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A practical Obstetric Manikin*
JACOBS:
605
PRACTICAL OBSTETRIC :MANIKIN
The gallbladder was full of large gallstones. The appendix appeared normal; neither of these organs was disturbed. Three days following the operation the patient's condition was very satisfactory, but on the fourth postoperative day she developed a suppurative left parotitis, which necessitated incision and drainage. Following this infection the patient became progre~sively more anemic, until one month after her admission to the hospital her red blood cells were 1,990,000, and hemoglobin was 24 per cent. On .runu ~4, Hl32, the patient developed a mild phlebitis of the left leg. There was however no elevation of the temperature above normal and no definite evidence of visc··ral hemorrhage. On account of the low cell count and hemoglobin, 580 c.c. of blo(.d were given by the direct transfusion method. Later the red blood cell eount ',..-as 2,500,000 and hemoglobin was 38 per cent, occult blood was found both in the urine and in the stool. E'in:dly thirty-seven days after admission to the hospital, the patient had a intestinal hemorrhage; she did not recover from this.
>H'VPI'P
In
1 etrospect it would seem that infeetion and delayed hemorrhage tunwtl the against recovery. In all probabilities not enough time had elapsed for immunization of the prritoncal cavity against the possible infection that might have been carried by the cannula inserted in surroundings that were not ideal.
~cale
The possibility of dehtycd hemorrhage demands that decompression of such a huge c:·st should be done very gradually, possibly a matter of weeks instead of days in ordtl' to avoid disaster.
A PRACTICAL OBSTETRIC MANIKIN* J. BAY
JACOBS,
M.D., F.A.C.S.,
WASHINGTON,
D.
c.
l'ACILITATE the teaching of the mechanisms of labor in vertex and face T 0pre,cntations, the author has c1evised the metal manikin herewith shown. lt i~ a reduplication of a normal female pelvis, which may be readily fastened to any table top; and when so attached, the inclinations of the plan~ of the inlet anc1 symphysis pubis corresponc1 to those of tho patient in modifiec1 lithotomy position, which she as5umes during normal labor.
In l'ig·. 1, 11 A'' shows the manner in which the pelvis may be secured to the table top. It may be permanently attachec1 by means of three heavy screws entering through the top of the bracket, or temporarily fastenec1 by a large thumb· screw •>n the inferior surface of the bracket. One who finds it desirable to carry the manikin from place to place, or who for other reasons desires to remove the model when not in usc, would naturally prefer the latter type. The original model of the skull was carefully carved by hand, and for teaching pul'poses it possesses many points of superiority over the skull of the normal fetus. The head of the expensive chamois doll that is routinely used in medical schools, is a poor representation of a theoretically perfect fetal skull . . .1\.lthough the dian1ctcrs of tho pelvis are normal, those of the skull have been slightly reduced in proportion to each other in order to permit flexion, extension, anc1 intcmal rotation to oceur in the cavity of tho true pelvis. The forces in*R0c·eived for publication, Janua1·y 8, 1934.
606
AMERICAN JOURNAL OF OBSTETRICS AND GYNECOLOGY
herent in the birth object are clearly demonstrated in this skull. The sutures and fontanels are not only imbedded into the metal but are painted black, making them visible at a great distance. A top view of this head shows the re· lationship in size of the bitemporal and biparietal diameters. The parietal rminences are prominent. The handle representing the neck shows clearly the existence and enables demonstration of the function of the two-arm lever, encour· aging flexion when the head encounters resistance. The junction of the head and neck permit of complete flexion and extension. The prominent ischial spines enable one to demonstrate without obstruction of the view when engagement has occurred. In teaching operative deliveries, the spines will serve to differentiate between high forceps, midforceps, and low forceps applications. In considering the mechanism of persistent occiput posterior, we recognize de· flection as a causative factor. For when the head is moderately extended, the sinciput comes in contact with the pelvic floor and rotates anteriorly, conveying the occiput into the hollow of the sacrum. •ro demonstrate this feature with a
Fig-, 1.
