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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. 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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  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?!

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

  21. Could we predict CPD?

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

  23. CLM provides a systematic approach for individual care

  24. Anything not covered?

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