And now And now alleviation of cause diagnostic

And now?

And now? • alleviation of cause • diagnostic intervention Ø Pulse oximetry Ø Scalp blood Ø ST analysis • immediate delivery

Before labor

Before term

Second twin

Term, in labor

Fetal intensive care unit

l l l surrogate standard historical only in teaching hospitals

T. Murphy Goodwin et al. 1994

l l reliability problem Garite 2000, Kuhnert 2004, Klauser 2005, East 2006, Bloom 2006 unfavorable (limited support) Cochrane review 2007 operative delivery rate unchanged

l l l l Westgate 1993 Amer-Wahlin 2001 Ojala 2006 favorable (some support) Cochrane review (2006) FDA approval Vayssière 2007 Large Dutch trial

Problems with STAN* The management guidelines are primarily based on the interpretation of the FHR pattern and will therefore not be of assistance if CTG interpretation is poor. False-negative cases are a reality. STAN events are common even in women with normal CTG patterns. *Ingemarsson & Westgren, 2007

Sensitivity for low cord p. H Sensitiviteit (%) Specificiteit (%) Conventional CTG Goeschen, 1984 Sykes, 1986 Steer, 1989 Hoffmann, 1990 Westgate, 1993 Van den Berg, 1996 Kianmanesh Rad, 1998 Strachan, 2000 72 23 67 24 46 82 57 31 81 85 86 90 96 76 81 85 CTG + Sp. O 2 Kühnert, 1996 Van den Berg, 1996 Carbonne, 1997 Luttkus, 2003 81 50 40 60 100 86 94 67 CTG + FECG Westgate, 1993 Strachan, 2000 Noren, 2007 Dervaitis, 2004 25 22 24 43 98 88 96 74 CTG + scalp p. H Luttkus, 2003 Noren, 2007 85 24 67 96

Sequentieel screenen! De vereiste dat, nadat een eerste test (CTG) afwijkend is gebleken, ook nog een tweede test (Sp. O 2 of STAN) afwijkend moet zijn alvorens te interveniëren, leidt er noodzakelijkerwijze toe dat de sensitiviteit (voor foetale nood) van de overall strategie afneemt

toekomst Analyse • • • van: ST STV PR