chan1ois doll or a norn1al fetus, one n1ust extend the head to a brow or almost a face presentation. With the skull shown, moderate deflection will bring the sinciput lower than the occiput, enabling one to demonstrate intelligently the mechanism of occiput posterior. To aid in the demonstration of the mechanism of labor in brow presentation, the malar bones were made unusually prominent. Face presentations are readily demonstrable. Some teachers prefer to have the skull attached to the manikin by a chain so that it will not be lost; this is desirable where the phantom is permanently attached. Others may prefer to elin1ina.te the chain. A metal pan (Fig. 2) properly shaped to support a dead fetus is readily at· tached to the pelvis. This is an aid in the demonstration of operative deliveries. By means of two thumbscrews the anterior n1argin of the pan is secured to the anterior inferior iliac spines. The posterior border of the pan is supported suitably by an adjustable bracket. Elevation of the posterior border simulates a uterine con· traction, the long axis of the fetus is made to approach the axis of the superior strait. Diminishing the heights of the posterior support, resembles uterine relaxation.
JACOBS:
PRACTICAL OBSTETRIC MANIKIN
607
It is noticed that elevation of the posterior border of the pan causes the fetal ~kull
to engage more readily. And when the occiput is directed anteriorly, there is not only a marked tendency toward engagement, but also a definite increase in the rate of descent. This corroborates the clinical observations regarding the rapid descent of the occiput anterior as compared to the occiput posterior. It also calls to our attention the desirability of so altering the inclination of the inlet, as to cause the forces of expulsion to approach the perpendicular to the superior strait, a factor to which on several occasions, I have directed attention.I The author believes that this phantom possesses many advantages over other teachi11g models. 1. The appliance is inexpensive and indestructible. It need not be handled with care. 2. This manikin, with skull attached, weighs only 5 pounds. 3. There are no leather or rubber parts which perish with age and are expensiv•J to replace.
Fig. 2.
4. The accessory parts that may add beauty, but obstruct view and teaching efficiency, are omitted. 5. The head of a chamois doll is a poor example of a theoretically accurate fetal skull. 6. In demonstrating face presentations with a chamois doll, the neck becomes torn from the chest. 7. Chamois dolls are expensive and their period of usefulness limited. 8. The structure of the bony pelvis, as well as the fetal skull, and the forces inherent in the birth canal and birth object, as related to the mechanisms of labor, may be demonstrated to large classes if so desired. 9. By means of an inexpensive, adjustable metal pan the manikin is readily adapted for the demonstration of operative deliveries with a dead fetus. 10. The effect of uterine contraction and relaxation may be simulated by increasing or decreasing the inclination of the fetal supporting pan. 11. One readily observes why the head in occiput anterior engages and de~cends more readily than in occiput posterior. At Georgetown University where the model has been used for two years, it is
608
AMERICAN
JOURNAL OF OBSTETRICS AND GYNECOLOGY
found convenient and inexpensive to have one of these manikins permmwntly attached in each of the six obstetric quiz rooms.
A manikin of this type may prove of value, not only in teaching classes of students and nurses, but also for use in the tlelin~rr room, whCie the indiviLlual doctor may study the mechanism of the ea~e with whil"ll he i,; pa1-ticularly concerned. REFERENcg
(1) Jacobs, J. Bay:
South. M. J. 22: 321, 1929.
