Limitations in the clinical prediction of intrapartum

fetal asphyxia
J.A. Low, MD, L.L. Simpson, MD, G. Tonni, MD, and S. Chamberlain, MD
Kingston, Ontario, Canada
OBJECTIVE: Our purpose was to demonstrate the predictive value of clinical risk scoring and fetal
assessment for intrapartum fetal asphyxia.
STUDY DESIGN: lntrapartum fetal asphyxia was defined by an umbilical artery buffer base ~34 mmol/L.
The predictive value of 20 antepartum and intrapat-tum risk factors was examined in 1909 consecutive
pregnancies. The predictive value of clinical risk factors with periodic fetal assessment was examined in a
second population of 100 consecutive pregnancies with biochemically determined intrapat-tum fetal
asphyxia.
RESULTS: The incidence of intrapartum was 2.3%. Two problems were apparent in these studies. A
significant proportion of intrapartum fetal asphyxia occurred in pregnancies with no risk factors. The
positive predictive value of clinical risk factors was low, 3%, resulting in a large number of false positives
requiring clarification.
CONCLUSION: Screening and fetal assessment methods must be improved to ensure the early
recognition of intrapartum fetal asphyxia that may require intervention during labor to avoid morbidity and
mortality. (AM J OBSTET GYNECOL 1995;i 72:801-4.)
Key words: Clinical risk scoring, fetal assessment, fetal asphyxia
Intrapartum fetal asphyxia may cause newborn com-
plications in the central nervous sytem, cardiovascular
system, respiratory system, and kidney and, in a few
of these children, brain damage with long-term neu-
rodevelopmental sequelae.4, 5 Prevention of these com-
plications is dependent on the early identification of
asphyxia during labor, with appropriate intervention in
selected cases.
The diagnosis of intrapartum fetal asphyxia can be
made with a blood gas and acid-base assessment of fetal
blood during labor or at delivery. The clinical problem
is the identification of those pregnancies at risk for this
complication. Current clinical practice is the definition
of risk pregnancies on the basis of the presence of
certain complications followed by an assessment of fetal
behavior.
The limited sensitivity of such assessment programs
was evident in a review of perinatal mortality in which
neuropathologic features resulting from fetal asphyxia
was identified during postmortem examination. The
results of this study were (1) 50% of antepartum as-
phyxia occurred in pregnancies with no risk factors; (2)
From the Department of Obstetrics and Gynecology, Queens Uni-
versity.
Received for publication May 11, 1994; revised July 8, 1994;
nccepted September 9, 1994.
Reprint requests: J.A. Low, MD, Department of Obstetrics and
Gynecology, QueenS University, Kingston, Ontario, Canada K7L
2V7.
Cofiyright 0 1995 by Mosby-Year Book, Inc.
0002-9378/95 $3.00 + 0 6/l/60511
50% of antepartum asphyxia occurred in risk preg-
nancies; however, periodic fetal assessment failed to
identify the asphyxial episode responsible for the neu-
ropathologic feature; and (3) the indicators of intrapar-
turn asphyxia were observed after the central nervous
system injury occurred.
This report presents the results of two studies that
examine the limitations of risk scoring and periodic
fetal assessment in the prediction of the pregnancy at
risk of intrapartum fetal asphyxia determined bio-
chemically at delivery.
Methods and results
Predictive value of clinical risk scoring. The pre-
dictive value of clinical risk factors for intrapartum fetal
asphyxia was examined in 1909 consecutive pregnancies
in which an umbilical vein and artery blood gas and
acid-base analysis was obtained at delivery. The criterion
of intrapartum fetal asphyxia was an umbilical artery
buffer base <34 mmol/L (equivalent to a base deficit
> 12 mmol/L). This occurred in 44 newborns (2.3%).
This was a retrospective review conducted without
awareness of the outcome at delivery. The antepartum
and intrapartum risk factors from the medical record
were documented, and incomplete data were obtained
by interview with the responsible physician. Current risk
scoring systems were reviewed. The 20 risk factors that
were considered most relevant for fetal asphyxia were
examined.
