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• W1997213486 abstract "Sir, We have read the article by Liljeström et al. (1) with great interest and have a number of comments we would like to make. The main issue with a diagnostic test such as fetal scalp blood sampling should be to prevent birth acidemia, which highlights the importance that the test must not have false-negative results (i.e. a normal test although the fetus suffers from hypoxia). Additionally, the numbers needed to treat, i.e operative interventions, to prevent a depressed newborn should be favorable. In the present retrospective study by Liljeström et al. (1), there is no detailed information about the women included in the groups compared (single testing with lactate or pH vs. combined testing), nor is there any information on why single or combined testing was chosen. Compared with pH measurements, lactate tests are simpler and more rapid to perform. Could it be that in fetuses with the most severe heart rate abnormalities, ‘single’ lactate tests might have been preferred, and early and rapid intervention could have prevented birth acidemia? The authors have great concerns about false-positive tests, but hardly discuss the false-negative ones. They also comment on our previously published large randomized controlled trial (2), which compared pH and lactate analysis in fetal scalp blood. The study actually showed no difference in operative delivery due to fetal distress between the management groups, in agreement with a previously published randomized controlled trial (3). However, in a subanalysis of cases, having the result of the scalp blood analysis available within 60 min of delivery, we found no false-negative tests for lactate analyses when evaluated for the most severe outcome, cord artery pH < 7.00, while six cases were found in the pH analysis arm (p < 0.03). The higher number of operative deliveries due to fetal distress in the lactate arm was mainly due to a higher number of analysis results available, and the ‘unnecessary intervention’ probably prevented six cases with severe neonatal morbidity. In the present study, a higher proportion of interventions was found in the single-test arm, where mainly lactate was analysed. We suggest that these were mainly preventive interventions to avoid birth acidemia and not unnecessary interventions due to false-positive tests. We question the use of pre-acidemic scalp blood values to evaluate intervention rate as an outcome, since pre-acidemia is not an indication for operative intervention according to guidelines (2). The use of cord artery pH < 7.15 as the definition of birth acidemia is very ‘liberal’ and rarely used because it has a low correlation with neonatal morbidity. Furthermore, we are concerned about the lack of comments on missing outcome data. In fact, one in four fetuses had no cord artery blood analyses. Additionally, the guidelines for clinical management with the combined test seem poor. How were decisions made when combined testing showed discrepancy; acidemic/normal, acidemic/pre-acidemic, pre-acidemic/normal or both pre-acidemic? Were both tests repeated? What was considered to be the ‘gold standard’? Was it feasible to interpret data correctly in daily practice? Several studies have shown lactate to be a better indicator than pH or metabolic acidemia in both prevention and prediction of fetal hypoxia. Lactate is also likely to be an earlier marker than pH in this process (4, 5). We share the thoughts about second stage and fetal scalp blood sampling. We know that both lactate and pH change during active pushing (6), but we do not know whether this is a change within the suggested normal range. With active bearing down, a fetus with pre-acidemia might reach acidemic values. If this could justify different cut-off values for intervention in the first and second stage of labor, and still prevent birth acidemia, we believe this has to be evaluated in future randomized controlled trials. However, less intervention with risk of increase in neonatal morbidity could not be a primary aim for intrapartum fetal surveillance!" @default.
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• W1997213486 date "2012-01-26" @default.
• W1997213486 modified "2023-10-02" @default.
• W1997213486 title "The value of fetal scalp blood lactate and/or pH analyses can only be evaluated in relation to neonatal outcome and not to frequency of interventions" @default.
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• W1997213486 doi "https://doi.org/10.1111/j.1600-0412.2011.01342.x" @default.
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