Dean Wallace, MD, PhD

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 "I'm       Jason Gardosi, the co-organizer of ISIS 5 in Stockholm, and I'm sitting       here with two of our invited speakers - Professor Arulkumaran, from Derby       and Nottingham University and Professor Mike Rogers, from Hong Kong. First       of all, I would like to ask them their impressions of the meeting so far,       and then to give us some idea about the work that they themselves are       involved in in the field of intrapartum surveillance. Aru, you have now       been here not only today, but also yesterday where you were a great help       with the participation of our first master class in CTG monitoring. That       of course, only represents your past experience which is tremendous in the       area of teaching of the interpretation of the CTG. Do you feel this is an       important aspect of a meeting like this?"
       
       

"Thank       you Jason. First of all, I think it's one of the highlights of the       meeting. I think the master class provided information, which the       participants really needed. I think it is time that we organize more       master classes like this. Based on the feedback of many of the       participants, they learned a lot and although we do similar classes in the       United Kingdom and in other places, this was an opportunity where you       could get the best teachers from around the world. I think that it was one       of the best sessions - appreciated by even the teachers."
       
       

 "Thank       you. I think we all appreciate it. Mike Rogers, if I may come to you -       your impressions about the first day?"
       
       

 "I       think it's been a very productive day, certainly the first sessions, which       I was involved in, were very argumentative. Everybody from the audience       gave us lots of participation. I think we had some very productive       discussions, and generally, I've been very pleased with it."
       
       

 "May I       ask that you, perhaps, elaborate on your special area of interest as far       as intrapartum monitoring is concerned? I know you have a whole range of       projects."
       
       

 "My       main interest is in interventional obstetrics; in order to assess the       value of intervention in obstetrics, I've felt for many years that we've       had inadequate outcome measures mainly because serious mobility and       mortality is very rare now a days. We've been left with measures such as       Apgar score and pH base excess, which I felt personally has been       inadequate as a means of assessing what we're doing as obstetricians. As       you know, we've been exploring other methods of assessing the baby, in       particular - lipid for oxidation. This is a footprint of oxygen radical       activity of possible fetal distress. We believe that we've come across a       mechanism which we can use, certainly in research - not necessarily in       practical obstetrics, but certainly in the research and intervention,       which is a much more precise and comparable."
       
       

 "Thank       you. Aru, you're busy in a whole number of different directions including       FIGO, where you're treasurer and have a lot of other international       commitments. Today you gave us an overview of the confidential inquiries       into stillbirths and deaths in infancy. Would you like to summarize what       are the take home messages, and what are the lessons that we can learn       from these reviews that have been going on in the U.K. over the last few       years?"
       
       

"Thank       you Jason. The issue, which I raised, was mainly to do with the messages       that came from the confidential inquiry - especially the fourth report,       which dealt with the intrapartum deaths. It was very clear from that, that       in about 70-80% of cases, the medical doctors and the midwives associated       with the cases could have acted differently in order to bring a different       outcome. We are talking about the mortality here, and when we talk about       numbers - it was about 873 cases. When we talk about mortality, there is       certainly some degree of mobility involved, which we didn't discuss today       but we discussed yesterday, and the medical difference union has paid out       260 million pounds last year in the U.K. So there's a considerable       importance that we had to pay for how we interpret fetal heart tracings,       how we are going to act, and how we can reduce this burden of mortality       and mobility. So the key message was that, although we are expected to       practice evidence based medicine, we don't have sufficient evidence to       reject continuous fetal heart rate monitoring, as certainly in the higher       situations and in the lower situations we have to adopt some selection       process so that we will reduce the mortality and mobility."
       
       

 "Thank       you very much gentlemen. You heard two perspectives, which in a way also       sum up the two issues that run in parallel in this meeting. On the one       hand, the examination of what we have today and what we're using as       technology and our methods and strategies to monitor the baby; also at the       same time, the new research to try to look at better outcome measures and       new technologies to take it further. This to me is what ISIS is about and       has been over the last ten years. I'm very pleased that we once again have       what is generally been regarded as a successful meeting. I hope that with       the continuation of these discussions, we will perhaps, make a difference       and improve monitoring of babies during labor."

