An internal and outlet pelvimeter, combined

MELLOR.

:

INTR~RNAL

AND

OUTLET

505

PELVIMETER

attached. A photograph, with a strong light source beneath the specimen, Fig. 2, showed the relationships more clearly, while the roentgenogram, Fig. 3, demonstrated t.he approximately equal development of the two compressed fetuses. The specimen was preserved intact and no attempt was made to determine by histologic examination of the membranes the essential character of the twin development, although it seems more probable that they were uniovular. We are Indebted to Mr. Frederick W. Kent, University Photographer, l-he photosaphs, and ?Mr. R. M. Tarrant who made the x-ray film.

AN INTERNAL LESTER

AND R.

OUTLET MELLOR,

PELVIMETER,

M.D.,

SYRACUSE,

who

took

COMBINED N.

Y.

T

HE taking of the outlet as also the internal pelvic measurements in the past This fact has been observed quite has usually been i-ound very unsatisfactory. practitioners who have been doing magenerally by both obstetricians and general ternity work. These measurements which are so essential to the practice have repeatedly been found wrong, due to various causes. localizing of the anatomic points from which these measurements the use of instruments which, although theoretically perfect, little value for everyday use. Realizing the above difficulty and striving during the hSt few years, I have combined and, with essential changes, have developed

of good obstetrics First, the careless are taken. Second, are practically of

for better technic in this procedure, the best points of several instruments the present combined instrument.

This instrument (Fig. 1) is made up of three parts: (1) a long curved four-sided section with the centimeter measure upon the front and back in the proper position for reading when in use, (2) a transverse, telescoping section fitted to slide upon the long piece, and (3) a short piece with an upright arm, which also slides on the long section, after removing the transverse member. The long section, with the transverse member fitted upon it, makes an outlet pelvimeter, while the small memher replacing the transverse upon the long section becomes an instrument for internal pelvimetry. The taking of the diagonal and true conjugate is usually a difficult and at times impossible undertaking, either with or without instruments, due to various reasons. First, in primiparas, the firm perinei interfere with the necessary upward pressure which the examining fingers must make to reach the promontory of the sacrum; second, the tilt of the pelvis makes it impossible to measure at times; third, a presenting part in the pelvis may make it impossible; fourth, some multiparous women have firm perinei which make the measurement difficult to take; fifth, pain, caused by the examination, may make it impossible without an anesthetic. Naturally, if the promontory of the sacrum cannot be reached by the fingers of the examin.ing hand, then one cannot hope t,o apply an instrument by hand to that point and be sure that it has reached its goal and, vice versa, if one can reach it with the tip of the examining finger, then it can be measured more accurately with an instrument. I have repeatedly demonstrated the above some fellow practitioners, also the possibility

observations of confusing

to students, internes, sacral ossifications

and with

The small piece of the instrument is l~lacctl ripon the long section xhich is helci >iith the cuue upward ~1 that the upright arm is nearest to the cnrx-e. (Fig. 2). After examining :md ascertaining the position of the promontory xitll the two examining fingers; the instruincnt is insertccl alongside of the fingWs kth the curve upv3rcl and the sl~ouldcr inward. The instrument is worlieii into place past the side of tire cervix trlnwrd to the promontory, placing and holding the shoulder of the instrument in 11l:L~e with the fingers or fingernail of the middle finger in the ;lepression behind the uplwr em1 of the sho~~lc!cr of the instrument. The left hand adjusts the upright sliding section 11rnc:tth the pubic llone and the ~liagonal conjugate measurement is wad off’ on the long section in wntimetcrs. Then the left !land clew-ates the upright arm within the \-aginx anti against the lnlhih bone ; witli

Fig. 2 sl~ows how this ixtrument is adapted to the measurements can then ?le taken TT-lrcnwcr the examining guish the lxomontorv of the sacrum.

Ijelric fkgers

These t.hree inlet. are able to distin-

always be t&elk with caution, so as not to These inside measuwments should injure the cervix nor disturb the proaenting part when it is in the pelvis. Saturxllp ir’ the presenting part is I.lelow the brim, jt is not nee2ssary to measure the true ,.,r diagonal conjugate. the anteropostwior tliameter of Continuing the iwe of these two :iieccs togetllei, the outlet can be olltninetl AS also the :lq)t.h of the l]ulCe bone. This is done 1,~ sacrun! posteriorly while the upright placing the curue6 tjp npon the end of the ai’m i,5 held jnst lxmm.th tile !)ui ii; arch, the:: the centimeter measure is read off This gives the anteroposterior 011 the shaft of the long ntcmber as yw face it. The .lopth ui? the pul~ic bone ean be accurately measured tiiailleter of the outlet. upon the small section, anteriorly.

MELLOR

To continue transverse piece

:

the outlet upon the

IKTERNAL

measurements, long section

AXD

OUTliET

remove as folloTvs:

507

PE,I,VIXETER,

the

small

member

and

put

the

The transverse section is held with the centimeter reading to the right, while the long section is threaded into the window of the encircling hand upon the crosspiece with the curve toward the patient and the shoulder end d-*---4 -L”,“II,IWIU. so that the sacrum is With the patient’s hips well orer the end of the table readily felt at its tip and free of pressure, you are nom ready to measure the transverse of the outlet and the posterior sagittal diameter. The instrument is held by placing the thumbs in the two oral rings, thumb nails facing each other and touching the measuring points on the instrument which are fitted to the tuberosities of the is&ii. This measurement is made upon the tuberosities edge and not taken from within.

