Search

Introduction: A revised intrapartum cardiotocography (CTG) classification was introduced in Sweden in 2017. The aims of the revision were to adapt to the international guideline published in 2015 and to adjust the classification of CTG patterns to current evidence regarding intrapartum fetal physiology. This study aimed to investigate adverse neonatal outcomes before and after implementation of the revised CTG classification. Material and Methods: A before-and-after design was used. Cohort I (n = 160 210) included births from June 1, 2014 through May 31, 2016 using the former CTG classification, and cohort II (n = 166 558) included births from June 1, 2018 through May 31, 2020 with the revised classification. Data were collected from the Swedish Pregnancy and Neonatal Registers. The primary outcome was moderate to severe neonatal hypoxic ischemic encephalopathy (HIE 2-3). Secondary outcomes were birth acidemia (umbilical artery pH

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.To evaluate clinical effectiveness of measuring lactate versus pH in preventing birth acidemia when FBS was performed during second stage of labor.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.Metabolic acidemia (pH7.05 and base deficit12 mmol/l) or pH7.00 in cord arterial blood at birth.A composite outcome (metabolic acidemia, pH7 or Apgar score4), and rates of operative deliveries.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 pH7 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).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.

The aim of this systematic review with meta-analysis was to evaluate the effect on length of labor when patients receive IVF with or without dextrose. Searches were performed in electronic databases from inception of each database to May 2018. Trials comparing intrapartum IVF containing dextrose (i.e. intervention group) with no dextrose or placebo (i.e. control group) were included. Only trials examining low-risk pregnancies in labor at ≥36 weeks were included. Studies were included regardless of oral intake restriction. The primary outcome was the length of total labor from randomization to delivery. The meta-analysis was performed using the random effects model. Sixteen trials (n = 2503 participants) were included in the meta-analysis. Women randomized in the IVF dextrose group did not have a statistically significant different length of total labor from randomization to delivery compared to IVF without dextrose (MD −38.33 min, 95% CI −88.23 to 11.57). IVF with dextrose decreased the length of the first stage (MD −75.81 min, 95% CI −120.67 to −30.95), but there was no change in the second stage. In summary, use of IVF with dextrose during labor in low-risk women at term does not affect total length of labor, but it does shorten the first stage of labor.

Birth acidemia is associated with short- and long-term morbidity in the child. Optimal intrapartum surveillance and timely interventions may reduce the incidence of these outcomes. Knowledge about conditions which increase the risks might be beneficial for optimal care. The aim with this study was to identify factors which increased the risk for lactacidemia in fetal scalp blood.A secondary analysis of a cohort study performed at Karolinska University Hospital Stockholm Sweden between February 2009 and February 2011. The study population included 1070 women in labor where fetal scalp blood sampling (FBS) was performed.In a univariate logistic regression analysis for lactate4.8 mmol/L at FBS, minor language barriers (OR 2.54; 95%CI 1.26-5.11), active bearing down (OR 2.46; 95%CI 1.12-5.39) and maternal height155 cm (OR 2.15; 95%CI 1.08-4.26) were found as risk factors. In a multivariate logistic regression analysis, minor language barriers (OR 2.21; 95%CI 1.05-4.67) and active pushing (OR 2.68; 95%CI 1.20-6.00) remained significant.Language barriers, active pushing and short stature were found to be significant risk factors for intrapartum lactacidemia. In the group with minor language problems better use of interpreters might be beneficial.

Introduction The aim of this study was to investigate the correlation between increasing time since fetal heart rate (FHR) accelerations, positive (no acceleration) stimulation tests and fetal acidemia. Materials and methods Observational study of FHR recordings from 1070 laboring women with indication for fetal scalp blood sampling (FBS). FHR traces were scrutinized regarding acceleration at FBS and duration since most recent acceleration. The appraiser was blinded to the FBS result. Results At the first sampling, 8.8% of fetuses had lactate concentration >4.8 mmol/L. There were no differences between those with recent accelerations (≤60 min), and absent accelerations (>60 min or never) prior to FBS (8.3% vs. 8.9%, p = 0.71). Corresponding analyses for subgroups were: fetuses with isolated absence of accelerations, 3.7% vs. 1.5% (p = 0.41), fetuses without decelerations (i.e. reduced variability and/or tachycardia), 6.1% vs. 5.1% (p = 0.81) and fetuses with serious decelerations (i.e. late or complicated variable), 15.0% vs. 16.1% (p = 0.87). Among fetuses with serious decelerations, increasing duration from most recent acceleration had a weak but statistically significant correlation to increased lactate concentration (rs = 0.12, p = 0.03). The positive likelihood ratio for acidemia with no response at FBS was 1.15. Conclusion In a population with FBS performed upon indication, there was no correlation between duration since last FHR acceleration and increased lactate concentration. The majority of fetuses are not acidemic even when the FHR trace is pathological and stimulation tests are only helpful when accelerations are provoked.