'vVAhHlNGTOK lvfEDICAL Bl-ILDIXG
A COMBINED INLE'r AND OUTLET PELVIMETBR SAMUEL HANSON, A.M., M.D., F.A.C.S., STOCKTON, CALIF. (F1·om the San Joaqui-n General
Ho~pital)
THE most important dimensions of the pelvis are the true conjugate,
and the biischial and posterior sagittal diameters. A simple instrument for the accurate measurement of all three of thes.e diameters is very much to be desired. The pur· pose of the present communication is to present an instrument designed to fill this need. The pelvimeter consists of two sliding detachable blades (Figs. 1, A and B) and a series of six gauges (Fig. 1, C). An open thimble is attached to one end of the lower blade to admit the tip of the middle finger. In its middle third the blade is curved spirally to :fit evenly to the dorsum of the middle finger, and to the dorsoradial side of the index finger. A thumb screw and a slot are provided near the opposite end to receive the upper blade. The upper blade consists of a straight bar with a Yertical arm of 2.i) em. in height at one end, and a ring to fit the tip of the index finger at the opposite end. In its middle third the blade has a slot to admit the thumb screw of the other blade. The blade is calibrated in centimeters, the graduations representing diagonal distances from the free border of the ring to the points marked on the blade. The instrument is so constructed that the same markings also represent the diagonal dis· tances from the free end of the vertieal arm on th<.' one l>lade, to the horizontal diameter of the thimble on tho other blade. Hoth thP- true conjugate and tho posterior sagittal diameter can therefore be read off on the same scale. For the actual measurement of the true conjug:,te (.b'ig. 2) the tip of the middle finger is passed through the thhrrblo, ancl the h1ade r\'sting on the radial side of the hand is introduced into tho vagina. The upper bladP1 held vertically, is introduced under the pubic arch, and is dropped to the horizontal position as it enters the vagina. The blades are locked, and the thimble is guided with the middle finger, toward the promontory of the sacrum. ·with the tip of the finger resting against: the promontory, the instrument is raised against the pubir arch, :md at the same time the lower blade is pm·tly dislodged from the finger tip until the thimble strikes the promontory. Traction is simultaneously made on the upper blade, :mel a reading is quickly taken on the scale as soon as definite resistance is felt at all three points, nan1ely, at the prontontory, at the pubie arr:b, nncl nt the upper and inn!?r border of the pubis. The value obtained represents in centimeters, the length of
605
PRACTICAL OBSTETRIC :MANIKIN
The gallbladder was full of large gallstones. The appendix appeared normal; neither of these organs was disturbed. Three days following the operation the patient's condition was very satisfactory, but on the fourth postoperative day she developed a suppurative left parotitis, which necessitated incision and drainage. Following this infection the patient became progre~sively more anemic, until one month after her admission to the hospital her red blood cells were 1,990,000, and hemoglobin was 24 per cent. On .runu ~4, Hl32, the patient developed a mild phlebitis of the left leg. There was however no elevation of the temperature above normal and no definite evidence of visc··ral hemorrhage. On account of the low cell count and hemoglobin, 580 c.c. of blo(.d were given by the direct transfusion method. Later the red blood cell eount ',..-as 2,500,000 and hemoglobin was 38 per cent, occult blood was found both in the urine and in the stool. E'in:dly thirty-seven days after admission to the hospital, the patient had a intestinal hemorrhage; she did not recover from this.
>H'VPI'P
In
1 etrospect it would seem that infeetion and delayed hemorrhage tunwtl the against recovery. In all probabilities not enough time had elapsed for immunization of the prritoncal cavity against the possible infection that might have been carried by the cannula inserted in surroundings that were not ideal.
~cale
The possibility of dehtycd hemorrhage demands that decompression of such a huge c:·st should be done very gradually, possibly a matter of weeks instead of days in ordtl' to avoid disaster.
A PRACTICAL OBSTETRIC MANIKIN* J. BAY
JACOBS,
M.D., F.A.C.S.,
WASHINGTON,
D.
c.
l'ACILITATE the teaching of the mechanisms of labor in vertex and face T 0pre,cntations, the author has c1evised the metal manikin herewith shown. lt i~ a reduplication of a normal female pelvis, which may be readily fastened to any table top; and when so attached, the inclinations of the plan~ of the inlet anc1 symphysis pubis corresponc1 to those of tho patient in modifiec1 lithotomy position, which she as5umes during normal labor.
