Evaluating the value of intrapartum fetal scalp blood sampling to predict adverse neonatal outcomes: A UK multicentre observational study

Wattar, Bassel H. Al; Lakhiani, Aarti; Sacco, Adalina; Siddharth, Aditi; Bain, A. D.; Calvia, Alexandra; Kamran, Atiyah; Tiong, Bing; Warwick, Bethan; MacMahon, Caroline; Marcus, Diana; Long, Emma; Coyle, Gillian; Lever, Gillian; Michel, Gina; Gopal, Gomathy; Baig, Hana; Price, Hannah Louise; H, Badri; Stevenson, Helen; Hoyte, Helene; Malik, Humaira Saeed; Edwards, Jade; Hartley, J.; Hemers, Jennifer; Tamblyn, Jennifer; Dalton, John A W; Frost, Jonathan; Subba, Kamana; Baxter, K.K.; Sivakumar, Kothandam; Murphy, Kelly J.; Papadakis, Konstantinos A.; Bladon, Laura Rachel; Kasaven, Lorraine S; Manning, Louisa; Prior, Mathew; Ghosh, Mausumi; Couch, Melanie; Altunel, Melis; Pearce, Melissa B.; Cocker, Michael; Stephanou, Michael; Jie, Michelle; Mistry, Manesh V.; Wahby, Mohammed Osama; Saidi, Nabila Shahid; Ramshaw, Nicola Louise; Tempest, Nicola; Parker, N.; Tan, Phoebe L; Johnson, Racheal; Harris, Rachel; Tildesley, Rachel; Ram, Ramya; Painuly, Ritu; Cuffolo, Romana; Bugeja, Roberta; Ngadze, R.; Grainger, Rosie; Gurung, Sabitra; Mak, Sammy; Farrell, Sara; Cowey, Sarah; Neary, Sarah; Quinn, Sarah; Nijjar, Simrit Kaur; Kenyon, Sophie; Lamb, Stephanie; Tracey, Susan; Lee, Tara; Kinsella, T; Davidson, Trecia; Corr, Trent; Sampson, Uzo; McQueen, Victoria; Smith, Warren J.; Castling, Zora

doi:10.1016/j.ejogrb.2019.06.012

Cited by 18 publications

(8 citation statements)

References 14 publications

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“…Not only the physiological and scientific basis of FBS has been recently questioned [28,29], the recent Cochrane Systematic Review has suggested that the use of fetal scalp blood sampling does not improve perinatal outcomes [30]. A recent prospective multicenter trial from 44 maternity units in the UK has also reported that FBS did not improve perinatal outcomes and increased intrapartum operative interventions by 60% [31]. The "Achilles Heel" of the STAN technology is the misinterpretation of the CTG trace due to inter and intra-observer variability as a result of using guidelines which are based on "pattern recognition" on all human fetuses with different individual physiological reserves.…”

Section: Are Our Results Reproducible?mentioning

confidence: 99%

The Impact of Physiological Interpretation of Cardiotocogram (CTG) in Conjunction with Fetal ECG (STAN) on Intrapartum Emergency Caesarean Sections

Chandraharan

2021

GJORM

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Background:The false-positive rate of the "pathological" CTG has been reported as >60%, which resulted in an exponential increase in emergency intrapartum caesarean sections for "fetal distress". Fetal ECG (ST-Analyser or STAN) was introduced into clinical practice to reduce the false positive rate of the CTG.Objective: To determine the impact of Physiological interpretation of Cardiotocogram (CTG) in Conjunction with Fetal ECG (STAN) on intrapartum emergency caesarean sections. Materials & Methods:A retrospective study at the Royal Gwent Hospital in South Wales following the introduction of STAN monitoring after training in Physiological Interpretation of CTG in 2014. Total Caesarean section rate, emergency caesarean section rate for fetal compromise (i.e., "fetal distress"), operative vaginal delivery rate and spontaneous vaginal delivery (SVD) rate were analyzed for the first 19 months after the intervention (October 2014-2016) and were compared with 2012 -September 2014).Result: There were 7977 deliveries during the 19-month period from 01 October 2014 to 30 April 2016. The average total Caesarean section rate was 23.5% and the emergency Caesarean section rate for suspected fetal compromise ("fetal distress") was 13.6%, an observed increase in the rate of spontaneous vaginal births from 63% to 71%. There was a statistically significant reduction in the intrapartum emergency caesarean sections performed for "fetal distress" immediately after the introduction of STAN following training on Physiological Interpretation of CTG from 5.57% to 2.1%. The rate of hypoxic ischaemic encephalopathy (HIE) due to CTG misinterpretation was reduced by 50% following the training on Physiological Interpretation of CTG. Conclusion:Training on physiological interpretation of the CTG before the introduction of STAN, and its use in conjunction with STAN resulted in a statistically significant reduction of intrapartum emergency caesarean section for "fetal distress", and a 50%reduction in the HIE rate due to CTG misinterpretation.

