for advanced study or
reference:
Preparation.—
Thorough asepsis, both subjective and objective.
Patient should be pulled down to the foot of the labor bed with feet in the
stirrups, or put upon the kitchen table or across the bed with the legs held
in the lithotomy position. (For breech cases, legs should not be fastened.)
Bladder and rectum must be empty.
Anæsthetic is necessary.
The position of the head must be accurately known.
Facilities for the treatment of asphyxia neonatorum must be at hand.
Conditions.—
Cervix effaced and os dilated, except when maternal or fœtal life is
threatened.
Bag of waters must be ruptured.
The head must be engaged.
The child should be living.

Indications.—
Insufficiency of the powers of labor.
Deep transverse arrest of the head.
Complications in labor, such as:
Eclampsia.
Fever.
Acute or chronic disease.
Hernia—especially if incarcerated.
Placenta previa.
Prolapse of the cord.
Face and brow presentations.
Contracted pelvis.
Occipito-posterior positions.
Dangers From Forceps.—
Injuries to Child.—Overcompression, especially with axis traction forceps or
in contracted pelvis.
Crushing of soft parts, or such lesions as abrasions, pressure marks,
hæmatomata, swelling of face and eyelids.
Bone injuries: Spoon-shaped depression where the head has been dragged
through a narrow inlet; fissures in the parietal or frontal bones; fractures.
When axis traction forceps are applied antero-posteriorly, the occipital
bone may be sprung inwards until it cuts the medulla.
Compression of the cord, especially if it is around the neck.
Hæmorrhage from the middle meningeal artery.
Injury to eye.
Erb’s paralysis.
Laceration of ears when the forceps are removed.
Facial paralysis from pressure of the blade.
Injury to Mothers.—
Infection.
Improper application of the blades outside the cervix uteri.

Soft parts torn by too rapid extraction. When os is not dilated, it is first
pulled down and then torn. The tear may extend into the vaginal
vault. Fistulæ may be produced.
Prolapse of the uterus from prolonged traction.
Vaginal tears from the blades or from malplaced head.
Slipping of blades. Traction must be not against the symphysis, but
down.
The forceps commonly used in this country (Simpson or Elliott)
are so made that the left blade must be introduced first on account of
the lock.
The mortality for the child in forceps cases is about six per cent.
Fig. 74.—Forceps operation. The left blade, in the
left hand, is introduced first into the left side of
the mother so that the curve of the blade fits the
child’s head (inside the cervix). (Hammerschlag.)
The axis traction instrument is used but seldom by good
obstetricians, since the danger to mother and child in this operation
is very serious and it should be reserved for emergencies of
exceptional character. Pubiotomy may precede the operation with
advantage in many cases. Asphyxia of the child and maternal
hæmorrhage must be prepared for.

Fig. 75.—Forceps operation. The introduction of
the right blade. (Hammerschlag.)
Fig. 76.—Forceps operation. Locking the handles.
(Hammerschlag.)

Fig. 77.—Forceps
operation. The way the
blades should grasp the
fœtal head.
(Hammerschlag.)
Fig. 78.—Forceps operation. Traction on the
handles. (Hammerschlag.)

Fig. 79.—Forceps operation. The delivery of the
head. (Hammerschlag.)
Fig. 80.—Version.
Seizing a foot.
(Hammerschlag.)
Version (Turning).—Version is a maneuver for altering the
presentation of the child while it is still in the uterus. A vertex may be
converted into a breech, a breech into a vertex or a transverse into
either a vertex or a breech.

Fig. 81.—Version. The
child rotates as pressure
is made upon the head
and traction upon the
foot. (Hammerschlag.)
Version usually means that a transverse or a vertex presentation is
changed into a breech and is followed by the extraction of the child.
The operation is serious and not to be undertaken without definite
indications. There is always the risk of sepsis and rupture of the
uterus as well as a high probability of a dead child. Perineorrhaphy
is, if anything, more frequent after this operation than after forceps.
Fig. 82.—Version is
complete when the knee
appears at the vulva.
(Hammerschlag.)

