Idaho Perinatal Project - idahoperinatal.org

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Childbirth Simulator Reservation Form

Childbirth Simulator Reservation Form
The Childbirth Simulator will be scheduled on a first come, first served basis as reservation requests forms are received. A confirmation email will be sent to confirm the date and verify delivery. Please make arrangements to pick it up whenever possible.

The Childbirth Simulator can be used to demonstrate cephalic or breech presentation, cesarean section, episiotomy, vertex presentation, and prolapse of the umbilical cord. The full-scale female torso, made of supple, lifelike vinyl, has all the major anatomical landmarks with a handpainted outline of the bony pelvis. It includes a male and female fetuses, six umbilical cords, removable diaphragm cover for manual positioning of the fetus, and three ultra-soft vulva inserts for episiotomy procedures. Also included is a labor and delivery module set which features six labor stations selected to represent conditions of the cervix and vagina prior to labor, during labor, and at birth in a primigravid woman.

The childbirth simulator is on loan for one month at a time. It is due in our office one month from the date you pick it up or we mail it to you. Please respect the needs of other members and return the materials on time. It must be returned in good condition, clean and ready to go out again.

Childbirth Simulator Reservation Form

First Name:	Last Name:
Title:
Facility:
Mailing Address:
Mailing Address2 :
City:	State: Zip:
E-mail address:
Phone Number:	( ) -
Fax Number:	( ) -

Date Needed:
Will Return:

Alternate Date:
Will Return:

Reserving Simulator From:	St. Luke's Wood River Medical Center St. Mary's Clinic in Cottonwood

	I will Pickup Materials
	On: (Date)

	Please Mail Materials
	Mail On: (Date)

Comments:

email: jacobssa@slrmc.org • location: 103 W. State Street, Boise, Idaho 83702 • phone:(208) 381-4174