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Section: Are Our Results Reproducible?mentioning

confidence: 99%

The Impact of Physiological Interpretation of Cardiotocogram (CTG) in Conjunction with Fetal ECG (STAN) on Intrapartum Emergency Caesarean Sections

Chandraharan

2021

GJORM

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“…Recently, a large observational study of FBS from 44 maternity units in the UK was published [25]. The conclusion of the study results was that FBS as an adjunct tool to cardiotocography, offered limited value to predict neonatal acidaemia, low Apgar Scores, and admission to NICU.…”

Section: Discussionmentioning

confidence: 99%

Fetal scalp blood sampling during second stage of labor – analyzing lactate or pH? A secondary analysis of a randomized controlled trial

Stål

Wennerholm

Nordström

et al. 2020

The Journal of Maternal-Fetal & Neonatal Medicine

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Background: Cardiotocography (CTG) is a widely used method for assessing fetal wellbeing during labor. It is well-known that CTG has high sensitivity but low specificity. To avoid unnecessary operative interventions, adjunctive methods such as fetal blood sampling (FBS) are used. Few studies have looked into whether FBS can be used during second stage of labor, and in that case, which of the methods (lactate or pH) are preferred. Objective: To evaluate clinical effectiveness of measuring lactate versus pH in preventing birth acidemia when FBS was performed during second stage of labor. Methods: Secondary analysis of a randomized controlled trial. Thousand three hundred and thirty-eight women with a singleton pregnancy, cephalic presentation, gestational age 34 weeks, and indication for FBS during second stage of labor were included. Main outcome measures: Metabolic acidemia (pH <7.05 and base deficit >12 mmol/l) or pH < 7.00 in cord arterial blood at birth. Secondary outcomes: A composite outcome (metabolic acidemia, pH <7 or Apgar score <4), and rates of operative deliveries. Results: Metabolic acidemia occurred in 4.1% in the lactate versus 5.1% in the pH group (relative risk (RR): 0.80; 95% confidence interval (CI): 0.48-1.35) and pH <7 in 1.4% versus 2.8% (RR: 0.51, 95% CI: 0.23-1.13). Composite outcome was found in 3.8 versus 4.9%, respectively (RR: 0.76; 95% CI: 0.46-1.26). No difference in total operative interventions was found. More cesarean deliveries were performed in the lactate group (16.5 vs. 12.4%; RR: 1.33; 95% CI: 1.02-1.74). Conclusion: When analyzing lactate or pH in fetal scalp blood during second stage of labor neonatal outcomes were comparable. The frequency of total operative interventions was similar but more cesarean deliveries were performed in the lactate group.

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“…This was evident almost immediately by complete cessation of the fetal scalp blood sampling (FBS) for "pathological" CTG traces by obstetricians of all grades, from approximately 12-15% earlier (i.e., 500-700 per year). Cochrane Systematic Reviews had repeatedly concluded that the use of fetal blood sampling (FBS) during labor (both fetal scalp lactate and pH) did not appear to influence any long-term neonatal outcomes or reduce intrapartum interventions [18,19], and scientific studies have shown that the use of FBS may in fact significantly increase the rate of emergency caesarean sections [20,21], and its anatomical, physiological, and scientific basis has been repetitively questioned recently [22][23][24][25]. Moreover, FBS has been found to be of limited value in the presence of meconium (i.e., bile acids would change the pH) [26], and contamination with the amniotic fluid (alkaline pH of the amniotic fluid would neutralize the acidic pH of the scalp sample leading to a false reassurance) resulting in poor perinatal outcomes [23][24][25]27].…”

Section: What Is the Impact Of Implementing Physiological Interpretation Of Ctg?mentioning

confidence: 99%

Introduction of the Physiological CTG Interpretation & Hypoxia in Labour (HIL) Tool, and its Incorporation into a Software Programme: Impact on Perinatal Outcomes

Chandraharan

2021

GJORM

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Each Baby Counts Reports in the UK from 2016-2021 have consistently highlighted that 33% of intrapartum related perinatal deaths and severe hypoxic ischaemic injuries in the UK were due to CTG misinterpretation. Moreover, in approximately 72% of cases, a different care may have given rise to different outcomes. International consensus guidelines on Physiological Interpretation of the CTG produced by 34 CTG experts from 14 countries was aimed at individualisation of care by considering the compensatory response of the individual human fetus to ongoing hypoxic and mechanical stresses during labour and determining the type of ongoing fetal hypoxia. This tool was introduced in a large maternity unit, and it also was incorporated into the Maternity software programme after midwives and obstetricians providing intrapartum care were trained on fetal physiology by conducting Physiological CTG Masterclasses. There was a total elimination of fetal scalp blood sampling (FBS), and a dramatic reduction in the number of babies with severe hypoxic ischaemic encephalopathy.

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Evaluating the value of intrapartum fetal scalp blood sampling to predict adverse neonatal outcomes: A UK multicentre observational study

Abstract: Please refer to published version for the most recent bibliographic citation information. If a published version is known of, the repository item page linked to above, will contain details on accessing it.

Cited by 18 publications

References 14 publications

The Impact of Physiological Interpretation of Cardiotocogram (CTG) in Conjunction with Fetal ECG (STAN) on Intrapartum Emergency Caesarean Sections

The Impact of Physiological Interpretation of Cardiotocogram (CTG) in Conjunction with Fetal ECG (STAN) on Intrapartum Emergency Caesarean Sections

Fetal scalp blood sampling during second stage of labor – analyzing lactate or pH? A secondary analysis of a randomized controlled trial

Introduction of the Physiological CTG Interpretation & Hypoxia in Labour (HIL) Tool, and its Incorporation into a Software Programme: Impact on Perinatal Outcomes

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