The antepartum risk factors were (1) prior stillbirth
801
802 Low et al March 1993
Am J Obstet Gym01
Table I. Predictive value of antepartum risk factors (group 1) and antepartum plus intrapartum risk factors
(group 2) for intrapartum fetal asphyxia
Group 1 Group 2
Asphyxia present* Asphyxia absent Asphyxia present Asphyxia absent
Risk present 22 663 34 1081
Risk absent 22 1202 10 784
Sensitivity (%) 50 77
Specificity (%) 64 42
Positive predictive value (%) 3 3
iSegative predictive value (%) 98 99
*Umbilical artery buffer base < 34 mmol/L.
Table II. Incidence of intrapartum fetal asphyxia in relation to antepartum and intrapartum risk factors
Asphyxia present
Risk factors Total (No.) No. 70
Antepartum
Prior perinatal death
Medical complications
PIH or preeclampsia
Antepartum hemorrhage
Growth retardation
Fetal, other
Intrapartum
Preterm
Postterm
Meconium
Abnormal labor
67
134
133
84
126
93
198 8
134 2
354 16
400 12
PIH, Pregnancy-induced hypertension.
*Umbilical artery buffer base < 34 mmol/L.
or neonatal death; (2) maternal medical complications,
including hypertension, renal disease, diabetes, col-
lagen disease, respiratory disease, endocrinopathies,
and severe acute infections during pregnancy; (3) ob-
stetric complications, including pregnancy-induced hy-
pertension or preeclampsia and antepartum hemor-
rhage; and (4) fetal complications, including major
congenital anomalies, fetal growth retardation, and oli-
gohydramnios or polyhydramnios. One or more an-
tepartum risk factors were present in 685 pregnancies,
or 36% of the total population.
The intrapartum risk factors were (1) preterm or
postterm labor, (2) meconium in the amniotic fluid, and
(3) abnormal labor, including prolonged labor, unfavor-
able progress in labor, or a major malpresentation. One
or more antepartum or intrapartum risk factor were
present in 1115 pregnancies, or 58% of the study
population.
The predictive value of antepartum risk factors and
antepartum plus intrapartum risk factors is presented
in Table I. Fifty percent of the pregnancies with intra-
partum fetal asphyxia with metabolic acidosis at deliv-
ery had a risk factor before the onset of labor, increas-
ing to 77% at delivery. Risk was determined by a wide
range of clinical complications with no single risk factor
demonstrating a strong association with intrapartum
fetal asphyxia. However, one in four cases of intrapar-
turn fetal asphyxia occurred in a pregnancy with no risk
factors.
The positive predictive value of both antepartum and
intrapartum risk factors for intrapartum fetal asphyxia
was 3%. Table II demonstrates that this low predictive
value was true for all risk factors. Thus clinical risk
scoring has a major problem with regard to false-
positive results in the prediction of intrapartum fetal
asphyxia.
Predictive value of clinical risk scoring and fetal
assessment. The predictive value of clinical risk factors
with periodic fetal assessment was examined in a second
population of 100 consecutive pregnancies with bio-
chemically determined intrapartum fetal asphyxia (i.e.,
an umbilical artery buffer base < 34 mmol/L [equivalent
to a base deficit greater than 12 mmol/L]). These oc-
curred in a series of 4368 pregnancies with umbilical
cord blood gas and acid base assessment at delivery, an
incidence of 2.3%.
Volume 172, Number 3
Am J Obstet Gynecol
Low et al. 803
Table III. Clinical complications and fetal assessment in antepartum and intrapartum periods in obstetric
patients in antepartum risk group, intrapartum risk group, and no antepartum or intrapartum
risk group
Antepartum risk Intrapartum risk No antepartum or
(n = 40) (n = 25) intrapartum risk (n = 35)
Antepartum
Clinical
Medical
Obstetric
Fetal
BPP
26
16
NST
Reactive
Nonreactive
Intrapartum
Clinical
Pretermiposterm
Meconium
NST
Reactive
Nonreactive
22
16
8
9
2
12
12
12
13
1 0 4
4 6 0
9
17
0
0
BPP, Biophysical profile.
