Traditional mismanagement of labour – What can we do?

1. Traditional mismanagement of labour – What can we do? Dan Farine MD Professor of Ob/Gyn & Medicine Head of Maternal Fetal Medicine University of Toronto

2. 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

3. 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)

4. Current assessment of Dilatation Inter-observer variability - Up to 6 cm (Bergsjo1982) - Average 1-2 cm (Phelps 1995) Stretching during examination? Contraction effect?

5. 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

6. 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

7. 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

8. Attempts to overcome these limitations • Cervicometry - Friedman, Zador, Wladimirof etc. • Data on contractions (Toko, pressure) • Surrogate parameters (compliance, distensibility etc.)

9. 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

10. Technology: Ultrasound distance receiver transmitter

11. Positioning system ATR ATR ATR distance ITR ITR

12. The measurement system External transmitters External anatomical marker Fetal head marker Cervical markers

13. H3 R C2 ATRs L C1 ITRs CLM in operation Connector box Cervix Dilatation Head Station Accurate Continuous monitoring Safe

14. 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

15. 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)

16. 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

17. A single patient partogram

18. A single patient partogram

19. Typical CLM curves?!

21. When does the active phase start? • Van Dessel – “Reaction point” The cervix started to oscillate around 4-5 cm • Cervicometry?

22. Could we predict CPD?

24. The future? • Early detection of labor abnormalities • Oxytocin administration based on “mini-partogram” • Improved outcome (CS, infections, satisfaction) • Costs (shorter labor, medico-legal)

25. CLM provides a systematic approach for individual care

26. Anything not covered?