Research

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OBSTETRICS

Prediction of intrapartum fetal compromise using the

cerebroumbilical ratio: a prospective observational study
Tomas Prior, BSc; Edward Mullins, BSc; Phillip Bennett, PhD; Sailesh Kumar, PhD
OBJECTIVE: To investigate the use of the fetal cerebroumbilical ratio to

predict intrapartum compromise in appropriately grown fetuses.

STUDY DESIGN: A prospective observational study set at Queen Charlottes and Chelsea hospital, London, UK. Fetal biometry and Doppler
resistance indices were measured in 400 women immediately before
established labor. Labor was then managed according to local protocols
and guidelines, and intrapartum and neonatal outcome details
recorded.
RESULTS: Infants delivered by cesarean section for fetal compromise

had significantly lower cerebroumbilical ratios than those born by spontaneous vaginal delivery (1.52 vs 1.82, P .001). Infants with a cere-

broumbilical ratio 10th percentile were 6 times more likely to be delivered by cesarean section for fetal compromise than those with a
cerebroumbilical ratio 10th percentile (odds ratio, 6.1; 95% confidence interval, 3.0312.75). A cerebroumbilical ratio 90th percentile appears protective of cesarean section for fetal compromise (negative predictive value 100%).
CONCLUSION: The fetal cerebroumbilical ratio can identify fetuses at

high and low risk of a subsequent diagnosis of intrapartum compromise, and may be used to risk stratify pregnancies before labor.
Key words: cerebroumbilical ratio, Doppler, fetal distress, fetal
compromise, labor

Cite this article as: Prior T, Mullins E, Bennett P, et al. Prediction of intrapartum fetal compromise using the cerebroumbilical ratio: a prospective observational
study. Am J Obstet Gynecol 2013;208:124.e1-6.

he intrapartum period represents

the time during pregnancy when
the fetoplacental relationship is challenged to the highest degree. Uterine
contractions are associated with up to
60% decline in uterine artery flow velocities,1 and the associated reduction in
placental perfusion may precipitate fetal
compromise. Fetal hypoxia can result in
significant neonatal sequelae including
neurologic injury, seizures (neonatal encephalopathy), and death. Although in

From the Centre for Fetal Care, Queen

Charlottes and Chelsea Hospital, and the
Institute for Reproductive and Developmental
Biology, Imperial College London, London,
England, UK.
Received July 20, 2012; revised Oct. 1, 2012;
accepted Nov. 14, 2012.
Funded by the Moonbeam Trust (Charity No.
1110691) and the Imperial College Healthcare
NHS Trust Comprehensive Biomedical
Research Centre (BRC) scheme.
The authors report no conflict of interest.
Reprint requests: Sailesh Kumar, PhD, Centre
for Fetal Care, Queen Charlottes and Chelsea
Hospital, Imperial College London, London,
UK, W12 0HS. Sailesh.Kumar@imperial.ac.uk.
0002-9378/$36.00
2013 Mosby, Inc. All rights reserved.
http://dx.doi.org/10.1016/j.ajog.2012.11.016

124.e1

the majority of infants, the etiology of

cerebral palsy or neonatal encephalopathy are in the antenatal period,2,3 a significant proportion (14.5%) are associated with intrapartum hypoxia.4,5 In
term infants, hypoxic-ischemic encephalopathy occurs in 2-3 cases per 1000 live
births in developed countries,6 whereas
this incidence is almost 10-fold greater in
developing nations.7 Up to 63% of cases
of intrapartum hypoxia occurs in pregnancies with no antenatal risk factors8
making identification of the fetus at risk
of intrapartum complications difficult.
Although in individual cases electronic
fetal heart rate monitoring may detect fetal
hypoxia, its widespread use has not resulted in a decrease in the incidence of cerebral palsy in developed countries.7
This may be because electronic fetal
heart rate monitoring has a poor positive
predictive value and is not being appropriately targeted to an at risk population.
Furthermore, the use of continuous electronic fetal heart rate monitoring has resulted in increased rates of cesarean section and instrumental delivery for
presumed fetal compromise.9 Individual
risk factor assessment based on maternal history, admission cardiotocography
(CTG), or measurement of amniotic