INTRODUCTION Fetal heart rate short term variation (STV) decreases with severe chronic hypoxia in the antenatal period. However, only limited research has been done on STV during labor. We have tested a novel algorithm for a valid baseline estimation and calculated STV. To explore the value of STV during labor, we compared STV with fetal scalp blood (FBS) lactate concentration, an early marker in the hypoxic process. MATERIAL AND METHODS Software was developed which estimates baseline frequency using a novel algorithm and thereby calculates STV according to Dawes and Redman in up to four 30-minute blocks prior to each FBS. Cardiotocography traces from 1070 women in labor who had had FBS performed on 2134 occasions were analyzed. RESULTS In acidemic cases (lactate >4.8 mmol/L; Lactate Pro™), median STV 30 minutes prior to FBS was 7.10 milliseconds compared with 6.09 milliseconds in the preacidemic (4.2-4.8 mmol/L) and 5.23 milliseconds in the normal (

Introduction Reliability in visual cardiotocography interpretation is unsatisfying, which has led to the development of computerized cardiotocography. Computerized analysis is well established for antenatal fetal surveillance but has yet not performed sufficiently during labor. We aimed to investigate the capacity of a new computerized algorithm compared with visual assessment in identifying intrapartum fetal heart rate baseline and decelerations. Material and methods In all, 312 intrapartum cardiotocography tracings with variable decelerations were analyzed by the computerized algorithm and visually examined by two observers, blinded to each other and the computer analysis. The width, depth and area of each deceleration was measured. Four cases (>100 variable decelerations) were subjected to in-depth detailed analysis. The outcome measures were bias in seconds (width), beats per minute (depth), and beats (area) between computer and observers using Bland-Altman analysis. Interobserver reliability was determined by calculating intraclass correlation and Spearman rank analysis. Results The analysis (312 cases) showed excellent intraclass correlation (0.89-0.95) and very strong Spearman correlation (0.82-0.91). The detailed analysis of >100 decelerations in four cases revealed low bias between the computer and the two observers; width 1.4 and 1.4 seconds, depth 5.1 and 0.7 beats per minute, and area 0.1 and -1.7 beats. This was comparable to the bias between the two observers: 0.3 seconds (width), 4.4 beats per minute (depth) and 1.7 beats (area). The intraclass correlation was excellent (0.90-.98). Conclusion A novel computerized algorithm for intrapartum cardiotocography analysis is as accurate as gold standard visual assessment, with high correlation and low bias.

Objective To correlate the value of lactate in fetal scalp blood at delivery and the outcomes of the offspring at four years of age. Methods: Cases where scalp blood lactate was taken within sixty minutes before delivery were identified from the randomized trial "Determination of pH or lactate in fetal scalp blood in management of intrapartum fetal distress”. Data were divided according to the generally accepted cutoffs for normality, pre-acidemia, acidemia and concentrations above mean +2 SD during the second stage. The outcome measures included gross-/fine motor function, vision, hearing, speaking and cognitive disorders, signs of central motor damage and referral to specialized pediatric services. Results: 307 cases were available for final analyse. With normal scalp lactate concentration, the number of children with a diagnosed disorder was lower compared to the pre-acidemic/acidemic groups, although the findings were only significant for fine motor dysfunction (p = 0.036). Elevated lactate values were significantly associated with increased risk for a poorer capacity of attention and understanding of instructions (OR 1.37, 95% CI 1.07-1.74), and for fine motor dysfunction (OR 1.22, 95% CI 1.00-1.49) at the age of four. Conclusion: Higher levels of lactate in fetal scalp blood are associated with increased risk of an aberrant developmental outcome at four years of age in some areas. If scalp lactate is normal, it seems safe to allow labor to continue.

