Metabolic acidosis at birth and suboptimal care--illustration of the gap between knowledge and clinical practice

Abstract

Objective: To evaluate the occurrence and nature of suboptimal intrapartum care in cases with metabolic acidosis in the newborn, and to estimate the degree to which this may be prevented.

Design: Case-control study. Clinical audit. Setting Delivery units at two university hospitals in Sweden.

Population: Out of 28 486 deliveries, 161 neonates > or =34 weeks of gestational age were born with metabolic acidosis.

Methods: Cases (n = 161): umbilical artery pH < 7.05 and base deficit > or =12 mmol/l. Controls (n = 322): pH > or = 7.05 and Apgar score > or =7 at 5 minutes. Obstetric characteristics and oxytocin administration were recorded. The last 2 hours of electronic fetal monitoring before delivery were evaluated blinded to outcome. Intrapartum management was analysed for suboptimal care by using predefined criteria.

Main outcome measure: Suboptimal intrapartum care.

Results: Case and control comparisons displayed an occurrence of suboptimal care in 49.1% versus 13.0% (P < 0.001), oxytocin misuse in 46.6% versus 13.0% (P < 0.001), a failure to respond to a pathological cardiotocographic pattern in 19.9% versus 1.2% (P < 0.001) and suboptimal care related to vacuum deliveries in 3.1% versus 0.3% (P < 0.01) respectively.

Conclusion: Metabolic acidosis at birth is often associated with suboptimal intrapartum care. The high rate of suboptimal care with regard to oxytocin use and fetal surveillance illustrate a gap between guidelines and clinical practice. Metabolic acidosis and related neonatal morbidity could potentially be prevented in 40-50% of cases. The adherence to guidelines must be checked.