The documented clinical risk factors included the
obstetric history and maternal, obstetric, fetal, and
labor complications recorded in the first study. An-
tepartum biophysical profiles and nonstress tests
(NSTs) were performed as requested by the attending
physician. Biophysical profiles were scored as follows:
fetal breathing, 2; fetal movement, 2; fetal tone, 2; and
amniotic fluid volume, 2; for a total score of 8. NSTs
included 20 or 40 minutes of fetal heart rate recording.
A NST was classified as reactive on the basis of at least
two accelerations of 15 beats/min in a 20-minute pe-
riod. Some patients had an admissions test early in
labor of 1 hour of fetal heart rate recording. This was
scored as an NST. The association between clinical risk
factors and the periodic fetal assessments and intrapar-
turn fetal asphyxia is presented in Table III. There were
40 pregnancies in the antepartum risk group. This
classification was determined on the basis of a wide
range of clinical risk factors and abnormal fetal assess-
ments. The designation was based on abnormal fetal
assessment alone in five cases. There were 25 pregnan-
cies in the intrapartum risk group. This designation was
based on an abnormal admissions test alone in four
cases. There were 35 pregnancies with no clinical risk
factors or abnormal fetal assessments. The degree of
metabolic acidosis at delivery was of the same order in
the three groups (Table IV).
Table IV; Degree of metabolic acidosis in
three risk groups
,-_J
Antepartum risk 40 31.2 3.7
Intrapartum risk 25 30.8 3.5
No antepartum or 35 31.6 2.4
intrapartum risk
significant proportion of intrapartum fetal asphyxia
occurs in pregnancies with no risk factors. This group is
equally important, with metabolic acidosis at delivery of
the same order as in the pregnancies with risk factors.
This is in keeping with the earlier observation of preg-
nancies with no risk factors in the perinatal mortality
study with neuropathologic features related to as-
phyxial insults.
Comment
Risk factors were present in approximately half the
pregnancies at the onset of labor and in two thirds of
the pregnancies before delivery. There were a wide
range of risk factors. No individual r&k factor demon-
strated a strong association with intrapartum fetal as-
phyxia. Biophysical profiles and NSTs were periodic
assessments that reflect the fetal state at the time of the
examination. These tests, as presently used, may add
modestly to the prediction of intrapartum fetal as-
phyxia.
The limitations of clinical risk scoring and periodic Risk scoring systems have been used for many pur-
fetal assessment in the prediction of intrapartum fetal poses. One of the earliest was the prediction of perina-
asphyxia is apparent. Both studies demonstrate that a tal mortality. A review of these studies indicates that to
804 Low et al. March 1995
Am J Obstet Gynecol
achieve a reasonable sensitivity in the prediction of
perinatal mortality it was necessary for the risk scoring
systems to identify a large proportion (i.e., >50%) of
the obstetric population to be at risk.H- On the basis of
the selected risk factors used in our studies, the pro-
portion of pregnancies with risk factors before the onset
of labor was 36% and before delivery 58%. The inci-
dence of intrapartum fetal asphyxia is approximately
2%. The result is a low positive predictive value of 3%
and a large number of false positives that require
clarification.
These findings highlight some of the problems facing
the clinician in the diagnosis of fetal asphyxia during
labor and delivery. Our objective is to assure the early
recognition of intrapartum asphyxia during labor to
avoid mortality or morbidity. To achieve this goal,
screening methods must be developed to identify those
asphyxial events occurring in pregnancies with no clini-
cal risk factors, and diagnostic methods such as elec-
tronic fetal heart rate monitoring, fetal electrocardio-
graphic monitoring, or continuous recording of fetal
blood gases must be improved to increase the sensitivity
and decrease the false positives in risk pregnancies.
Until this goal is achieved the only definitive method
to assure the diagnosis of intrapartum fetal asphyxia is
routine umbilical cord blood gas analysis at delivery.
This permits the nursery to be forewarned of a possible
problemwhen a significant metabolic acidosis is present.
It also serves to confirm that fetal asphyxia during labor
did not occur in 98% of the babies delivered.
1.
2.
3.
4.
6.
7.
8
9
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