Fig. Z.-Showing use of internal pelvinleter, taking the true conjugate and thickness Of pubic bone while in place. This demonstrates the cwve in the long section so as 10 reach more fully the promontory when presenting parts, uterus or cervix, are in idle way. Small ring under instrument is for traction to coml2lete accuracy in measuring both the true conjugate and thickness of pubic bone on smaller instrument.

By proper palpatiun with the thunlb tips going beyond and then returning, one eventually can most accurately secure this measurement, which becomes evident on the transrene bar as it is adapted to the perineum of the patient. Next, by placing the thumb and first finger of the ri@t hand into the cups on the transverse member and pressing firmly against the tissues to retain its position, the thumb and first finger of the left hamI adjusts the curTed section at its tip 1:o the end of the sacrum, posteriorly. The posterior sagit,tal reading becomes evident at the lower inner edge of the vindom where the sections cross. The instrument can then be removed, with readings unchanged, as the ratchets hold their adjustments (see Fig. 3). With this type of instrument, all measurement points are checked up with the finger tips and recordings are correspondingly accurate.

508

AMERIC2xN

JOUBSAL,

OF O%STE,TRICS

AND

GYNECOLOGY,

This instrument is of special value in funnel and generally contracted pelves in the accurate measurements of borderline cases, which naturally require the judgment in their method of delivery.

and best

Closer observation on these pelvic measurements and correct interpretation of their sign.ificxnce, when cansldering the best method of delivery to safeguard maternal and fetal life, cannot help but to improve our mortality and morbidity rate in the future. Inasmuch as the biparietal diameter of the fetal skull is of such significance in borderline cases of pelvic contraction, I have been making biparietal notations in reference to fetal weight. In a small series of 100 cases, 93 per cent of babies weighing 6 pounds or over had a biparietal diameter of 9 cm. or more, while 84 per cent of babies under 6 pounds had a diameter averaging 8.4 cm. Only 3 babies under 6 pounds had a biparietal measurement of 9 cm. Generally speaking, bi-

Fig. 3.-Outlet pelvimeter has been taped in place. Small internal section of instrument has been removed and transverse section threaded upon long section. Readings can be observed for both posterior sagittal and transverse outlet after instruments are removed as ratcheting keeps centimeter measure correct. Instrument made by Donald Thomas, 116 Windham Street, Syracuse, ?J. Y. parietal measurements of babies at birth, weighing from ‘7 pounds up, did not increase with their difference of weight and were therefore usually as diflieult to deliver at 7 pounds in contracted or borderline pelves as those weighing much more. Under 6 pounds, the biparietal diameter is usually markedly reduced from 1 to 1.5 cm., making delivery of these lighter weight children more suecessfu1 in moderately contracted pelves. Premature pelves and

infants do not stand prolonged labor very well in contracted a closer check upon the fetal heart is advisable in these cases.

The saying that small heads must be considered ease.

or funnel

babies have large heads and large babies relatively small the rule, unless you can prove otherwise in the individual

BARRETT Accuracy in pelvic deviates from normal for mother and child

:

GENCSEE

has proved very useful, it accurate when the anatomic

is small, easily points are first

STREET

RUPTURED

UTERUS : PERITONITIS, ANDRECOVERY

RALPH (From

509

UTERUS

mensuration becomes most important when the type of pelvis and the question of how to deliver to secure the best results frequently presents a very difficult problem.

In my hands, this new pelvimeter carried, easily read and surprisingly checked by the examining fingers. 608 EAST

RUPTUR,RD

L.

BARRETT,

the Obstetric

Service

M.D., Nxw of

the

OPERATION

YORK,

EXckerbooker

N. Y. Hospital)

T THE Woman’s Hospital, in the last thirteen years, there have been twelve cases of uterine rupture associated with pregnancy or labor. Eleven of these patients had prompt laparotomy with hysterectomy or repair. All these patients recovered. One patient was treated by tamponade together with transfusion. No 1aParOtOmy was done. This patient died forty-eight hours later of peritonitis and shock.

A

The case which I wish to present illustrates the difficulty in making a diagnosis of It also illustrates uterine rupture postpartum when the lesion is of minor degree. the dangers to which these women are subjected if the diagnosis and treatment are delayed. Mrs. M. spontaneous

Il., aged deliveries

thirty-one of normal

years, white, gravida babies at term.

iii.

She had

had

two

previous

She was admitted to the Knickerbocker Hospital Obstetrical Service Oct. 9, 1935, in the first stage of labor, at full term. Her antepartum period had been entirely normal. Her labor in the Hospital appeared to be uneventful for about eighteen hours, contractions occurring at threeto eight-minute intervals and of moderate severity. Examination on admission indicated a vertex presentation in right occipitoposterior position with the presenting part floating and gradually settling in and fixing in the brim. Sixteen hours after admission to the hospital and about twentytwo hours after onset of labor the membranes ruptured spontaneously. She was e,xamined by the interne at this time, who found the presenting part wedged in the brim in what he considered to be right occipitoposterior position with the cervix fully dilated. The patient continued to have strong uterine contractions for the next two hours but as there seemed to be no progress in the descent of the child, he called an attending obstetrician. I saw the patient shortly after this, probably from two to two and one-half hours after the rupture of the membranes and the attainment of full dilatation. It was evident that there was some obstruction to delivery. Contractions of the uterus were violent and prolonged. The fetal heart was irregular, carying from 100 to 169, with considerable passage of meconium. The patient’s pulse was then I12 and temperature 101’. Vaginal examination revealed a face presentation with the chin to f.he Ieft and posterior. This was wedged tightly into the brim of the pelvis, and there was no advance with the uterine contractions. While the baby was large, the patient had an entirely adequate bony pelvis and, due to previous childbirth i.njuries, there was no obstruction from the soft parts. It was apparent that de-