American Journal of Obstetrics & Gynecology FEBRUARY 2013

fluid index (AFI) may be used to identify

a population to whom electronic fetal
heart rate monitoring should be applied.
However, a recent Cochrane review assessed the use of admission CTG as a
screening test for intrapartum fetal
compromise and concluded that there
was no evidence to support this practice.10 Similarly, assessment of admission AFI has been demonstrated to be
of limited value in identifying fetuses at
risk of compromise.11
During periods of either acute or
chronic hypoxia the fetus preferentially redistributes its cardiac output to perfuse vital organs such as the brain. A decrease in
the fetal middle cerebral artery pulsatility index (MCA PI) is suggestive of this
cerebral distribution, which is a physiologic response seen in fetuses exposed to
hypoxic conditions.12 These changes can
be measured using pulse wave Doppler,
with a low middle cerebral artery and a
high umbilical artery pulsatility index
(low cerebroumbilical [C/U] ratio) indicative of cerebral redistribution.
We aimed to investigate the predictive
value of the fetal C/U ratio, measured
just before established labor, in identification of fetuses at risk of intrapartum
fetal compromise and subsequent ob-

Obstetrics

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stetric intervention. We hypothesized
that those fetuses with a low C/U ratio
would be at increased risk of compromise during labor, leading to increased
rates of obstetric intervention and emergency delivery.

M ATERIALS AND M ETHODS

Four hundred women at term (37-42
weeks) were recruited at Queen Charlottes and Chelsea Hospital, Imperial
College Healthcare NHS Trust, London,
UK. All recruited patients were approached before active labor (cervical
dilatation 4 cm), had singleton pregnancies, were identified as low risk on the
basis individual chart review with no fetal concerns identified antenatally. Exclusion criteria included cervical dilatation of 4 cm, multiple pregnancy,
preeclampsia, previously identified fetal
growth restriction, known fetal anomaly,
evidence of intrauterine infection, or
maternal age 16 years. We aimed to recruit women likely to deliver within 72
hours. Ethical approval for this study was
granted by the London Research Ethics
Committee (Ref no: REC 10/H0718/26).
All women had an ultrasound examination performed in a supine position with
the head of the bed elevated at 45 degrees.
Fetal biometry and AFI were recorded. In
addition, the pulsatility index of the umbilical artery and middle cerebral artery was
recorded using an automated trace of at
least 3 consecutive waveforms. All Doppler
waveforms were recorded in the absence of
fetal breathing movements or uterine contractions. The angle of insonation was kept
30 degrees. Each parameter was recorded 3 times and a mean of these values
used for data analysis. In a subcohort of 50
women, recording of Doppler indices were
repeated by the same operator after a 30minute interval to ascertain intraobserver
variability and by a different trained operator to establish the interobserver variability of these parameters. Information about
maternal age, ethnicity, parity, booking
blood pressure, gestation at onset of labor,
body mass index (BMI), history of smoking, preexisting maternal medical disorders, history of previous fetal growth restriction, stillbirth, or neonatal death was
documented. All ultrasound examinations