Lactate Pro™ (LP1) is the only lactate meter evaluated for fetal scalp blood sampling (FBS) in intrapartum use. The reference values for this meter are: normal value4.2 mmol/L, preacidemia 4.2-4.8 mmol/L, and acidemia4.8 mmol/L. The production of this meter has been discontinued. An updated version, Lactate Pro 2TM (LP2), has been launched and is shown to be differently calibrated. The aims of the study were to retrieve a conversion equation to convert lactate values in FBS measured with LP2 to an estimated value if using LP1 and to define reference values for clinical management when using LP2.A cross-sectional study was conducted at a university hospital in Sweden. A total of 113 laboring women with fetal heart rate abnormalities on cardiotocography (CTG) had FBS carried out. Lactate concentration was measured bedside with both LP1 and LP2 from the same blood sample capillary. A linear regression model was constructed to retrieve a conversion equation to convert LP2 values to LP1 values.LP2 measured higher values than LP1 in all analyses. We found that 4.2 mmol/L with LP1 corresponded to 6.4 mmol/L with LP2. Likewise, 4.8 mmol/L with LP1 corresponded to 7.3 mmol/L with LP2. The correlation between the analyses was excellent (Spearman's rank correlation, r=0.97).We recommend the following guidelines when interpreting lactate concentration in FBS with LP2:6.4 mmol/L to be interpreted as normal, 6.4-7.3 mmol/L as preacidemia indicating a follow-up FBS within 20-30 min, and7.3 mmol/L as acidemia indicating intervention.

Background Cardiotocography (CTG) has high sensitivity, but less specificity in detection of fetal hypoxia. There is need for adjunctive methods easy to apply during labor. Low fetal heart rate short term variation (STV) is predictive for hypoxia during the antenatal period. The objectives of our study were to methodologically evaluate monitoring of STV during labor and to compare two different monitors (Sonicaid™ and EDAN™) for antenatal use. Methods A prospective observational study at the obstetric department, Karolinska University hospital, Stockholm (between September 2011 and April 2015). In 100 women of ≥ 36 weeks gestation, STV values were calculated during active labor. In a subset of 20 women we compared STV values between internal and external signal acquisition. Additionally we compared antenatal monitoring with two different monitors in another 20 women. Results Median STV in 100 fetuses monitored with scalp electrode during labor (EDAN™) was 7.1 msec (range 1.3–25.9) with no difference between early (3–6 cm) and late (7–10 cm) labor (7.1 vs 6.8 msec; p = 0.80). STV calculated from scalp electrode signals were positively correlated with delta-STV (STV internal –external) (R = 0.70; p

Please cite this paper as: Holzmann M, Cnattingius S, Nordstrom L. Lactate production as a response to intrapartum hypoxia in the growth-restricted fetus. BJOG 2012;119:1265–1269. Objective To analyse whether the increase in lactate in response to intrapartum hypoxia differs between small- (SGA), appropriate- (AGA) and large-for-gestational-age (LGA) fetuses. Design Observational cohort study. Setting Ten obstetric units in Sweden. Population A cohort of 1496 women. Methods A secondary analysis of a randomised controlled trial, in which 1496 women with fetal heart rate abnormalities, indicating fetal scalp blood sampling, were randomised to lactate analyses. After delivery, the neonates were divided according to birthweight for gestational age into SGA, AGA and LGA groups. Main outcome measure Lactate concentration in fetal scalp blood. Secondary outcome measures Acid–base balance in cord artery blood and Apgar score 4.8 mmol/l (lactacidaemia), the corresponding median (range) values were 6.2 (4.9–14.6), 5.9 (4.9–15.9) and 5.7 mmol/l (5.0–7.9 mmol/l), respectively (no significant differences between the groups). The proportions of neonates with cord artery pH