Preparations.—The room and patient are arranged as for forceps,
except that the stirrups can not be put in. The legs must be held by
assistants, for the delivery of the after-coming head may be
complicated and require the Walcher position, which can not be
quickly obtained if the legs are fast. Only eight minutes are allowed
for the delivery of the child after the navel passes the vulva, if it is
expected to live.
The bladder and rectum must be empty.
Asepsis must be rigid and both subjective and objective.
The dorsal position on a table is imperative.
The diagnosis must be accurate and the anæsthesia carried to the surgical
degree.
Facilities for treating asphyxia neonatorum must be provided.
The following summary of the indications and conditions may be
convenient for reference.
Indications.—Contracted pelvis. (Consider pubiotomy.)
Abnormal position of the head. (Face position with chin posterior.)
Prolapse of cord or an extremity with a presentation of the head.
Placenta previa.
Transverse position after the seventh month.
Any condition requiring rapid delivery.
Conditions.—Cervix effaced and os dilated.
Uterus not in tetanus nor contracted down over the child.
The fœtus must be movable.
The head should not be engaged.
The Walcher position is produced by bringing the patient down to
the end of the table so that the sacrum rests upon the edge. The
thighs and legs are allowed to hang down of their own weight and the
patient is restrained from falling off by traction upwards on the
axillæ.

In the Walcher position the diameter of the pelvic inlet is increased
from ⅓ to ½ inch (1 cm.) and thereby the delivery of heads that
otherwise could not pass becomes possible.
In addition to the Walcher position other measures may be
required to help the head through. Thus, traction from below may be
carried to the limit of safety and in spite of the Walcher position the
head may not pass the inlet.
Then pressure from above is added. This maneuver will have to be
executed in many cases by the nurse.
The fingers palpate the head above the pubes. Then one or both
fists are placed upon the abdomen over the head and force is exerted
to crowd the head down into the pelvis. This is known as the
Wiegand compression.
For the operations destructive to the child, craniotomy or
decapitation, the same arrangements are made.
Fig. 83.—The Walcher position. (American Text
Book.)
Cranioclasis is the crushing of the fœtal skull so that in its
reduced condition the child can be delivered and the mother’s life
spared. In addition to the solutions, the only instruments required
are the Auvard cranioclast, a Naegele perforator, and a douche bag
with glass, or any tip that can be sterilized.

In many of these cases, both mother and child could be saved if
seen early enough to have a Cæsarean operation.
Decapitation is done to save the maternal life in cases of
transverse or shoulder presentation. The preparations are the same
as already described for forceps and version and the only instrument
needed is a Braun blunt hook. (Fig. 73.)
Fig. 84.—The Wiegand
compression of the
child’s head to force it
into the pelvis.
(Hammerschlag.)
Cæsarean section is the delivery of the child through an opening
in the abdomen.
It is made necessary by contraction of the pelvic bones, or by the
presence of a fleshy or bony mass which diminishes the size of the
inlet. It may be required on account of the closure of the vagina or
cervix by scars or on account of urgent conditions of the mother,
such as eclampsia, heart disease, and sometimes placenta previa.
The technic is simple, but good judgment must be used in knowing
when to do it. Many operators find it so easy that they prefer it to the
harder but safer obstetrical operations.

