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Meta-Analysis
. 2015 May 1;2015(5):CD006174.
doi: 10.1002/14651858.CD006174.pub3.

Intrapartum fetal scalp lactate sampling for fetal assessment in the presence of a non-reassuring fetal heart rate trace

Christine E East  1 , Leo R Leader, Penelope Sheehan, Naomi E Henshall, Paul B Colditz, Rosalind Lau
Affiliations
Meta-Analysis

Intrapartum fetal scalp lactate sampling for fetal assessment in the presence of a non-reassuring fetal heart rate trace

Christine E East et al. Cochrane Database Syst Rev. .

Abstract

Background: Fetal scalp blood sampling for lactate estimation may be considered following identification of an abnormal or non-reassuring fetal heart rate pattern. The smaller volume of blood required for this test, compared with the more traditional pH estimation, may improve sampling rates. The appropriate use of this practice mandates systematic review of its safety and clinical effectiveness prior to widespread introduction.

Objectives: To evaluate the effectiveness and risks of fetal scalp lactate sampling in the assessment of fetal well-being during labour, compared with no testing or alternative testing.

Search methods: We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 January 2015).

Selection criteria: All published and unpublished randomised and quasi-randomised trials that compared fetal scalp lactate testing with no testing or alternative testing to evaluate fetal status in the presence of a non-reassuring cardiotocograph during labour.

Data collection and analysis: We used the standard methodological procedures of the Cochrane Pregnancy and Childbirth Group. Two review authors independently assessed the studies.

Main results: The search identified two completed randomised controlled trials (RCTs) and two ongoing trials. The two published RCTs considered outcomes for 3348 mother-baby pairs allocated to either lactate or pH estimation of fetal blood samples when clinically indicated in labour. Overall, the published RCTs were of low or unclear risk of bias. There was a high risk of performance bias, because it would not have been feasible to blind clinicians or participants.No statistically significant between-group differences were found for neonatal encephalopathy (risk ratio (RR) 1.00, 95% confidence interval (CI) 0.32 to 3.09, one study, 2992 infants) or death. No studies reported neonatal seizures. We had planned to report death with other morbidities, for example, neonatal encephalopathy; however, the data were not available in a format suitable for this, therefore death due to congenital abnormality was considered alone. The three reported neonatal deaths occurred in babies with diaphragmatic hernias (n = 2) or congenital cardiac fibrosis (n = 1). All three babies had been randomised to the pH group and were not acidaemic at birth.There were no statistically significant differences for any of the pre-specified secondary fetal/neonatal/infant outcomes for which data were available. This included low Apgar score at five minutes (RR 1.13, 95% CI 0.76 to 1.68, two studies, 3319 infants) and admission to neonatal intensive care units (RR 1.02, 95% CI 0.83 to 1.25, one study, 2992 infants), or metabolic acidaemia (RR 0.91, 95% CI 0.60 to 1.36, one study, 2675 infants) considered within the studies, either overall or where data were available for those where fetal blood sampling had occurred within 60 minutes of delivery.Similar proportions of fetuses underwent additional tests to further evaluate well-being during labour, including scalp pH if in the lactate group or scalp lactate if in the pH group (RR 0.22, 95% CI 0.04 to 1.30, two studies, 3333 infants;Tau² 1.00, I² = 58%). Fetal blood sampling attempts for lactate and pH estimation were successful in 98.7% and 79.4% of procedures respectively in the one study that reported this outcome.There were no significant between-group differences in mode of birth or operative birth for non-reassuring fetal status, either for all women, or within the group where the fetal blood sample had been taken within 60 minutes of delivery (for example, caesarean section for all enrolled, RR 1.09, 95% CI 0.97 to 1.22, two studies, 3319 women; operative delivery for non-reassuring fetal status for all enrolled RR 1.02, 95% CI 0.93 to 1.11, one study, 2992 women).Neither study reported on adverse effects of fetal scalp lacerations or maternal anxiety.

Authors' conclusions: When further testing to assess fetal well-being in labour is indicated, fetal scalp blood lactate estimation is more likely to be successfully undertaken than pH estimation. Further studies may consider subgroup analysis by gestational age, the stage of labour and sampling within a prolonged second stage of labour. Additionally, we await the findings from the ongoing studies that compare allocation to no fetal blood sample with sampling for lactate and address longer-term neonatal outcomes, maternal satisfaction with intrapartum fetal monitoring and an economic analysis.

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Conflict of interest statement

C East is the principal investigator for an ongoing randomised controlled trial that will be included in this review upon completion. Two review authors not involved in that trial will evaluate it for inclusion in the review and abstract the results.

Figures

1
1
'Risk of bias' graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.
2
2
'Risk of bias' summary: review authors' judgements about each risk of bias item for each included study.
1.1
1.1. Analysis
Comparison 1 Lactate versus pH analysis of fetal blood sampling, Outcome 1 Neonatal encephalopathy.
1.2
1.2. Analysis
Comparison 1 Lactate versus pH analysis of fetal blood sampling, Outcome 2 Neonatal death.
1.3
1.3. Analysis
Comparison 1 Lactate versus pH analysis of fetal blood sampling, Outcome 3 Apgar score < 7 at 5 minutes.
1.4
1.4. Analysis
Comparison 1 Lactate versus pH analysis of fetal blood sampling, Outcome 4 Metabolic acidemia (umbilical arterial pH < 7.05 + base defecit > 12 mmol/L).
1.5
1.5. Analysis
Comparison 1 Lactate versus pH analysis of fetal blood sampling, Outcome 5 Low umbilical arterial pH.
1.6
1.6. Analysis
Comparison 1 Lactate versus pH analysis of fetal blood sampling, Outcome 6 Umbilical arterial lactate > 4.68 mmol/L.
1.7
1.7. Analysis
Comparison 1 Lactate versus pH analysis of fetal blood sampling, Outcome 7 Umbilical arterial base deficit.
1.8
1.8. Analysis
Comparison 1 Lactate versus pH analysis of fetal blood sampling, Outcome 8 Umbilical arterial base deficit > 19.2.
1.9
1.9. Analysis
Comparison 1 Lactate versus pH analysis of fetal blood sampling, Outcome 9 Admission to neonatal intensive care unit.
1.10
1.10. Analysis
Comparison 1 Lactate versus pH analysis of fetal blood sampling, Outcome 10 Number of additional tests to evaluate fetal well‐being.
1.11
1.11. Analysis
Comparison 1 Lactate versus pH analysis of fetal blood sampling, Outcome 11 Success rate of fetal blood sampling.
1.12
1.12. Analysis
Comparison 1 Lactate versus pH analysis of fetal blood sampling, Outcome 12 Normal vaginal birth.
1.13
1.13. Analysis
Comparison 1 Lactate versus pH analysis of fetal blood sampling, Outcome 13 Assisted vaginal birth.
1.14
1.14. Analysis
Comparison 1 Lactate versus pH analysis of fetal blood sampling, Outcome 14 Caesarean section.
1.15
1.15. Analysis
Comparison 1 Lactate versus pH analysis of fetal blood sampling, Outcome 15 Operative birth for non‐reassuring fetal status.
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Update of

References

References to studies included in this review

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References to other published versions of this review

East 2010
    1. East CE, Leader LR, Sheehan P, Henshall NE, Colditz PB. Intrapartum fetal scalp lactate sampling for fetal assessment in the presence of a non‐reassuring fetal heart rate trace. Cochrane Database of Systematic Reviews 2010, Issue 3. [DOI: 10.1002/14651858.CD006174.pub2] - DOI - PubMed

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