Traditional mismanagement of labour what can we do
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Traditional mismanagement of labour – What can we do?. Dan Farine MD Professor of Ob/Gyn & Medicine Head of Maternal Fetal Medicine University of Toronto. The issues in L&D. Fetal distress - <2% of labours Non progressive labour and Oxytocin use – 40-50%

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Traditional mismanagement of labour – What can we do?

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Traditional mismanagement of labour – What can we do?

Dan Farine MD

Professor of Ob/Gyn & Medicine

Head of Maternal Fetal Medicine

University of Toronto


The issues in L&D

  • Fetal distress - <2% of labours

  • Non progressive labour and Oxytocin use – 40-50%

  • Increased CS rate –mainly for failure to progress


Labor monitors

  • Fetal distress (<2%)

    • Fetal heart rate (mid 20th century)

    • Scalp pH (mid 20th century)

    • Fetal ECG -STAN (late 20th century)

    • Pulse Oximetry (late 20th century)

  • Labour progress (30-50%)

    • Fingers (17th century)


Current assessment of Dilatation

Inter-observer variability

- Up to 6 cm (Bergsjo1982)

- Average 1-2 cm (Phelps 1995)

Stretching during examination?

Contraction effect?


Current assessment of labor progress - Position

Misdiagnosed position in 61% (defined as + 45 degrees)Sherer et al. 2001

Misdiagnosed 46% of occipito posterior/ transverse – Prior to forceps.

Potential misapplication in 25%

Akmal & Nicolaides 2003


Current assessment of labor progress - Station

  • Definition of station checked with 243 care givers in 4 Denver Units

  • Four different definitions were provided

  • Care givers were not aware of other care givers different definition

    Carollo et al. 2004


Current assessment of labor progress - Station

  • Simulator used to assess station

  • Wrong station:

    Residents 50-88% Staff: 36-80%

  • Wrong level (high, mid…) – 30% vs. 34%

    Dupuis et al. 2004


Attempts to overcome these limitations

  • Cervicometry - Friedman, Zador, Wladimirof etc.

  • Data on contractions (Toko, pressure)

  • Surrogate parameters (compliance, distensibility etc.)


Results of the limitations of our fingers

  • PTL - diagnosed (too) late

  • Latent phase - retrospective diagnosis

  • Active phase – Start? End?

    • examinations q 1-4 hours (20-120 contractions)

    • Dystocia is not suspected/diagnosed for this interval


Technology: Ultrasound

distance

receiver

transmitter


Positioning system

ATR

ATR

ATR

distance

ITR

ITR


The measurement system

External transmitters

External anatomical marker

Fetal head marker

Cervical markers


H3

R

C2

ATRs

L

C1

ITRs

CLM in operation

Connector box

Cervix Dilatation

Head Station

Accurate

Continuous

monitoring

Safe


System advantages

  • Add-on system

    • (as opposed to stand alone)

  • Compatible with GE and Phillips

  • Data display and collections at all levels

    • Monitor, central system, internet


Results of clinical trials

  • Safety – >600 attachments

    • 1 laceration, 1 single stitch

  • Accuracy – 1-3 mm

  • Displacement – Rare (mainly exams)

  • Satisfaction – Good (both patients and MDs)


Benefits of cervicometry

  • Accurate data

    • eliminates inter and intra-observer variability

  • Real time data -

    • Eliminates delays in diagnosis & therapy

    • Detection of precipitous labors

  • Documentation

  • Reduces number of vaginal examinations

    • Patient satisfaction/control

    • infections

    • Emergency effect


  • A single patient partogram


    A single patient partogram


    Typical CLM curves?!


    When does the active phase start?

    • Van Dessel – “Reaction point”

      The cervix started to oscillate around 4-5 cm

    • Cervicometry?


    Could we predict CPD?


    The future?

    • Early detection of labor abnormalities

    • Oxytocin administration based on “mini-partogram”

    • Improved outcome (CS, infections, satisfaction)

    • Costs (shorter labor, medico-legal)


    CLM provides a systematic approach for individual care


    Anything not covered?


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