Objective To assess whether lactate determination in vaginal fluid is associated with and can predict onset of labour for women with suspected preterm prelabour rupture of membranes (PPROMs). Design Prospective observational study. Setting Labour ward at South General Hospital, Stockholm, Sweden. Population/participants Women with suspected PPROMs at 20–36 completed weeks of gestation (n = 81). Methods All women underwent a speculum examination and a test for determining lactate concentration in vaginal fluid. We used logistic regression to estimate the association between lactate concentration in vaginal fluid and time to onset of labour. Main outcome measure Time from examination to spontaneous onset of labour (cervix ≥4 cm). Results The median time between examination and onset of labour was 13.6 hours for those with a high (≥4.5 mmol/l) lactate concentration and 1152 hours (i.e. 48 days) for those with a low (

BACKGROUND: Cardiovascular disease (CVD) is the leading cause of death in women after menopause. In essence major risk factors for CVD are similar in women as for men inclusive of serum lipid perturbations. The effects of estrogens and hormone replacement therapy on lipid metabolism is widely discussed and warrant further evaluation especially when combined with other lipid lowering drugs. STUDY DESIGN: Postmenopausal women were studied by an open randomised study during 9 months. Subjects were recruited from outpatient clinics in a rural area of Sweden. Major inclusive criteria comprised body mass index (BMI) >28, serum triglycerides >1.5 mmol/l. Participants were at least 12 months postmenopause with a concomitant serum Follicle Stimulating Hormone (FSH) above 28 IU/l. After inclusion in the study patients were instructed to adhere to a low-fat and caloric diet for 3 months and after this period randomised into two groups of intervention; a lipidlowering fibrate (LLF) group and one hormone replacement therapy group (HRT). The LLF group was given gemfibrozil 600 mg orally twice daily and HRT group received 2 mg oestradiol in combination with 1 mg norethisterone acetate as a continuous combined therapy once daily. After 3 months, the LLF group added the HRT regimen and patients in the HRT group added gemfibrozil. Hence, all participants received the regimens combined for the last 6 months of the study. RESULTS: Serum s-cholesterol was markedly decreased in both groups during the first 3 months of single treatment (P

To investigate if repeat (≥ 3) fetal scalp blood sampling (FBS) is associated with increased risk of caesarean delivery and worse neonatal outcome than occasional (1-2) FBS.Prospective cohort study of women undergoing intrapartum FBS at Karolinska University Hospital, Sweden. FBS with lactate analysis was performed if the attending doctor found the cardiotocography (CTG) tracing suspicious or abnormal. Lactate concentration was measured bedside. As a routine in all deliveries, acid-base analyses were performed on umbilical artery and vein blood immediately after delivery. Main outcome measures were metabolic acidemia in umbilical artery at delivery, Apgar score7 at 5 min and caesarean delivery.During the study period there were 2134 FBSs performed on 1070 laboring women with a median of two samplings (range 1-8). There were no differences in Apgar score7 at 5 min or metabolic acidemia in umbilical artery blood at birth between labors with 1-2 FBS and ≥ 3 FBS. Among women who underwent 1-2 FBS, 23% had a caesarean delivery as compared with 42% of those having ≥ 3 FBS. After adjustment for confounders, repeat FBS remained an independent risk factor for caesarean delivery (adj OR 2.05; 95%C.I 1.5-2.8).Fetal monitoring with repetitive FBS (≥ 3) during labors with CTG changes is safe for the baby, but the rate of caesarean delivery is doubled as compared to labors where 1-2 FBS are needed. Still, more than 50% of women with repetitive FBS will be delivered vaginally, and 1/3 of these spontaneously.

Aim: To identify cardiotocography (CTG) patterns associated with increased risk of intrapartum fetal acidemia. Methods: A prospective observational cohort study of 1070 women with fetal scalp blood sampling (FBS) during labor was conducted at Karolinska University Hospital, Stockholm, Sweden. Women with a nonreassuring CTG pattern underwent FBS, and lactate concentration was measured at the bedside. Lactate concentrations >4.8 mmol/L were defined as fetal acidemia. A senior obstetrician, blinded to the lactate concentration at FBS, visually interpreted the CTG tracings that had prompted FBS. Results: There were 2134 FBSs performed on 1070 laboring women, constituting 11% of all deliveries at this labor ward. The CTG patterns with the highest frequency of lactacidemia at FBS were late or severe variable decelerations combined with tachycardia (20%–25% at first FBS and 33%–49% at last FBS). With a normal baseline fetal heart rate, normal variability, and absence of serious decelerations, the fetal scalp blood lactate concentration at the first FBS was normal in 97.5% of cases. The group with isolated reduced variability had no increased prevalence of acidemia and median lactate concentration did not differ from the normal group. Conclusion: Isolated reduced variability is in most cases not a sign of hypoxia. If development of hypoxia is ruled out with one FBS, this pattern does not require monitoring with repetitive FBSs throughout labor. Late decelerations and severe variable decelerations increase the risk for intrapartum fetal metabolic acidemia to the same extent. The combination of these decelerations and tachycardia was associated with the highest rate of fetal metabolic acidemia.

