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 ≥34 weeks of gestational age were born with metabolic acidosis. Methods Cases ( n = 161): umbilical artery pH < 7.05 and base deficit ≥12 mmol/l. Controls ( n = 322): pH ≥ 7.05 and Apgar score ≥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.