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OBGYN.net Conference Coveragefrom: International Symposium on Intrapartum Surveillance (ISIS)5th Meeting - Stockholm, Sweden - June, 1999

Work in Intrapartum Surveillance

:      “We’re going to discuss vacuum assisted deliveries and some  of the problems and issues that we’ve seen here in the United States and  actually throughout the world.  I have with me Dr. Arulkumaran, and I’d  like to ask him a question about what in his opinion are some of the  problems and issues that faces us today on vacuum extraction?”

:      “Thank you, it’s a very important topic.  As you know, in the  United Kingdom about 12% are assisted vaginal deliveries and this could  be vacuum delivery or it could be forceps deliveries.  There have been a  number of concerns raised about fetal injuries and the failure of  vacuum deliveries; these are the two main concerns and I think it’s  mainly due to the problems with training.  The doctors who come for  training are not properly trained and they’re not given an explanation  as to how they should use the equipment.  So I would like to just  demonstrate first one or two issues, and perhaps, I’ll start with the  model of the baby’s head.  If you look at the baby’s deflexed head the  longitudinal diameter is long. If a vacuum cup is put straight onto the  baby’s head, then we will be pulling a larger diameter through the  pelvis.  The vacuum cup has to be on the flexion point which is just in  front of the posterior fontanel so the head comes down like an egg with  it’s shortest saggital diameter along the axis of the pelvis. In the  occipital posterior and, occipital transverse positions the head might  be slightly deflexed and the cup has to be applied further back and  laterally. The cups obviously have to be made in such a way that the cup  could reach the flexion point.  The cups that has a slim design and  where the tube to create the vacuum does not interfere to allow the cup  to be slipped through the vagina posteriorly and laterally to the  flexion point will give the best results with occipito posterior and  lateral positions of the head. With traction the head will flex and  rotate permitting the smallest diameters of the head to descend. 
     
     The reasons for failure are because the cups are applied directly to  whatever area of the head within the vaginal introitus. This could be a  deflexing paramedian application rather than a flexing median  application. The center of the cup has to go on the flexion point, which  is about 3 cm in front of the posterior fontanel. The sagital suture  should bisect the cup indicating it is a median application.  When the  head comes down, the pull should be directed posteriorly and downwards  for the head to follow the axis of the pelvis.  There’s a tendency to  pull upwards and anteriorly to keep the tube handle of the cup  perpendicular to the cup to prevent it from ‘popping off’. This may  bring the largest transverse diameter of the head behind the narrow arch  of the symphysis pubis preventing the head from coming down and the cup  ‘pops’ off.  To prevent the cup detaching whilst pulling at an angle  counter pressure should be applied on the opposite side of the cup. Too  much force and pulling the head when there is disproportion also allows  the cup to detach. In summary there are few reasons for the cups to  slip; application of the wrong design of the cup, incorrect application,  wrong direction of traction, too much traction and traction when there  is disproportion. The cups specially designed for vertex in the  occipito-posterior lateral position should be used for such positions.  Any cup could be used for an occipito-anterior position with the flexed  head.”

:      “Dr. Arulkumaran, what kind of problems do we see if the cup is applied wrong or improperly?”

:      “If it is a deflexing paramedian application, then a larger  diameter is pulled down.  As a result, the cup tends to either pop off  or there is a greater force between the scalp aponeurosis and the bone  and there is a possibility of a cephalhaematoma or rarely subgaleal  hemorrhage. In a cephalhaematoma the blood that leaks is collected  within the suture margins of the piece of bone that forms the skull like  the parietal bone.  The minor injuries are abrasion around the cup,  which tends to disappear in 24-48 hours. The minor abrasions are not a  problem. The main concerns are cephalhematoma and subgaleal hemorrhage.   The most important thing is training. Training is about selection of  appropriate cases, cups, placement, and direction of traction and to  realise the limitations in each case.  I would emphasize training all  the time because that is the most crucial aspect in any operative  delivery.  Thank     you.”

OBGYN.net Conference CoverageFIGO 2000 INTERNATIONAL FEDERATION of GYNECOLOGY & OBSTETRICS: Washington DC, USA

Dean Wallace, MD, PhD

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Work in Intrapartum Surveillance

Operative Vacuum-Assisted Vaginal Delivery