Aim. To study possible detrimental maternal and neonatal effects of immersion in warm water during labor.Design. Prospective randomized controlled bathing during ilig;rst stage of labor vs no bathi...

Lactate has been measured to evaluate fetal metabolic acidosis for some decades. However, not until the past few years have reliable lactate meters become available for bedside obstetric practice. The new technology, which requires only 5 microl blood, has reduced the sampling failure rate of fetal scalp blood to almost nil. A growing body of evidence has also shown lactate to be good at predicting neonatal outcome.

Objective To determine longitudinally fetal and maternal blood lactate concentrations during the second stage of labour. Design Prospective, observational study of randomly selected labours. Setting Labour ward, Sultanah Aminah General Hospital, Johore Bahru, Malaysia. Main outcome measures Fetal scalp and maternal venous blood lactate, umbilical arterial and vein lactate and acid–base balance at delivery. Results Sixty-nine women and their infants were monitored in the second stage of labour. Mean maternal venous lactate by the end of the first stage was 2.6 ± 1.0 (±S.D.) mmol/L and increased to 3.6 ±1.4, 4.2 ±1.7, 4.8 ±1.6, 5.4 ±2.1 and 4.3±0.9 mmol/L, respectively, for every 15 minute of bearing down. Corresponding values for fetal scalp blood lactate were 2.4 ±1.1, 3.1 ±1.6, 3.2 ±1.8, 4.2 ±2.4, 4.9 ±2.8 and 5.8±1.9 mmol/L. The mean slope of maternal lactate increase was 0.070 mmol/L per minute (95% CI 0.050, 0.090) and for fetal lactate increase 0.032 mmol/L per minute (95% C.I.: 0.018, 0.045). The duration of active second stage was significantly associated with fetal lactate (P

We present a case at 30 weeks gestation with transient abnormal fetal cerebral function after a road traffic accident, with loss of fetal movements and abnormal FHR tracings for almost 1 week. The pregnancy had after this incident a normal course and a healthy baby boy was born at term. We suggest the mechanism to be related to fetal hypoxia after excessive maternal psychological stress.

Accuracy of lactate determinations in cord blood was tested for one reflectometric (Accusport) and one amperometric (Lactate Pro) microvolume test strip lactate meter. Both meters, using a whole blood sample, measure lower levels of lactate than a reflectometric device considered as a reference method, which analyses lactate in plasma. Readings were unaffected irrespective of lactate concentrations for the Lactate Pro, whilst the Accusport overestimated low lactate concentrations and underestimated high values. Both lactate meters underestimated lactate concentrations at high hematocrits, as compared with the reference method. The Lactate Pro has a fixed sample volume of 5 microliters while the Accusport uses random blood drop as sample volume. However, in analyses with less than 20 microliters sample volume considerable underestimation was found with the Accusport. Coefficient of variation was 3.8-8.9% for the Accusport and 3.1-4.0% for the Lactate Pro within lactate concentrations between 2.1 and 5.3 mmol/l. The amperometric device, the Lactate Pro, performed best in these tests dealing with fetal blood lactate concentrations. The new technique can be a useful tool in perinatal research as well as in obstetric practice.

