Traditional mismanagement Traditional mismanagement of labour – of labour –

What can we do?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 Current assessment of DilatationDilatation

Inter-observer variability

- Up to 6 cm (Bergsjo 1982)

- Average 1-2 cm (Phelps 1995)

Stretching during examination?

Contraction effect?

Current assessment of labor Current assessment of labor progress - Positionprogress - 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 Current assessment of labor progress - Stationprogress - 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 Current assessment of labor progress - Stationprogress - 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 Attempts to overcome these limitationslimitations

• Cervicometry - Friedman, Zador,

Wladimirof etc.

• Data on contractions (Toko, pressure)

• Surrogate parameters (compliance,

distensibility etc.)

Results of the limitations of Results of the limitations of our fingersour 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

transmitter receiverdistance

Positioning systemPositioning system

ATR ATR

ITR

ATR

ITRdistance

The measurement systemThe measurement system

External transmitters

External anatomical marker

Fetal head marker

Cervical markers

CLM in operationCLM in operation

LC1

H3 RC2

ATRs

Connector box

ITRs

Safe

Accurate

Continuousmonitoring

Cervix Dilatation

Head Station

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 trialsResults 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 cervicometryBenefits 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

TOCO / IUP4:00 PM3:45 PM3:30 PM3:15 PM3:00 PM2:45 PM2:30 PM2:15 PM2:00 PM1:45 PM1:30 PM1:15 PM1:00 PM12:45 PM

FHR

200

150

100

50 1007550250

Pito

cin

20 c

l

4:00 PM3:45 PM3:30 PM3:15 PM3:00 PM2:45 PM2:30 PM2:15 PM2:00 PM1:45 PM1:30 PM1:15 PM1:00 PM12:45 PM12:30 PM

6

5

4

3

2

1

0

-1 6

5

4

3

2

1

0

-1

Pito

cin

20 c

l

4:00 PM3:45 PM3:30 PM3:15 PM3:00 PM2:45 PM2:30 PM2:15 PM2:00 PM1:45 PM1:30 PM1:15 PM1:00 PM12:45 PM

109876543210 5

43210-1-2-3-4-5

Typical CLM curves?!

contraction effect on dilatation

Contraction# with effect

% of contractions with effect

0-4 mm 60 8%

5-9 mm 319 42%

10-14 mm 253 33%

15-19 mm 90 12%

20-24 mm 31 4%

>24 mm 14 2%

When does the active phase start?

• Van Dessel – “Reaction point”

The cervix started to oscillate around 4-5 cm

• Cervicometry?

Could we predict CPD?

TOCO / IUP1:45 PM1:30 PM1:15 PM1:00 PM12:45 PM12:30 PM12:15 PM12:00 PM11:45 AM11:30 AM11:15 AM11:00 AM

FHR

200

150

100

50 1007550250

12:

20 i.

u.p;

Pito

cin

1:45 PM1:30 PM1:15 PM1:00 PM12:45 PM12:30 PM12:15 PM12:00 PM11:45 AM11:30 AM11:15 AM11:00 AM

6

5

4

3

2

1

0

-1 6

5

4

3

2

1

0

-1

12:

20 i.

u.p;

Pito

cin

1:45 PM1:30 PM1:15 PM1:00 PM12:45 PM12:30 PM12:15 PM12:00 PM11:45 AM11:30 AM11:15 AM11:00 AM

109876543210 5

43210-1-2-3-4-5

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?