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ORIGINAL ARTICLE
STLUND2 &
MARIA JONSSON1, SOLVEIG NORDEN-LINDEBERG1, INGRID O
ULF HANSON1
1
Department of Womens and Childrens Health Uppsala University, Uppsala, Sweden, and 2the Departments of Obstetrics
rebro University Hospitals, Uppsala and O
rebro, Sweden
and Gynecology, Uppsala and O
Abstract
Objective. Evaluate obstetric characteristics during the last two hours of labor in neonates born with acidemia. Design. Casecontrol study. Setting. Delivery units at two university hospitals in Sweden. Study population. Out of 28,486 deliveries during
19942004, 305 neonates had an umbilical artery pH value B7.05 at birth. Methods. Cases: neonates with an umbilical
artery pH B7.05. Controls were neonates with pH ]7.05 and an Apgar score ]7 at 5 minutes. Obstetric characteristics,
cardiotocographic patterns and oxytocin treatment during the last two hours of labor were recorded. Results. In the
univariate analysis, ] 6 contractions/10 minutes (odds ratio (OR) 4.94, 95% confidence interval (CI) 3.257.49), oxytocin
use (OR 2.20, 95% CI 1.662.92), bearing down ]45 minutes (OR 1.77, 95% CI 1.312.38) and occipito-posterior
position (OR 2.18, 95% CI 1.193.98) were associated with acidemia at birth. In the multivariate analysis, only ]6
contractions/10 minutes (OR 5.36, 95% CI 3.328.65) and oxytocin use (OR 1.89, 95% CI 1.212.97) were associated with
acidemia at birth. Among cases with ]6 contractions/10 minutes, 75% had been treated with oxytocin. Pathological
cardiotocographic patterns occurred in 68.8% of cases and in 26.1% of controls (p B0.001). Conclusion. A hyperactive
uterine contraction pattern and oxytocin use are the most important risk factors for acidemia at birth. The increased uterine
activity was related to overstimulation in the majority of cases. The duration of bearing down is less important when uterine
contraction frequency has been considered.
Key words: Neonatal acidemia, oxytocin, uterine contractions, second stage labour management
Introduction
Uterine activity progressively increases during delivery and the second stage of labor is characterized by
uterine contractions that are more frequent, intense
and prolonged (1). The active phase of the second
stage, the period when uterine activity is superimposed by a maternal urge to bear down, is
considered critical to the fetus since it can have an
adverse impact on fetal oxygenation. During the
active phase of the second stage there is a decline in
fetal pH and an increase in lactic acid, with hypoxic
effects on the fetus (24).
It is a common belief that fetal asphyxia develops
during the second stage of labor and several authors
have recommended a time limit from complete
Correspondence: Maria Jonsson, Department of Womens and Childrens Health, Uppsala University, SE-751 85 Uppsala, Sweden.
E-mail: maria.jonsson@kbh.uu.se
746
M. Jonsson et al.
Table I. Obstetric and neonatal characteristics in the case and control group.
Characteristics
Parity
nulli para
multi para
Age (years)
Gestational length (weeks)
Post-term pregnancy, ]42 wks
Pregnancy complication or intercurrent disease
Birth weight (g)
SGABmean2 SD
LGA]mean2 SD
Male gender in neonates
Values are given as n (%) and means9standard deviation (SD).
LGAlarge for gestational age; SGAsmall for gestational age.
nsnon-significant.
747
Cases n305
n (%)
Controls n610
n (%)
p-value
180 (59.0)
125 (41.0)
30.795.0
39.891.4
33 (10.8)
51 (16.7)
3,5689506
6 (2.0)
11 (3.6)
163 (53.4)
360 (59.0)
250 (41.0)
29.395.0
39.691.4
32 (5.2)
75 (12.3)
3,5719518
10 (1.6)
16 (2.6)
305 (50.0)
B0.001
ns
B0.05
ns
ns
ns
ns
ns
748
M. Jonsson et al.
Table II. Methods of delivery, analgesia and other intrapartum variables among cases and controls.