Objective. To assess metabolic control and pregnancy outcome in women with insulin- dependent diabetes mellitus (IDDM) in a defined rural area of Sweden and to compare results for three four-year periods (1982-85, 1986-89, 1990-93). Material and method. All pregnancies in women with IDDM during the 12-year period, 1982-93, received their antenatal care from a 'diabetic team' at the County Hospital, Ostersund. There were 50 women in the series, accounting for a total of 91 pregnancies. Spontaneous or induced abortions occurred in 19 cases. Case notes from maternity, neonatal and pediatric care were retrospectively scrutinized. Results. In period one 31% of the pregnancies occurred in gravidae with diabetes classified as White D, F or R, as compared with 46% and 71% during periods two and three (p= 0.001). Maternal hypertension was also more frequent in period three (12%, 26% and 54%, respectively; p=0.001). Fewer antenatal admissions (p=0.02) but more frequent ultrasound scannings (p=0.014) were recorded for period three. HbAlc levels decreased continuously from prepregnancy through first and third trimesters (9.7%, 8.4%, and 7.4%, respectively; p

Summary Background Selective serotonin reuptake inhibitors (SSRIs) are known to increase the risk of gastrointestinal bleeding. Objective Study the risk of bleeding-related complications in relation to SSRI in pregnancy. Patients/Methods This was a hospital-based cohort study. All women who gave birth at Karolinska University Hospital in Stockholm over a 5-year period (2007 to 2011) were included in the study. Those women who the electronic maternal health record indicated were using SSRI (n = 500) were considered exposed, and all other women formed a control population (n = 39 594). The main outcome measures were blood loss, postpartum hemorrhage (PPH), PP anemia and length of hospitalization. Results The absolute risk of PPH and PP anemia for the 1.2% exposed to SSRI were 18.0% and 12.8%, respectively. Women with a vaginal non-surgical delivery who reported use of SSRI during pregnancy had approximately a 2-fold increased risk of both PPH (OR, 2.6; 95% CI, 2.0–3.5) and PP anemia (OR, 2.1; 95% CI, 1.5–2.9), as compared with controls. Blood loss and length of hospitalization were significantly higher among women using SSRI than non-users (arithmetic mean 484 mL vs. 398 mL, 3.8 days vs. 2.4 days, respectively). Conclusion The use of SSRI during pregnancy increases blood loss and doubles the risk of PPH and PP anemia in a setting where SSRI had not been considered a risk factor for increased blood loss. Because PPH is a leading cause of maternal mortality and morbidity, the awareness of bleeding-related complications is important, both in relation to pregnancy and to surgery in general.

Objective To study whether a routine with a routine ultrasound examination (routine scan) at 41 gestational weeks as compared with ultrasound on clinical indication (indicated scan), lowered the risk of severe adverse fetal outcome in post-term period. Design A retrospective cohort study. Setting Karolinska University Hospital, Stockholm, Sweden. Population Eight years of deliveries, 2002–2009. Method One of the two delivery units at Karolinska University Hospital used a routine scan at 41 week of gestation and the other unit used an indicated scan. Severe adverse fetal outcome were defined: severe asphyxia, death or cerebral damage. The study was analysed using logistic regression with adjustment for potential confounders. Main outcome measures Differences in post-term severe adverse fetal outcome. Results No increased risk of post-term severe adverse fetal outcome was seen at the unit using a routine scan; conversely, a 48% significantly increased risk was seen at the unit using an indicated scan (OR 0.89, 95% confidence interval, CI, 0.5–1.5 and OR 1.48, 95% CI 1.06–2.1, respectively). Comparing post-term periods, there was no significantly increased risk at the unit using indicated scans (OR 1.6, 95% CI 0.9–3.0). There was a 60% increased prevalence of small-for-gestational age (SGA) newborns in the post-term period at the unit using indicated scans (OR 1.6, 95% CI 1.1–2.4), but no differences in operative delivery. Conclusion A policy to use routine scans at 41 weeks of gestation seems to normalise an increased post-term risk of severe adverse fetal outcome, possible due to increased awareness of SGA and/or oligohydramniosis.

Summary Lactate is a metabolite that can safely and easily can be determined in fetal scalp blood using new microvolume (5–20 μl) lactate meters. However, new lactate analysing methods need their own reference values. There are factors other than hypoxia that might increase fetal lactate levels, although this does not disqualify this parameter for intrapartum surveillance. Available data on fetal lactate determination give support that it can simplify FBS in labour and is likely to predict fetal tissue hypoxia at least as well as is pH determination. Prospective randomized studies are needed before the method can be introduced into clinical practice. As a predictor of neonatal outcome, lactate can substitute pH in routine assessment of cord artery blood at delivery.