were undertaken by a single trained practitioner using a portable ultrasound machine (GE Volusune, 4-8 MHz transabdominal curvilinear transducer; GE,
Chalfont St. Giles, UK). Information obtained from the ultrasound examination
was not made available to either the clinicians responsible for the patients intrapartum care, or the patients themselves, to ensure that management of labor was not
influenced by the ultrasound findings.
Labor was then managed as per local
protocols and guidelines. After delivery,
intrapartum and neonatal outcome data
were collected from patient case notes.
Outcome measures for this study included mode of delivery, diagnosis of fetal compromise (based on CTG abnormalities, abnormal fasting blood sugar
[FBS] [pH 7.20], or both), presence of
meconium stained liquor or CTG abnormalities (classified according to National
Institute for Health and Clinical excellence [NICE] guidelines13) and duration
of labor before a diagnosis of fetal compromise. Neonatal outcome was assessed
by examining birthweight, as well as a
composite neonatal outcome score that
included cord arterial pH and base excess at delivery, Apgar score at 1 and 5
minutes, and neonatal unit admission.
Data analysis was performed using
SPSS version 19 (SPSS, Inc, Cary, NC).
Infants were categorized according to
mode of delivery and C/U ratio (10th
percentile, 10th-90th percentile, 90th
percentile). Statistical analysis included
1-way analysis of variance (ANOVA), 2
test, independent sample 2-tailed t tests,
and logistic regression.

R ESULTS
Four hundred women were recruited to
the study over a 1-year period. Patient
demographics are reported in Table 1
and mode of delivery details for all patients in Table 2. No difference in maternal age, BMI, or ethnicity, was observed
between the different modes of delivery
groups.
The mean umbilical artery pulsatility
index (UA PI) for the entire cohort was
0.80 (range, 0.461.53). The UA PI had
good intra- and interobserver variability
(correlation coefficient of 0.98 and 0.97,

Research

respectively).Infants delivered by cesarean section for presumed fetal compromise had the highest mean UA PI,
whereas those delivered by instrumental
delivery for a prolonged second stage
had the lowest mean UA PI (0.86 vs 0.76,
P .002). Infants born by spontaneous
vaginal delivery (SVD) had a mean UA
PI significantly lower than the cesarean
section cohort (0.79 vs 0.86, P .005).
Infants born by instrumental delivery
(ventouse or forceps) for presumed fetal
compromise had a mean UA PI of 0.82
(P .16). The difference in UA PI between the mode of delivery groups was statistically significant when compared using
1-way ANOVA (P .009). Receiveroperator curves (ROC) were constructed
to evaluate the use of UA PI to predict cesarean delivery for presumed fetal compromise and resulted in an area-undercurve (AUC) of 0.63.
The mean MCA PI for the entire cohort was 1.37 (range, 0.682.29). Similarly, the MCA PI had good intra- and
interobserver variability (correlation coefficient of 0.97 and 0.95, respectively).
Infants delivered by cesarean section for
presumed fetal compromise had the
lowest mean MCA PI when compared
with those delivered by instrumental delivery for a prolonged second stage (1.26
vs 1.41, P .004) or those born by SVD
(1.26 vs 1.41, P .001). Infants born by
instrumental delivery for presumed fetal
compromise had a mean MCA PI of 1.32
(P .17). When all mode of delivery
groups were compared using 1-way
ANOVA, the difference in mean MCA PI
was statistically significant (P .004).
ROC curve analysis for the MCA PI as a
predictor of cesarean section for presumed fetal compromise resulted in an
AUC of 0.64.
MCA PI and UA PI were then used to
calculate the C/U ratio. The mean C/U
ratio for the entire cohort was 1.77
(range, 0.593.15). The C/U ratio, too,
had good intra- and interobserver variability (correlation coefficient of 0.97
and 0.94, respectively). Infants delivered
by cesarean section for presumed fetal
compromise had the lowest mean C/U
ratio, whereas those delivered by instrumental delivery for a prolonged second
stage had the highest mean C/U ratio

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124.e2

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TABLE 1

Maternal demographics, intrapartum, and neonatal outcome according to mode of delivery

Demographic
Number of patients

Overall

Emergency
cesarean fetal
compromise

400

46 (11.5%)

SVD
175 (43.8%)

Instrumental
fetal
compromise

Instrumental
prolonged
second stage

71 (17.8%)

45 (11.3%)

Emergency
cesarean other

ANOVA/2
P value

63 (15.8%)

................................................................................................................................................................................................................................................................................................................................................................................

