PeriGen presents a whole new way to assess labor with a labor curve shown by research published in the American Journal of Obstetrics & Gynecology to be five times more precise. The full presentation, video, and article access are available at http://perigen.com/rethinking-the-labor-curve/
2. Featuring Emily Hamilton, MDCM
Senior Vice President of Clinical Research
An experienced obstetrician, Dr.
Hamilton is currently an Adjunct
Professor of Obstetrics and Gynecology
at McGill University, as well as leading
PeriGen’s clinical research team.
Dr. Hamilton is the inventor of the
PeriCALM advanced fetal monitoring
system, holding 30 US and international
patents for her research work. She is an
internationally-known clinical thought
leader on the use of technology to
improve obstetric outcomes. She
presents her research regularly at
obstetric conferences and in peer-
reviewed journals.
5. An Obstetrical Landmark
Original Friedman Graphs 1965, 1978
Friedman EA, Sachtleben MR. Station of the
fetal presenting part. II. Effect on the course of
labor. Am J Obstet Gynecol. 1965 Oct 15;93(4):
530-6
Friedman E: Labor: Clinical Evaluation and
Management, 2nd ed. New York, Appleton-
Century-Crofts, 1978) page 41
5
6. Angular Sigmoid Shape
Regions constant dilation rates
Narrow range of variation
Phases defined
Disorders defined
Arrest disorder
Protraction disorders
6
16. Highly Reliable Time Based Curves
! Direct and Fixed Relationship to time
Distance travelled by
a dropped ball
Gravity
16
17. ! Well-defined relationship to time
! Narrow range of variation
Fetal growth curves
Useful Time-Based Curves
17
18. Minimally Useful Time-Based Curves
! Indirect
relationship to
time (other things
cause the effect)
! Wide range of
variation
Global Fertility Rates 18
20. Mathematical Models are Equations
Describe Natural Behavior
Distance = ½ a * time 2
a = Uniform Acceleration Constant
20
21. Physiology: Many factors, often in constant flux
Multifactorial adaptive ± range
1. natural biological variation
2. measurement inaccuracy
3. unmeasured factors
21
22. ! Dilation has an indirect relationship to time
! Dilation is a direct response to contractions
! Other factors can modify the response
Parity, effacement, epidural, rotation…
! All change over time
Determinants of Dilation
22
23. Model Dilation as a Function of Contractions
Dilt = χ + γContractions+ αdil t-1 + βeffacement t-1 - δstation t-1 + øepidural ± range
+0 cm 10 cm
23
24. Normal Nulliparous Labor
GA 40.1
PVB 0
Delivery
Type NVD
BWT
3635
Apgar
1
min 5
Apgar
5
min 9
UA
pH 7.16
UA
Base
Excess -‐7.2
Second
Stage
(hours) 0
Second
Stage
(minutes) 19
EBL 250
CPR
Intubation
in
Delivery
Room
Indication
24
27. Nulliparous
CS Arrest of dilation, CPR, Intubation, EBL 1000
GA 41.3
PVB 0
Delivery
Type CS
BWT
3458
Apgar
1
min 3
Apgar
5
min 8
UA
pH 7.24
UA
Base
Excess -‐0.7
Second
Stage
(hours)
Second
Stage
(minutes)
EBL 1000
CPR yes
Intubation
in
Delivery
Room yes
Indication
Arrest
of
Dil
27
31. Figure 1 PSA biomarkers for the
diagnosis of prostate cancer
Ploussard, G. & de la Taille, A. (2010) Urine biomarkers in prostate cancer
Nat. Rev. Urol. doi:10.1038/nrurol.2009.261
Urine PCA 3
AUC 0.787
Total PSA
AUC 0.564
%inCancerpts
% in normals
32.
Intervention
Outcomes
Clinical Outcomes
First Stage CD for
Labor Progress
Disorder
CD for
Fetal Heart
Rate
Concern
Obstetrical
Hemorrhag
e
Neonatal
Depression
32
33.
Intervention
Outcomes
Clinical Outcomes
First Stage CD for
Labor Progress
Disorder
CD for
Fetal Heart
Rate
Concern
Obstetrical
Hemorrhag
e
Neonatal
Depression
Duration of arrest
at dilation ≥6 cm
Dilation percentile
Station percentile
33
34.
Intervention
Outcomes
Clinical Outcomes
First Stage CD for
Labor Progress
Disorder
CD for
Fetal Heart
Rate
Concern
Obstetrical
Hemorrhag
e
Neonatal
Depression
Duration of arrest
at dilation ≥6 cm
0.65*
0.55*
0.52
0.52
Dilation percentile
Station percentile
34*P<0.01
35.
Intervention
Outcomes
Clinical Outcomes
First Stage CD for
Labor Progress
Disorder
CD for
Fetal Heart
Rate
Concern
Obstetrical
Hemorrhag
e
Neonatal
Depression
Duration of arrest
at dilation ≥6 cm
0.65*
0.55*
0.52
0.52
Dilation percentile
0.93*
0.81*
0.60*
0.61*
Station percentile
35*P<0.01 Bold P<0.01 for comparison to duration of arrest
36.
Intervention
Outcomes
Clinical Outcomes
First Stage CD for
Labor Progress
Disorder
CD for
Fetal Heart
Rate
Concern
Obstetrical
Hemorrhag
e
Neonatal
Depression
Duration of arrest
at dilation ≥6 cm
0.65*
0.55*
0.52
0.52
Dilation percentile
0.93*
0.81*
0.60*
0.61*
Station percentile
0.82*
0.78*
0.61*
0.58*
*P<0.01 Bold P<0.01 for comparison to duration of arrest36
37. ROC Nullipara with First Stage CS for Labor Disorder
37
Sensi'vity
False
posi've
Likelihood
Ra'o
>
4
hrs.
12.2
0.6
20.4
38. ROC Nullipara with First Stage CS for Labor Disorder
38
Sensi'vity
False
posi've
Likelihood
Ra'o
<10th
percen2le
69.3
4.9
14.2
<
5th
percen'le
43.6
1.7
26.3
39. Labor Progress Assessment
Time Curves
Arrest Criteria
• Static “One size fits all”
• Applicable in late labor only
• Pass/fail criteria for labor disorders
• Weak association with labor related
interventions
Adaptive Models
• Adjusts for multiple factors, adaptive
• Applicable from 3 cm onward
• Finely graded assessment
• Strong association with labor related
interventions
39
40. Acknowledgments
Antonio Ciampi PhD Mathematics
Gabrielle Simoneau MSc Mathematics
Philip Warrick PhD Engineering
Bruno Bendavid BSc Comp Sci
Ebi Kimanani PhD Mathematics
Samuel Smith MD
Kathleen Collins RN
Thomas Garite MD
40
