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Metabolic acidosis at birth and suboptimal care - illustration of the gap between knowledge and clinical practice
Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health. (Obstetrik)
Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health. (Obsterik)
Kvinnokliniken, Universitetssjukhuset Örebro.
Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health. (Obstetrik)
2009 (English)In: BJOG: an international journal of obstetrics and gynaecology, ISSN 1470-0328 (Print), Vol. 116, no 11, 1453-1460 p.Article in journal (Refereed) Published
Abstract [en]

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.

Place, publisher, year, edition, pages
2009. Vol. 116, no 11, 1453-1460 p.
Keyword [en]
metabolic acidosis, suboptimal care, oxytocin, foetal surveillance, labour
National Category
Medical and Health Sciences
Research subject
Obstetrics and Gynaecology
Identifiers
URN: urn:nbn:se:uu:diva-100461DOI: 10.1111/j.1471-0528.2009.02269.xISI: 000269590100003PubMedID: 19656149OAI: oai:DiVA.org:uu-100461DiVA: diva2:210371
Available from: 2009-04-01 Created: 2009-03-31 Last updated: 2010-07-08Bibliographically approved
In thesis
1. Use and Misuse of Oxytocin During Delivery
Open this publication in new window or tab >>Use and Misuse of Oxytocin During Delivery
2009 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Obstetric malpractice claims, concerning delivery during a period of eight years, were analysed for motives behind disciplinary actions, and for the frequency of inappropriate oxytocin use.Failure to respond to signs of foetal distress, injudicious use of oxytocin and a failure to effect a timely delivery were the recurrent problems that accounted for the majority of disciplinary actions. Inappropriate use of oxytocin was more frequent than reported in earlier studies. (Paper I)

In a case-control study, differences in the obstetric management in neonates born with and without acidaemia (umbilical artery pH < 7.05), was evaluated. Out of 28,486 deliveries during 1994–2004, 305 neonates were born with acidaemia. Uterine hyperactivity and oxytocin use were independently associated to acidaemia at birth. The increased uterine activity was related to oxytocin treatment in 75 % of cases. Pathological cardiotocographic patterns occurred significantly more often in the case group. The results indicate that guidelines on oxytocin use and foetal surveillance are not followed. The duration of bearing down is less important when uterine contraction frequency has been considered. (Paper II)

In a subset of study II, cases with metabolic acidosis (umbilical artery pH < 7.05 and base deficit ≥12 mmol/L) and controls were audited for the occurrence of suboptimal intrapartum care, and the nature of such care. It was found that suboptimal care occurred in half (49%) of the cases, while it was less frequent but not uncommon among controls (13%). Suboptimal care consisted of injudicious use of oxytocin and a failure of appropriate action upon signs of foetal distress. A high rate of NICU admissions and diagnosis of encephalopathy in the case group confirms that metabolic acidosis should be avoided. We estimate that metabolic acidosis could probably have been prevented in 40-50% of the cases.(PaperIII)

Women (n=103) scheduled for elective caesarean section in regional anaesthesia were randomised to 5 or 10 units oxytocin, given as an intravenous bolus (double blinded), and electrocardiograms were analysed for ST depressions as a sign of myocardial ischaemia. ST depressions were associated with oxytocin administration significantly more often in subjects receiving 10 compared with 5 units. A dose of 10 units resulted in a more marked decrease of the mean arterial blood pressure, but no difference in increase of the heartrate. There was no difference in estimated blood loss. (paper IV)

Place, publisher, year, edition, pages
Uppsala: Acta Universitatis Upsaliensis, 2009. 69 p.
Series
Digital Comprehensive Summaries of Uppsala Dissertations from the Faculty of Medicine, ISSN 1651-6206 ; 443
National Category
Medical and Health Sciences Obstetrics, Gynecology and Reproductive Medicine
Research subject
Obstetrics and Gynaecology
Identifiers
urn:nbn:se:uu:diva-100357 (URN)978-91-554-7481-2 (ISBN)
Public defence
2009-05-15, Rosénsalen, Ingång 95/96 nb, Akademiska Sjukhuset, Uppsala, 13:15 (Swedish)
Opponent
Supervisors
Available from: 2009-04-24 Created: 2009-03-31 Last updated: 2009-04-27Bibliographically approved

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