Determination of pH or Lactate in Fetal Scalp Blood in Management of Intrapartum Fetal Distress: Randomized Controlled Multicenter Trial

Abstract

The mechanisms underlying cervical insufficiency, a cause of spontaneous second-trimester abortion and early preterm birth, remain poorly understood. There is, however, evidence that amniotic fluid (AF) infection is a key factor in pregnancy outcomes and postoperative complications. This study was an attempt to determine the frequency and clinical importance of intraamniotic inflammation in 52 patients with acute cervical insufficiency, defined as cervical dilation of 1.5 cm or more. The patients, seen at 17 to 29 weeks' gestation, had intact membranes, and were not having regular uterine connections. AF samples were cultured for aerobic and anaerobic bacteria and genital mycoplasmas, and assayed for matrix metalloproteinase-8; a level exceeding 23 ng/mL was deemed to represent the presence of intraamniotic inflammation.Intraamniotic inflammation was present in 42 of the 52 study patients (81%), and 4 patients (8%) had a positive AF culture. All culture-positive patients had intraamniotic inflammation. Among patients with intraamniotic inflammation but not AF infection, preterm delivery occurred within 7 days in 50%, and delivery before 34 weeks gestation, in 84%. More than half of newborn infants (55%) whose mothers had inflammation but not infection died within 24 hours of birth. The presence of intraamniotic inflammation was associated with a shorter interval between amniocentesis to delivery. The risk of an adverse pregnancy outcome did not differ between patients with intraamniotic inflammation and a negative culture on the one hand and, on the other, between those with confirmed AF infection. Fetal morbidity was not substantially altered by cesarean delivery.Whether the AF is culture-positive, a large majority of patients with acute cervical insufficiency have intraamniotic inflammation, and this is a risk factor for both preterm delivery and adverse pregnancy outcomes. ABSTRACTShoulder dystocia is an uncommon event that is largely unpredictable, and that may cause serious morbidity in both the mother and infant. Brachial plexus injury may be worsened by inappropriate treatment. This retrospective observational study compared the management and outcome of births complicated by shoulder dystocia before and after introducing 1 day of training that utilized a prototype shoulder dystocia training mannequin. Training included risk factors, recognition, documentation, helpful maneuvers, and a simulated shoulder dystocia scenario.A total of 15,908 pretraining births were compared with 13,117 taking place after the introduction of training. Rates of shoulder dystocia were similar: 2.04% in the pretraining group and 2.00% in the posttraining group. Before training, none of the several maneuvers recommended for the resolution of shoulder dystocia (including McRoberts' position, suprapubic pressure, internal rotation, delivery of the posterior arm, and the All-Fours-Maneuvers) were utilized in half or more of the affected infants. After training, in contrast, at least 1 of the recommended maneuvers was utilized in mor...

Clinical evaluation of Statstrip® Lactate for use in fetal scalp blood sampling

“…Concern has been raised that combined sampling (pH and lactate) might increase the rate of operative delivery for fetal distress, due to an increased rate of abnormal results compared with single tests. Liljestrom et al showed that combined sampling results in a 66% operative delivery rate vs. 95% if single testing is used (pH or lactate) . One may argue that the use of a test with a 20% failure rate is not justified.…”

“…For the purpose of this study only data from the umbilical artery were used in the analysis, assuming it to reflect fetal condition best. Severe metabolic acidosis at birth was defined as pH <7.05 and BD >12.0 mmol/L in umbilical artery blood .…”

“…Persistent hypoxia/ischemia leads to lactate accumulation and metabolic acidosis, which is the most important indicator of subsequent neonatal morbidity . Several studies, including randomized controlled trials, have shown that scalp blood lactate has similar or better predictive properties in identifying short‐term neonatal morbidity compared with fetal pH, without affecting the rate of metabolic acidosis at birth or operative deliveries for suspected fetal distress .…”