.001

% primiparous

65.5% (262/400)

89.1% (41/46)

37.1% (65/175)

87% (62/71)

80.0% (36/45)

92.1% (58/63)

Mean maternal age

32 (18-47)

32

32

33

31

33

.38

Mean BMI

25 (17-42)

26

25

24

24

25

.05

................................................................................................................................................................................................................................................................................................................................................................................
................................................................................................................................................................................................................................................................................................................................................................................
................................................................................................................................................................................................................................................................................................................................................................................

Ethnicity, %

.......................................................................................................................................................................................................................................................................................................................................................................

White

65.5% (262/400)

56.5% (26/46)

66.3% (116/175)

77.5% (55/71)

62.2% (28/45)

58.7% (37/63)

.62

Asian

16% (64/400)

19.6% (9/46)

12.6% (22/175)

14.1% (10/71)

20% (9/45)

22.2% (14/63)

.44

Afro-Caribbean

13% (52/400)

15.2% (7/46)

15.4% (27/175)

7.0% (5/71)

6.7% (3/45)

15.9% (10/63)

.32

8.7% (4/46)

5.7% (10/175)

1.4% (1/71)

11.1% (5/45)

3.2% (2/63)

.18

40 wks 3 d

40 wks 3 d

40 wks 3 d

.04

.......................................................................................................................................................................................................................................................................................................................................................................
.......................................................................................................................................................................................................................................................................................................................................................................
.......................................................................................................................................................................................................................................................................................................................................................................

Other

5.5% (22/400)

................................................................................................................................................................................................................................................................................................................................................................................

Mean gestation of ultrasound

scan

40 wks 2 d (37 42 1)

40 wks 6 d

40 wks 1 d

................................................................................................................................................................................................................................................................................................................................................................................

Neonatal outcomes

.......................................................................................................................................................................................................................................................................................................................................................................

Birthweight

3517 g (17804940 g)

3475 g

3523 g

3399 g

3552 g

3641 g

.047

48

55

45

54

60

.01

.......................................................................................................................................................................................................................................................................................................................................................................

Birthweight percentile

53 (1-99)

.......................................................................................................................................................................................................................................................................................................................................................................

Apgar 7 at 5 min

4/400 (1%)

1/46 (2.2%)

Cord arterial pH 7.20

114/400 (28.5%)

10/46 (21.7%)

Neonatal unit admission

1.5% (6/400)

2.2% (1/46)

Neonatal encephalopathy

0% (0/400)

Composite neonatal
outcome score

0.71

0/175 (0%)

1/71 (1.4%)

1/45 (2.2%)

1/63 (1.6%)

.49

51/175 (29.1%)

35/71 (49.3%)

9/45 (20%)

9/63 (14.3%)

.002

0.6% (1/175)

4.2% (3/71)

0% (0/45)

1.6% (1/63)

.21

0% (0/46)

0% (0/175)

0% (0/71)

0% (0/45)

0% (0/63)

n/a

0.65

0.66

1.30

0.55

0.33

.001

.......................................................................................................................................................................................................................................................................................................................................................................
.......................................................................................................................................................................................................................................................................................................................................................................
.......................................................................................................................................................................................................................................................................................................................................................................
.......................................................................................................................................................................................................................................................................................................................................................................

................................................................................................................................................................................................................................................................................................................................................................................

Composite neonatal outcome scored as follows:

1. Apgar 7 @ 1 min 0, 7 @ 1 min 1, 7 @ 5 min 2
2. Cord arterial pH 7.20 0, 7.20 1, 7.10 2, 7.00 3
3. Base excess 8 0, 8 and 12 1, 12 2
4. NNU admission No 0, Yes 1
ANOVA, analysis of variance; BMI, body mass index; n/a, not applicable; NNU, neonatal unit; SVD, spontaneous vaginal delivery.
Prior. Prediction of intrapartum compromise. Am J Obstet Gynecol 2013.