Characteristics
p-value
53.0947
85 (27.9)
31 (10.2)
5 (1.6)
23 (7.5)
86 (28.2)
104 (34.1)
16 (5.2)
7 (2.3)
38.8938
54 (8.9)
48 (7.9)
6 (1.0)
22 (3.6)
79 (13.0)
234 (38.4)
21 (3.4)
5 (0.8)
B0.001
B0.001
ns
ns
B0.01
B0.001
ns
ns
ns
Discussion
The study demonstrated that acidemia at birth is
strongly associated with a pattern of hyperactive
uterine contractions during the last two hours of
labor. In the majority of cases with hyperactive labor,
oxytocin treatment had been given. Oxytocin remained as an independent risk factor for acidemia
after controlling for uterine contraction frequency.
Other findings were that bearing down for ]45
minutes and occipito-posterior position had no
significant association with acidemia after adjustment for hyperactive labor and oxytocin use.
A strength of this study is that umbilical blood gas
sampling and analysis was done prospectively and
results were continuously documented. The sampling rate was comparable to what is achieved by
others (14). Based on previous demonstrations of
associations with complications a pH value B7.05
was used as a definition of acidemia to identify those
fetuses adjusting to hypoxia (1719).
A shortcoming was the frequently missing CTG
tracings, which was more common in the control
group. It is reasonable to assume that the deliveries
in the control group were less complicated and more
often quick, and were allowed to be supervised by
intermittent auscultation of fetal heart beats according to hospital policy. The distribution of missing
CTG tracings, more marked in the pH intervals
Table III. Use of oxytocin and frequency of contractions during the last 2 hours preceding delivery. Four or more contractions overlapping
with 6 contractions/10 minutes.
Cases n305 n (%)
Oxytocin use during the last two hours of labor
]4 contractions/10 minutes*
]6 contractions/10 minutes*
]6 contractions/10 minutes and oxytocin treatment*
Values are given as n (%).
*In cases and controls in which tocography was performed.
186
195
84
63
(61.0)
(90.3)
(38.9)
(28.3)
(41.6)
(80.1)
(11.3)
(7.4)
p-value
B0.001
0.001
B0.001
B0.001
749
Table IV. Logistic regression analysis of intrapartal factors associated with pHB7.05. Age and post-term pregnancy are included in the
analysis.
Characteristics
]6 contractions/10 minutes
Oxytocin infusion during the last two hours of labor
Cordentanglement
Occipito-posterior position
Bearing down for ]45 minutes
Univariate analysis
OR (95% CI)
4.94
2.20
2.65
2.18
1.77
Multivariate analysis
OR (95% CI)
(3.257.49)
(1.662.92)
(1.883.73)
(1.193.98)
(1.312.38)
5.36
1.89
4.08
1.59
1.42
(3.328.65)
(1.212.97)
(2.496.67)
(0.604.18)
(0.912.22)
ing the association between oxytocin use and acidemia are conflicting. An explanation for this may be
that if strict guidelines for oxytocin administration
with regard to supervision of contraction frequency
and fetal heart rate patterns, are followed the risk of
acidemia at birth could be avoided.
Neither in the whole study population nor in the
subgroup analysis was there a difference with regard
to duration of oxytocin administration or maximal
infusion rates between cases and controls in the
present study. These results support that responses
of the uterus and the fetus are more important than
the infusion rate or duration of oxytocin administration.
Our results highlight the need of paying more
attention to uterine contractions and fetal response
to uterine activity, especially in oxytocin-stimulated
labors. Clark et al. identified oxytocin administration
as a high risk situation in obstetric care and dealt
with this in an attractive way. A simple checklistbased protocol to standardize the routines of oxytocin administration was implemented and neonatal
outcome appeared to have been improved without
prolongation of labor or increase in cesarean delivery
rates (36). It would be interesting to align future
studies to this approach in clinical practice to
improve patient safety.
References
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Int J Gynaecol Obstet. 1976;14(5):45571.
3. Caldeyro-Barcia R, Giussi G, Storch E, Poseiro JJ, Lafaurie
N, Kettenhuber K, et al. The bearing-down efforts and their
effects on fetal heart rate, oxygenation and acid base balance.
J Perinat Med. 1981;9(Suppl 1):637.
4. Nordstrom L, Achanna S, Naka K, Arulkumaran S. Fetal and
maternal lactate increase during active second stage of labour.
BJOG. 2001;108(3):2638.
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