In l'ig·. 1, 11 A'' shows the manner in which the pelvis may be secured to the table top. It may be permanently attachec1 by means of three heavy screws entering through the top of the bracket, or temporarily fastenec1 by a large thumb· screw •>n the inferior surface of the bracket. One who finds it desirable to carry the manikin from place to place, or who for other reasons desires to remove the model when not in usc, would naturally prefer the latter type. The original model of the skull was carefully carved by hand, and for teaching pul'poses it possesses many points of superiority over the skull of the normal fetus. The head of the expensive chamois doll that is routinely used in medical schools, is a poor representation of a theoretically perfect fetal skull . . .1\.lthough the dian1ctcrs of tho pelvis are normal, those of the skull have been slightly reduced in proportion to each other in order to permit flexion, extension, anc1 intcmal rotation to oceur in the cavity of tho true pelvis. The forces in*R0c·eived for publication, Janua1·y 8, 1934.
606
AMERICAN JOURNAL OF OBSTETRICS AND GYNECOLOGY
herent in the birth object are clearly demonstrated in this skull. The sutures and fontanels are not only imbedded into the metal but are painted black, making them visible at a great distance. A top view of this head shows the re· lationship in size of the bitemporal and biparietal diameters. The parietal rminences are prominent. The handle representing the neck shows clearly the existence and enables demonstration of the function of the two-arm lever, encour· aging flexion when the head encounters resistance. The junction of the head and neck permit of complete flexion and extension. The prominent ischial spines enable one to demonstrate without obstruction of the view when engagement has occurred. In teaching operative deliveries, the spines will serve to differentiate between high forceps, midforceps, and low forceps applications. In considering the mechanism of persistent occiput posterior, we recognize de· flection as a causative factor. For when the head is moderately extended, the sinciput comes in contact with the pelvic floor and rotates anteriorly, conveying the occiput into the hollow of the sacrum. •ro demonstrate this feature with a
Fig-, 1.
chan1ois doll or a norn1al fetus, one n1ust extend the head to a brow or almost a face presentation. With the skull shown, moderate deflection will bring the sinciput lower than the occiput, enabling one to demonstrate intelligently the mechanism of occiput posterior. To aid in the demonstration of the mechanism of labor in brow presentation, the malar bones were made unusually prominent. Face presentations are readily demonstrable. Some teachers prefer to have the skull attached to the manikin by a chain so that it will not be lost; this is desirable where the phantom is permanently attached. Others may prefer to elin1ina.te the chain. A metal pan (Fig. 2) properly shaped to support a dead fetus is readily at· tached to the pelvis. This is an aid in the demonstration of operative deliveries. By means of two thumbscrews the anterior n1argin of the pan is secured to the anterior inferior iliac spines. The posterior border of the pan is supported suitably by an adjustable bracket. Elevation of the posterior border simulates a uterine con· traction, the long axis of the fetus is made to approach the axis of the superior strait. Diminishing the heights of the posterior support, resembles uterine relaxation.
JACOBS:
PRACTICAL OBSTETRIC MANIKIN
607
It is noticed that elevation of the posterior border of the pan causes the fetal ~kull
to engage more readily. And when the occiput is directed anteriorly, there is not only a marked tendency toward engagement, but also a definite increase in the rate of descent. This corroborates the clinical observations regarding the rapid descent of the occiput anterior as compared to the occiput posterior. It also calls to our attention the desirability of so altering the inclination of the inlet, as to cause the forces of expulsion to approach the perpendicular to the superior strait, a factor to which on several occasions, I have directed attention.I The author believes that this phantom possesses many advantages over other teachi11g models. 1. The appliance is inexpensive and indestructible. It need not be handled with care. 2. This manikin, with skull attached, weighs only 5 pounds. 3. There are no leather or rubber parts which perish with age and are expensiv•J to replace.