(1.52 vs 1.90, P .001). Infants born by

SVD had a mean C/U ratio of 1.83 and
those born by instrumental delivery for
presumed fetal compromise had a mean
C/U ratio of 1.67, both significantly
higher than the cesarean section cohort
(P .001 and P .04, respectively).
When all modes of delivery were compared using 1-way ANOVA, the difference in mean C/U ratio remained statistically significant (P .001). ROC curve
analysis for the C/U ratio as a predictor
of cesarean section for presumed fetal
compromise resulted in an AUC of 0.69.
The optimal positive discriminatory
C/U ratio was 1.24 resulting in a sensitivity of 32.5%, specificity of 93.2%, and a
positive predictive value of 36.4% for presumed fetal compromise. Conversely, the
optimal negative discriminatory C/U ratio
was 2.34 and resulted in a 100% negative
predictive value (NPV).
124.e3

The C/U ratio was normally distributed throughout the study population
(Kolmogorov-Smirnov test P .13).
This distribution resulted in a 10th percentile C/U ratio value of 1.24 and a 90th
percentile value of 2.35, with a median of
1.76. Cases were subclassified according
to C/U ratio percentile group as 10th
percentile, 10th-90th percentile, and
90th percentile on the basis of our

ROC curve analyses. No significant differences in maternal age, BMI, ethnicity,

or parity were observed between the different C/U ratio percentile groups. These
results are summarized in Table 3.
Higher rates of cesarean section for
presumed fetal compromise (P .001)
and diagnoses of fetal compromise at any
time during labor (P .001) were observed in fetuses with the lowest C/U ra-

TABLE 2

Mode of delivery for 400 patients

109 cesarean section (27%)
46 for presumed fetal
compromise (42%)

63 other
indication
(58%)

175 SVD (44%)

116 instrumental deliveries (29%)

71 for presumed
fetal compromise
(61%)

45 for prolonged
second stage
(39%)

..............................................................................................................................................................................................................................................

Cesarean sections not because of fetal compromise were performed for failure to progress in 60/63 cases, and 1 case each
of unstable lie, uterine scar rupture, and shoulder presentation.
SVD, spontaneous vaginal delivery.
Prior. Prediction of intrapartum compromise. Am J Obstet Gynecol 2013.

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Research

TABLE 3

Maternal demographics, intrapartum, and neonatal outcome according to C/U ratio percentile group
Demographic

Overall

C/U ratio <10th

percentile

C/U ratio 10th90th percentile

C/U ratio >90th

percentile

ANOVA/2
P value

% primiparous

65.5% (262/400)

84% (37/44)

64.9% (205/316)

50% (20/40)

.15

Mean maternal age

32 (18-47)

32

32

34

.16

Mean BMI

25 (17-42)

25

25

24

.19

................................................................................................................................................................................................................................................................................................................................................................................
................................................................................................................................................................................................................................................................................................................................................................................
................................................................................................................................................................................................................................................................................................................................................................................

Ethnicity, %

.......................................................................................................................................................................................................................................................................................................................................................................

White

65.5 (262/400)

61.4 (27/44)

66.1 (209/316)

65.0 (26/40)

.94

Asian

16.0 (64/400)

15.9 (7/44)

16.5 (52/316)

12.5 (5/40)

.84

Afro-Caribbean

13.0 (52/400)

15.9 (7/44)

12.7 (40/316)

12.5 (5/40)

.85

10.0 (4/40)

.38

39 wks 5 d

.004

.......................................................................................................................................................................................................................................................................................................................................................................
.......................................................................................................................................................................................................................................................................................................................................................................
.......................................................................................................................................................................................................................................................................................................................................................................

Other

5.5 (22/400)

6.8 (3/44)

4.7 (15/316)

.......................................................................................................................................................................................................................................................................................................................................................................

Mean gestation at time of U/S

40 wks 2 d

40 wks 5 d

40 wks 3 d

................................................................................................................................................................................................................................................................................................................................................................................