Objective To determine fetal scalp blood lactate with a new test strip method in parturients with normal and abnormal cardiotocograms during labour and to describe the relation to maternal lactate, fetal scalp blood pH, cord artery lactate and acid-base balance. Setting Labour wards at the University Hospitals of Huddinge and Lund and at the County Hospital of Ostersund, Sweden. Materials and method Fetal scalp blood was sampled for lactate (n= 269) and pH (n= 285) determination in 177 parturients with abnormal intrapartum CTG. Lactate and pH were also analysed in a group of 64 women with normal pregnancies and with a reactive fetal heart rate tracing prior to sampling of fetal scalp blood. At fetal blood sampling lactate was also determined in maternal capillary blood, while at birth lactate and acid-base balance in cord artery blood was performed in almost all cases. Main outcome measurements Medians and percentiles (lactate and acid-base balance). Correlation between fetal scalp blood lactate (dependent) and scalp blood pH, cord artery blood lactate and acid-base parameters and labour time prior to fetal blood sampling. Results In the group with abnormal cardiotocograms, fetal scalp and umbilical artery blood lactate and acid-base parameters differed significantly from the same parameters in the normal group. The fetal-maternal lactate gradient changed from negative in the normal group to positive in the fetal distress group. Multiple regression analysis, with scalp lactate as the dependent parameter, revealed a significant correlation with fetal scalp blood pH (P < 0.001) and umbilical artery lactate (P < 0.01). Conclusions Intrapartum scalp blood lactate was significantly correlated with pH and cord artery lactate. The results indicate that increased lactate levels in fetal blood sampling describes fetal lactacidosis. The new disposable test strip requiring only 5 μl of blood for lactate determination may be better than traditional methods for monitoring fetal wellbeing in labour.

AIM To analyze short-term neonatal outcome and the sampling to delivery interval in cases with severe intrapartum acidemia diagnosed with fetal scalp blood sampling (FBS). METHODS This is a secondary analysis of data from a trial of 2992 women, who were, when indicated, randomized to either lactate or pH analyses by FBS. Median and 95(th) centile values for lactate analyses were 2.9 mmol/L and 6.6 mmol/L, respectively. Corresponding pH values were 7.30 and 7.17. We defined severe intrapartum acidemia as lactate >6.6 mmol/L or pH

To describe an extensive process to implement guidelines for oxytocin use during labor and to report its effects on compliance to clinical practice guidelines after 1 year.A multifaceted strategy was developed to involve all obstetric staff and identify possible local barriers to change in advance. The process lasted for more than 1 year.To describe the implementation of oxytocin use according to the new guidelines, and to compare management in clinical practice with guideline recommendations from audits performed before and after the project.Identification of possible barriers to change, academic detailing, audits with feedback, and local opinion leaders were important factors for a successful process. Documentation of the indication for oxytocin use increased from 54% before, to 86% after the completion of the project (P0.01). The percentage of incidents in which oxytocin augmentation was started before the diagnosis of labor dystocia was reduced from 40% to 11% (P0.01). Improvement was found in the documentation of cardiotocography (from 5% to 58%, P0.01) and contraction frequency at the start of the infusion (from 23% to 63%, P0.01).Our multifaceted strategy involved all obstetric staff, lasted for more than a year, and improved management of oxytocin use according to clinical guidelines. Established rules for documentation were used as a check list to monitor oxytocin use. However, audits with feedback need to continue for medical safety, and have been planned to take place every 6 months.

To examine the effectiveness of pH analysis of fetal scalp blood compared with lactate analysis in identifying hypoxia in labour to prevent acidaemia at birth.Randomised controlled multicentre trial.Labour wards.Women with a singleton pregnancy, cephalic presentation, gestational ageor=34 weeks, and clinical indication for fetal scalp blood sampling.Standard pH analysis (n=1496) or lactate analysis (n=1496) with an electrochemical microvolume (5 mul) test strip device. The cut-off levels for intervention were pH7.21 and lactate4.8 mmol/l, respectively.Metabolic acidaemia (pH7.05 and base deficit12 mmol/l) or pH7.00 in cord artery blood.Metabolic acidaemia occurred in 3.2% in the lactate group and in 3.6% in the pH group (relative risk 0.91, 95% confidence interval 0.61 to 1.36). pH7.00 occurred in 1.5% in the lactate group and in 1.8% in the pH group (0.84, 0.47 to 1.50). There was no significant difference in Apgar scores7 at 5 minutes (1.15, 0.76 to 1.75) or operative deliveries for fetal distress (1.02, 0.93 to 1.11).There were no significant differences in rate of acidaemia at birth after use of lactate analysis or pH analysis of fetal scalp blood samples to determine hypoxia during labour.ISRCT No 1606064.