Fig. 85.—The Naegele perforator.
(Hammerschlag.)
The time of election is when the woman is at term but not in labor.
This, of course, can be determined by the history, but more certainly
by careful measurements of the child.
When it becomes necessary to operate on a woman who has been
in labor a long time and especially if she has been examined
frequently, the mortality is disproportionately high.
It is a hospital operation, but may be done in the house. If not an
emergency, the bowels are emptied by a laxative and enema the day
before. Regular preparations for laparotomy are made, plus the
equipment necessary for tieing the cord and resuscitating the child. A
table must be found large enough to hold the patient in the
horizontal position at full length. Solutions of lysol 1 per cent and
sterile water are placed on each side of the table. The instrument
table carries towels and suture material as well.
On a stand behind the operator is placed the hot bath and tracheal
catheter. This center is presided over by someone skilled in the
treatment of respiratory difficulties in the new born. Altogether, five
assistants are required for the operation: an anæsthetizer, a clean
nurse, and a nonsterile nurse to manage supplies, an operating
assistant and one to take charge of the child.
Rubber gloves must be worn by the clean assistants.

Instruments.—
2 scalpels.
2 scissors.
10 six-inch artery forceps.
4 sponge carriers.
4 tenaculum forceps.
2 rat-toothed tissue forceps.
4 full curved round needles for uterine wall.
4 smaller needles for the fascia.
2 Hagedorn needles for the skin.
2 needle holders.
1 dressing forceps.
Plenty of suture material, both catgut (No. 3 and 4) and silkworm gut
for the abdominal wall.
Supplies.—
1 doz. laparotomy sponges with metal rings sewed in or
a long tape attached.
6 large laparotomy pads.
1 large pillow slip full of sterile cotton.
Sponges.
1 laparotomy sheet.
1 dozen towels.
1 pair of leggins.
Gowns and head dressings (gauze will do) for the operator and
assistants; rubber gloves, basins and accessories. All are
sterilized.
If the woman has been examined, the vagina should be sponged
out with tincture of iodine. The abdomen is shaved, scrubbed with
green soap, nail brush, and hot water for five minutes. It is then
rinsed with ether and painted with iodine.
The presentation of the child, the presence and location of the
heart tones must be determined before operation.
The patient is anæsthetized with ether, chloroform or gas.
The incisions are made; the child delivered to the proper assistant;
the placenta and membranes removed; the sponges counted; and the
uterus and abdominal wall sutured.

After-care.—The nurse watches the patient for sighing respiration,
rapid pulse, pallor, and other symptoms of hæmorrhage, either
external or internal. Artificial heat is supplied. Hæmorrhage from
vagina should be looked for. It is normal. Salt solution by
hypodermoclysis may be required. Hot water by mouth in small sips
or tap water by rectum (drop method) will relieve the thirst.
Morphine may be given if pain is extreme. An enema may be given
on the second day or calomel may be started in the morning of the
second day. Distention from gas, with or without nausea and
vomiting, hiccough and rise of temperature are all signs of danger.
No milk should ever be given on account of the gas it causes.
The child is put to breast as usual after twelve hours.
The stitches are to be taken out on the tenth or twelfth day.
Symphyseotomy is a separation of the pelvis at the pubic joint
and is done with a scalpel or a specially devised knife.
Pubiotomy is the division of the pelvis, three or four centimeters
to the right or left of the pubic joint. The division passes through the
pubic bone and is usually done with a serrated wire called the Gigli
saw. It is introduced subcutaneously by a special instrument called a
pubiotomy needle. Both symphyseotomy and pubiotomy are
preparatory to delivery. Pubiotomy is the more desirable and
successful operation. The ends of the severed bones separate from
one and a half to two inches, and the child delivers easily through the
enclosed opening. The after-care is usually simple.
Instruments.—
1 scalpel.
2 Gigli saws.
1 pubiotomy needle.
6 artery forceps.
1 needle holder.
2 retractors.
Suture material and sponges as usual.
The hips are strapped in circumference with zinc adhesive plaster
to support the bones.

The danger of infection of the wound from the lochia is always
present. The main difficulty is in moving the patient, who is more
than usually helpless. The bony ring of the pelvis is broken and she
can not raise her leg. The repair is cartilaginous at first, but solidifies
in a few months so that locomotion is not impaired. Especial pains
must be taken to avoid bed sores.