Evidence of fetal compromise

.......................................................................................................................................................................................................................................................................................................................................................................

Rate of meconium stained liquor

10.8% (43/400)

22.7% (10/44)

10.1% (32/316)

2.5% (1/40)

Rate of CTG abnormalities

35.3% (141/400)

86% (38/44)

31.0% (98/316)

12.5% (5/40)

.02

.......................................................................................................................................................................................................................................................................................................................................................................

.001

................................................................................................................................................................................................................................................................................................................................................................................

Delivery category

.......................................................................................................................................................................................................................................................................................................................................................................

Cesarean section fetal compromise

11.5% (46/400)

36.4% (16/44)

9.5% (30/316)

0% (0/40)

.001

Fetal compromise diagnosed at any time during labor

29.3% (117/400)

63.6% (28/44)

26.6% (84/316)

12.5% (5/40)

.001

SVD

43.8% (175/400)

22.7% (10/44)

44.9% (142/316)

57.5% (23/40)

Vaginal delivery of any kind

72.8% (291/400)

52.3% (23/44)

74.1% (234/316)

85% (34/40)

.18

Cesarean section other indication

15.8% (63/400)

11.4% (5/44)

16.5% (52/316)

15% (6/40)

.71

.......................................................................................................................................................................................................................................................................................................................................................................
.......................................................................................................................................................................................................................................................................................................................................................................

.04

.......................................................................................................................................................................................................................................................................................................................................................................
.......................................................................................................................................................................................................................................................................................................................................................................
.......................................................................................................................................................................................................................................................................................................................................................................

Length of labor before fetal compromise diagnosed

510 min (0-1817)

576 min

493 min

422 min

.40

................................................................................................................................................................................................................................................................................................................................................................................

Neonatal outcome

.......................................................................................................................................................................................................................................................................................................................................................................

Birthweight

3518 g (1780-4940g)

3448 g

3514 g

3622 g

.23

47

53

63

.04

.......................................................................................................................................................................................................................................................................................................................................................................

Birthweight percentile

53 (1-99)

.......................................................................................................................................................................................................................................................................................................................................................................

Apgar 7 at 5 min

4/400 (1%)

1/44 (2.3%)

3/316 (0.9%)

Cord arterial pH 7.20

114/400 (28.5%)

13/44 (29.5%)

90/316 (28.5%)

Neonatal unit admission

1.5% (6/400)

4.5% (2/44)

Neonatal encephalopathy

0% (0/400)

Composite neonatal outcome score

0.71

0/40 (0%)

.57

.......................................................................................................................................................................................................................................................................................................................................................................

11/40 (27.55%)

.98

1% (3/316)

2.5% (1/40)

.19

0% (0/44)

0% (0/316)

0% (0/40)

0.75

0.71

0.70

.......................................................................................................................................................................................................................................................................................................................................................................
.......................................................................................................................................................................................................................................................................................................................................................................

n/a

.......................................................................................................................................................................................................................................................................................................................................................................

.96

................................................................................................................................................................................................................................................................................................................................................................................

ANOVA, analysis of variance; BMI, body mass index; CTG, cardiotocography; C/U, cerebroumbilical; n/a, not applicable; SVD, spontaneous vaginal delivery; U/S, ultrasound.
Prior. Prediction of intrapartum compromise. Am J Obstet Gynecol 2013.