Objectives To assess whether lactate determination in vaginal fluid is associated with, and can predict, onset of labour for women with suspected prelabour rupture of the membranes (PROM). Design Prospective observational study. Setting Labour ward at Soder Hospital, Stockholm, Sweden. Population Women with suspected PROM after 34 weeks of gestation, who later had spontaneous onset of labour (n= 179). Methods All women underwent a speculum examination and a test for determining lactate concentration in vaginal fluid. We used logistic regression to estimate the association between lactate concentration in vaginal fluid and time to onset of labour. Main outcome measures Time from examination to onset of labour (cervix ≥4 cm), within 24 hours and 48 hours. Results The median time interval between examination and spontaneous onset of labour was 8.4 hours for women with ‘high’ lactate (≥4.5 mmol/l) and 54 hours for those with ‘low’ lactate concentrations (

Objective: To analyze the indications and Robson classes associated with the rapid increase in cesarean section (CS) rates at Soder Hospital, Stockholm, Sweden, in the late 1990s. Method: Records of women who underwent CSs in 1994 and 1999 at Soder Hospital were retrospectively reviewed. Diagnostic frequency and Robson class, which takes into account characteristics such as parity, previous deliveries, prematurity, and fetal presentation, were compared for the 2 years. Results: Suspected fetal distress (+ 1.6%; P = .0001), maternal request (+ 1.5%; P P = .03) were associated with the increase in CS rates. The rate of CSs with cephalic presentation and spontaneous onset of labor at term, as well as the rate of CSs following induced labor or elective CSs, increases significantly in both nulliparas and multiparas (Robson classes 1–4) ( P Conclusion: The increasing CS rate was due to maternal preference and lower thresholds of decision for physicians.

Objectives To assess whether lactate determination in vaginal fluids, ‘Lac test’, can be used as a diagnostic test for prelabour rupture of membranes (PROM) and to derive the best cutoff value for a positive test. Design Prospective observational study. Setting Labour ward at Soder Hospital in Stockholm, a large clinical service. Population Women living in the centre of Stockholm, the capital of Sweden. Methods We selected 200 cases with a history of suspect PROM for determination of lactate concentrations in vaginal fluid. In 100 of these cases, actim PROM tests were also analysed. Main outcome measures Sensitivity, specificity, positive and negative predictive values, likelihood ratios (LR) and Kappa indices in the identification of visible amniotic fluid at speculum examination. Results A lactate concentration ≥4.5 mmol/L was found to be the best cutoff value for a positive test. The ‘Lac test’ had a sensitivity of 86%, specificity 92%, positive and negative predictive values of 92% and 87%, respectively. Corresponding values for the actim PROM test were 60%, 98%, 97% and 71%. LR for a positive ‘Lac test’ was 10.75 and for a negative test 0.15. Corresponding values for the PROM test were 30.0 and 0.4, respectively. The Kappa index was higher for the ‘Lac test’ as compared with the actim PROM test (78% and 59%, respectively). Conclusion Lactate determination is a valid test in cases with a history of suspect PROM and may even be a better predictor than the actim PROM test.

Lactate measurements have been evaluated in intrapartum fetal surveillance for some 30 years. However, it was not until reliable, handheld, microvolume devices were launched during the 1990s that lactate became a clinical option. Retrospective data suggest that lactate determinations in fetal scalp blood are better than pH for predicting severe neonatal morbidity. A randomised controlled trial comparing these two measurements found lactate to be more favourable in clinical practice in terms of less sampling failure and reduced time from the decision to do a fetal scalp blood sample to the clinician receiving the result. At present, a large multicenter randomised control trial is in progress in Sweden to compare lactate and pH measurement for the clinical management of suspected fetal compromise. Main end-points in the study are metabolic acidemia or pH