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

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

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

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

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

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

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 station1

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

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

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

Technology: Ultrasound

distance

receiver

transmitter


Positioning system

Positioning system

ATR

ATR

ATR

distance

ITR

ITR


The measurement system

The measurement system

External transmitters

External anatomical marker

Fetal head marker

Cervical markers


Clm in operation

H3

R

C2

ATRs

L

C1

ITRs

CLM in operation

Connector box

Cervix Dilatation

Head Station

Accurate

Continuous

monitoring

Safe


System advantages

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

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

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


    A single patient partogram1

    A single patient partogram


    Typical clm curves

    Typical CLM curves?!


    When does the active phase start

    When does the active phase start?

    • Van Dessel – “Reaction point”

      The cervix started to oscillate around 4-5 cm

    • Cervicometry?


    Could we predict cpd

    Could we predict CPD?


    The future

    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

    CLM provides a systematic approach for individual care


    Anything not covered

    Anything not covered?


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