tios. A C/U ratio 10th percentile was

associated with a 6-fold increased rate of
cesarean section for presumed fetal compromise (odds ratio [OR], 6.1; 95% confidence interval [CI], 3.0312.75) when
compared with a C/U ratio 10th percentile, and a 5-fold increased rate of
fetal compromise being diagnosed at
any time during labor (OR, 5.25; 95%
CI, 2.7210.15). Fetuses with a C/U
ratio 10th percentile were almost 3
times more likely to be born by SVD
(OR, 2.94; 95% CI, 1.416.13), and
more than twice as likely to have a vaginal delivery of any kind (OR, 2.78;
95% CI, 1.475.23) compared with

the cohort of fetuses with C/U ratios

10th percentile. A C/U ratio 10th
percentile resulted in a positive predictive value (PPV) for cesarean section
for presumed fetal compromise of
36.4%, whereas a C/U ratio 10th percentile results in a NPV of 91.6%. A
C/U ratio 90th percentile yielded a
100% NPV for cesarean section for
presumed fetal compromise.
No difference in the duration of labor
before a diagnosis of fetal compromise
was seen between the 3 C/U ratio groups.
As some infants in the study were born
with a birthweight 10th percentile, and
could have been growth restricted, the

analysis was repeated with these small infants excluded. Significant differences in
the rate of cesarean section for presumed
fetal compromise, diagnoses of fetal
compromise, and SVD rate remained.
Potential confounding variables
such as parity, BMI, gestation, and
birthweight were controlled for using
logistic regression analysis. The C/U
ratio remained an independent predictor of cesarean section for presumed
fetal compromise.
Other intrapartum evidence of fetal
compromise was also evaluated. Infants
with a C/U ratio 10th percentile had
significantly higher rates of meconium

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stained liquor (22.7% vs 10.1% vs 2.5%,

P .02) and CTG abnormalities (classified as either suspicious or pathologic according to NICE guidelines) when compared with infants with a C/U ratio in the
10th-90th percentile, or 90th percentile (82% vs 31% vs 11%, P .001)
(Table 3).
Neonatal outcome was assessed by examining birthweight, Apgar scores, UA
pH, neonatal unit admission, and diagnosis of neonatal encephalopathy (Table
3). No significant difference in birthweight was observed between the C/U
ratio groups. Gestation matched birthweight percentiles were calculated to
control for gestation. These demonstrated significantly higher birthweight
percentiles among infants with the highest C/U ratios. No significant difference
in the incidence of Apgar score 7 at 5
minutes, umbilical cord arterial pH
7.20, rate of neonatal unit admission,
or neonatal encephalopathy was observed between the C/U ratio percentile
groups. Similarly, no significant difference in the composite neonatal outcome
score was observed between the C/U ratio groups.

C OMMENT
The results from this study demonstrate
that assessment of the fetal C/U ratio, in
term infants from low risk pregnancies
before active labor, can predict the diagnosis of intrapartum fetal compromise
(based on abnormal CTG, abnormal fetal blood sampling, or both) and the
need for emergency delivery with good
reliability. Currently, multivessel Doppler assessment of fetal well-being is considered valuable only in cases of fetal
growth restriction. Our data suggests
that assessment of the fetal C/U ratio can
also be of value in the apparently normally grown fetus at term. Although the
risk of intrapartum fetal compromise being diagnosed is highest in infants with
the lowest C/U ratios, a high C/U ratio
appears to suggest better fetal tolerance
to the stresses of labor, with a reduced
incidence of abnormal fetal heart rate
patterns necessitating emergency delivery. No infants in our study with a C/U
ratio 90th percentile required delivery
124.e5