CHAPTER XIII
MINOR OPERATIONS
Aseptic Care.—Place patient on a clean bed pan. It need not be
sterile. Drape with a sheet and arrange it so the fold may be easily
raised by nurse’s elbow. Have sterile basin with cotton pledgets to be
filled with solution of lysol 1 per cent. Lysol must be put in basin first
and the water added. Take to bedside. Nurse scrubs her hands ten
minutes with a sterile brush, hot water, and green soap. Use no
towel, no gloves. Keep hands wet and clean. Cleanse vulva with wet
pledgets from above downward. Apply sterile pad.
Sterile Specimen.—To get a sterile specimen of urine without
catheter, give aseptic care, tampon vagina with large pledget of
sterile cotton. Have patient urinate in a sterile basin. Remove
tampon.
Sterile Specimen from Child.—Take a glass test tube and
thrust its round end through a hole in a square piece of adhesive
plaster. Push it down until the plaster is caught and stopped by the
enlarged rim at the mouth of the tube, with adhesive side of plaster
on same side as opening of tube. Fasten the tube over the male penis
or female vulva by applying the plaster to the surrounding skin.
Leave until full.
Aseptic Douche.—Boil douche point and basin. Leave point in
sterile basin. Fill douche can with sterile water, temperature 104° to
110° F. Put clean bedpan under patient who is draped with a sheet.
Have at hand a sterile basin containing solution of lysol 0.5 per cent,
or boric acid 5 per cent in which cotton pledgets are immersed. Scrub
the hands as for aseptic care. Cleanse the vulva with cotton pledgets,
washing always toward the anus, and use each pledget but once.
Adjust the douche point and introduce it just inside the labia. The

douche can should be only a trifle higher than the pelvis. When can is
empty, apply a sterile pad.
Fig. 86.—
Apparatus for
getting a sterile
specimen of
urine from an
infant.
If the douche is to be used as a deodorant after the fifth day of the
puerperium, either of the following solutions may be employed:
Potassium permanganate, 1:5000; formaldehyde 1 dram to quart, or
chinosol 1:1000.
The vaginal douche may be used in cases of gonorrhœal
infection in pregnancy during the last weeks, in the hope of avoiding
infection of the child’s eyes.
It is given like the aseptic douche (q. v.) with potassium
permanganate 1:5000, or chinosol 1:1000. It should be hot (112° to
120° F.), and be begun not long before term, so that in case labor
comes on, the danger to the child will be minimized. The reservoir
must not be too high, nor the douche point inserted much beyond
the labia. The woman should be on her back and the douche point
should be rubber or glass.

Removal of Sutures.—On, or about, the tenth day the removal
of sutures is required.
The nurse will sterilize by boiling, 1 pair of long-handled, sharp-
pointed scissors, 1 pair of tissue forceps, and if the sutures extend far
into the vagina, a vaginal retractor.
A basin of lysol solution (1 per cent) with cotton sponges, a sterile
towel to lay the instruments on, a dish to receive the soiled dressings,
sutures and discarded sponges, completes the arrangement.
The patient is now draped with sheets as for examination. The
doctor prepares his hands as for operation. The nurse holds the
limbs of the patient in lithotomy position and the operation is begun.
Uterine Tampon.—Packing the uterus is mostly employed for
hæmorrhage after labor. The patient, therefore, has been prepared
and only fresh sponging with lysol solution is required.
The instruments are, 1 vaginal retractor, 1 pair of dressing forceps,
1 vulsellum forceps and a jar of gauze, four to six inches wide and ten
or twelve feet long. Always use a single continuous strip. A very large
quantity is necessary to fill the uterine cavity. Any sterile gauze may
be used, but weak iodoform is satisfactory.
Fig. 87.—Tampon of the uterus. (Hammerschlag.)
The vagina is held open with retractors, the cervix seized with a
tenaculum and pulled down, the end of the gauze strip is then carried
into the uterus as far as the fundus, the dressing forceps withdrawn

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