Fig. 2.
4. The accessory parts that may add beauty, but obstruct view and teaching efficiency, are omitted. 5. The head of a chamois doll is a poor example of a theoretically accurate fetal skull. 6. In demonstrating face presentations with a chamois doll, the neck becomes torn from the chest. 7. Chamois dolls are expensive and their period of usefulness limited. 8. The structure of the bony pelvis, as well as the fetal skull, and the forces inherent in the birth canal and birth object, as related to the mechanisms of labor, may be demonstrated to large classes if so desired. 9. By means of an inexpensive, adjustable metal pan the manikin is readily adapted for the demonstration of operative deliveries with a dead fetus. 10. The effect of uterine contraction and relaxation may be simulated by increasing or decreasing the inclination of the fetal supporting pan. 11. One readily observes why the head in occiput anterior engages and de~cends more readily than in occiput posterior. At Georgetown University where the model has been used for two years, it is
608
AMERICAN
JOURNAL OF OBSTETRICS AND GYNECOLOGY
found convenient and inexpensive to have one of these manikins permmwntly attached in each of the six obstetric quiz rooms.
A manikin of this type may prove of value, not only in teaching classes of students and nurses, but also for use in the tlelin~rr room, whCie the indiviLlual doctor may study the mechanism of the ea~e with whil"ll he i,; pa1-ticularly concerned. REFERENcg
(1) Jacobs, J. Bay:
South. M. J. 22: 321, 1929.
'vVAhHlNGTOK lvfEDICAL Bl-ILDIXG
A COMBINED INLE'r AND OUTLET PELVIMETBR SAMUEL HANSON, A.M., M.D., F.A.C.S., STOCKTON, CALIF. (F1·om the San Joaqui-n General
Ho~pital)
THE most important dimensions of the pelvis are the true conjugate,
and the biischial and posterior sagittal diameters. A simple instrument for the accurate measurement of all three of thes.e diameters is very much to be desired. The pur· pose of the present communication is to present an instrument designed to fill this need. The pelvimeter consists of two sliding detachable blades (Figs. 1, A and B) and a series of six gauges (Fig. 1, C). An open thimble is attached to one end of the lower blade to admit the tip of the middle finger. In its middle third the blade is curved spirally to :fit evenly to the dorsum of the middle finger, and to the dorsoradial side of the index finger. A thumb screw and a slot are provided near the opposite end to receive the upper blade. The upper blade consists of a straight bar with a Yertical arm of 2.i) em. in height at one end, and a ring to fit the tip of the index finger at the opposite end. In its middle third the blade has a slot to admit the thumb screw of the other blade. The blade is calibrated in centimeters, the graduations representing diagonal distances from the free border of the ring to the points marked on the blade. The instrument is so constructed that the same markings also represent the diagonal dis· tances from the free end of the vertieal arm on th<.' one l>lade, to the horizontal diameter of the thimble on tho other blade. Hoth thP- true conjugate and tho posterior sagittal diameter can therefore be read off on the same scale. For the actual measurement of the true conjug:,te (.b'ig. 2) the tip of the middle finger is passed through the thhrrblo, ancl the h1ade r\'sting on the radial side of the hand is introduced into tho vagina. The upper bladP1 held vertically, is introduced under the pubic arch, and is dropped to the horizontal position as it enters the vagina. The blades are locked, and the thimble is guided with the middle finger, toward the promontory of the sacrum. ·with the tip of the finger resting against: the promontory, the instrument is raised against the pubir arch, :md at the same time the lower blade is pm·tly dislodged from the finger tip until the thimble strikes the promontory. Traction is simultaneously made on the upper blade, :mel a reading is quickly taken on the scale as soon as definite resistance is felt at all three points, nan1ely, at the prontontory, at the pubie arr:b, nncl nt the upper and inn!?r border of the pubis. The value obtained represents in centimeters, the length of