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by emergency cesarean section for presumed fetal compromise (NPV 100%).
Infants born by emergency cesarean
section for presumed fetal compromise
had the highest mean UA PI, the lowest
mean MCA PI, and the lowest mean C/U
ratio of any mode of delivery group.
Raised UA PI is associated with increased
placental resistance and has previously
been suggested as a surrogate marker of
placental function.14 UA PI is known to
be elevated in cases of fetal growth restriction, however, its use in early labor
does not appear to be a good predictor of
adverse perinatal outcome.15 Our results
suggest that although both a high UA PI
and a low MCA PI are associated with
increased risk of emergency cesarean
section for presumed fetal compromise,
the C/U ratio has better predictive value
allowing for more accurate identification
of fetuses likely to require emergency
delivery.
We observed higher rates of meconium stained liquor in infants with the
lowest C/U ratios. This is in contrast to
the findings of Lam et al,16 who evaluated the use of AFI, MCA PI, UA PI, and
C/U ratio in the surveillance of postdates
pregnancy. They found that MCA PI was
the only parameter that had a statistically
significant correlation with the passage
of thick meconium.16 In our study, however, infants with a C/U ratio 10th percentile also had a significantly higher incidence of CTG abnormalities than those
with a C/U ratio in the 10-90th percentile
or 90th percentile. The incidence of
CTG abnormalities in infants with a C/U
ratio 90th percentile was just 11%,
supporting our premise that these infants have an increased tolerance to the
stresses of labor. No difference in the
length of labor before a diagnosis of fetal
compromise was observed between the
C/U ratio percentile groups, suggesting
that a potential diagnosis of intrapartum
fetal compromise was independent of
the length of labor. Diagnoses of intrapartum fetal compromise were more
common in the latter stages of labor,
when contractions are more frequent,
and the fetus more advanced in its descent through the birth canal. As labor
rarely progresses in a linear fashion, it is
not unsurprising that a linear relation-

American Journal of Obstetrics & Gynecology FEBRUARY 2013

ship does not exist between the C/U ratio

and the length of labor endured by the
fetus.
We did not observe any difference in
neonatal Apgar scores or UA pH values
between the different C/U ratio percentile groups. Although these provide further evidence of fetal compromise, they
are often normal or close to normal in
infants where abnormal heart rate patterns consistent with fetal compromise
are recognized and acted on. Neonatal
unit admission and neonatal encephalopathy are infrequent occurrences.
Given this, the sample size in this study
was not considered large enough for inferences to be drawn regarding these
outcome measures. When neonatal outcomes were combined to create a composite outcome score, there remained no
significant difference between the C/U
ratio groups. However, as the obstetric
team managing the labor was blinded to
the ultrasound results, neonatal outcomes cannot be reliably correlated to
C/U ratio values. Such conclusions can
only be drawn when intrapartum management decisions are guided by the C/U
ratio alone.
The C/U ratio has been used in the
management of the growth restricted fetus17-19 but to our knowledge this is the
first time that it has been used in a low
risk appropriately grown cohort. This
study suggests that the fetal C/U ratio,
measured before established labor, can
predict a diagnosis of intrapartum fetal
compromise, identifying fetuses at both
high and low risk of requiring emergency
delivery in labor. This effect is independent of parity, gestation, birthweight,
and maternal BMI. The negative predictive value of a C/U ratio 90th percentile
was 100% in this study suggesting that
the likelihood of fetal compromise was
minimal. We suggest this technique may
therefore be used to risk stratify pregnancies before active labor, allowing informed decisions to be made regarding
the mode and place of delivery. A recent
review of planned delivery locations (obstetric unit vs alongside midwifery unit
vs midwifery unit vs homebirth) for a
low risk cohort of women in the UK
demonstrated high transfer rates for all
nonobstetric birthplace settings.20 Prior

Obstetrics

www.AJOG.org
identification of fetuses at risk of intrapartum compromise may help alleviate
this problem.
Experience in our unit suggests the
Doppler studies described here can be
performed reliably by both doctors and
midwives once suitably trained. Reference ranges can be stored on portable
ultrasound machines available on most
delivery suites, allowing immediate
identification of at risk fetuses. This assessment is acceptable to patients, minimally invasive, and easily transferable to
clinical practice, allowing improved risk
stratification of pregnancies before labor.
ACKNOWLEDGMENTS
We thank Ms Sara Patterson-Brown for her expert opinion and helpful comments, the staff of
the delivery suite and day assessment unit at
Queen Charlottes and Chelsea hospital for their
kind assistance, and the Moonbeam Trust
(Charity no. 1110691) for funding this research.
All authors were funded by the Imperial College
Healthcare NHS Trust comprehensive Biomedical Research Centre (BRC) scheme.

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