Traditional mismanagement of labour – What can we do?
This presentation by Dr. Dan Farine, a leading expert in Maternal-Fetal Medicine at the University of Toronto, explores significant challenges in labor management, including the prevalence of fetal distress, misdiagnosis of labor progress, and the impact of traditional practices on cesarean section rates. The discussion emphasizes the need for better assessment methods using innovative technologies like cervicometry and continuous monitoring systems. By enhancing accuracy in labor evaluations, we can improve patient outcomes, reduce unnecessary interventions, and increase overall satisfaction in maternal care.
Traditional mismanagement of labour – What can we do?
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Presentation Transcript
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
When does the active phase start? • Van Dessel – “Reaction point” The cervix started to oscillate around 4-5 cm • Cervicometry?
The future? • Early detection of labor abnormalities • Oxytocin administration based on “mini-partogram” • Improved outcome (CS, infections, satisfaction) • Costs (shorter labor, medico-legal)
