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 20 th century) –Scalp pH (mid 20 th century) –Fetal ECG -STAN (late 20 th century) –Pulse Oximetry (late 20 th century) Labour progress (30-50%) –Fingers (17 th century)

Current assessment of Dilatation Inter-observer variability - Up to 6 cm ( Bergsjo 1982) - 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 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 ( contractions) –Dystocia is not suspected/diagnosed for this interval

Technology: Ultrasound transmitter receiver distance

Positioning system ATR ITR ATR ITR distance

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

CLM in operation ATRs Connector box ITRs Safe Accurate Continuous monitoring 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 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

A single patient partogram

Typical CLM curves?!

contraction effect on dilatation Contraction# with effect % of contractions with effect 0-4 mm608% 5-9 mm31942% mm25333% mm9012% mm314% >24 mm142%

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

Could we predict CPD?

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?