Acta Obstetricia et Gynecologica.

2008; 87: 745
750

ORIGINAL ARTICLE

Acidemia at birth, related to obstetric characteristics and to oxytocin

use, during the last two hours of labor

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
1994
2004, 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) 3.25
7.49), oxytocin
use (OR 2.20, 95% CI 1.66
2.92), bearing down ]45 minutes (OR 1.77, 95% CI 1.31
2.38) and occipito-posterior
position (OR 2.18, 95% CI 1.19
3.98) were associated with acidemia at birth. In the multivariate analysis, only ]6
contractions/10 minutes (OR 5.36, 95% CI 3.32
8.65) and oxytocin use (OR 1.89, 95% CI 1.21
2.97) 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 (2
4).
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

dilatation of the cervix to delivery, regardless of the

urge to bear down, to ensure fetal well-being (2,5,6).
However, subsequent research has reported conflicting results on the effect of the duration of the second
stage on fetal morbidity (7
10).
In reports dealing with the second stage of labor,
information on uterine contraction frequency is
consistently lacking and oxytocin treatment is often
not thoroughly considered. The association between
oxytocin use, hyperstimulation and fetal distress is
well known (11
13). A few studies have reported an
association between acidemia at birth and oxytocin
administration (14,15). Considering the drugs
widespread and liberal use, this is of great importance in the assessment of obstetric care.

Correspondence: Maria Jonsson, Department of Womens and Childrens Health, Uppsala University, SE-751 85 Uppsala, Sweden.
E-mail: maria.jonsson@kbh.uu.se

(Received 19 March 2008; accepted 21 May 2008)

ISSN 0001-6349 print/ISSN 1600-0412 online # 2008 Informa UK Ltd. (Informa Healthcare, Taylor & Francis AS)
DOI: 10.1080/00016340802220352

746

M. Jonsson et al.

The aim of this study was to find possible

differences in the obstetric characteristics during
the last two hours of labor, especially with regard
to uterine contraction frequency and oxytocin use, in
neonates with and without acidemia at birth.
Material and methods
This is a case-control study of the period 1994
2004
rebro and Upfrom the delivery departments of O
psala University Hospitals in Sweden. The wards
maintain a computerized database containing data
prospectively entered from the medical charts,
delivery records and neonatal records by midwifery
rebro for the
personnel. Data were collected from O
years 1994
2002 and from Uppsala for 2003
2004.
Hospital policy at the centers included obtaining
umbilical blood gases in all deliveries whether
vaginal or cesarean. The database was searched for
all singleton newborns ]34 weeks gestational age
with an umbilical artery pH B7.05 irrespective of
Apgar score. The first two newborns delivered after
each study case with a cord artery pH ]7.05 and a
normal Apgar score (]7 at 5 minutes) were chosen
as controls and matched for parity. Newborns
delivered by elective cesarean section were excluded
as were cases with obstetric catastrophes (placental
abruption, cord prolapse and eclampsia).The delivery records were reviewed and maternal information
retrieved on age, parity, gestational age at delivery,
complications of pregnancy, use of intrapartal analgesia, mode of delivery and duration of bearing
down efforts. Complications of pregnancy or intercurrent disease such as hypertension disorders,
diabetes, autoimmune disease and asthma were
recorded. Neonatal gender, birth weight, Apgar
score, umbilical artery blood gas results, cord
entanglement and admission to the neonatal intensive care unit (NICU) were noted. At the delivery
ward in Uppsala, umbilical blood gas was obtained
from both artery and vein, which enabled quality
rebro only the umbilical
control of samples. In O
artery blood gas was analyzed but otherwise the
sampling technique was the same.
Of the blood gas samples in which paired pH and
pCO2 results were available, a venous-arterial pH
difference B0.03 and a pCO2 difference B1.0 kPa
were considered to originate from the same vessel.
Metabolic acidemia at birth was defined as umbilical
artery pH B7.05 and base deficit ]12 mmol/L. A
subanalysis of cases with metabolic acidemia was
done. Cardiotocography (CTG) tracings during the
last two hours of labor were reviewed in a blinded
fashion and according to the International Federation of Gynaecology and Obstetrics (FIGO) classi-

fication (16). If there was no tracing, if the trace was

too short (B20 minutes) to enable interpretation or
if intermittent auscultation was used, the tracing
was regarded as missing. Analysis of how the missing
CTG tracings were distributed among cases and
controls was done by creating pH intervals, viz.
B6.95, 6.95
6.99, 7.00
7.04, 7.05
7.09, . . . ]
7.30. Within the intervals the proportion of missing
CTG tracings was calculated. A hyperactive contraction pattern was defined as six or more contractions/10 minutes. Oxytocin use during the last two
hours of labor was recorded. The labor ward
protocol for oxytocin use was available at both units
with guidelines on how to monitor the effect of
oxytocin infusion and to avoid hyperstimulation.
Continous CTG tracings with oxytocin treatment
were required.
Onset of the second stage of labor was defined as
the time of full dilatation of the cervix. As it is not
possible to precisely determine the moment of full
dilatation the last two hours of labor were studied in
an attempt to analyze the second stage or the last
part of the second stage of labor. At the delivery
wards a tradition of delayed pushing is practised, i.e.
awaiting the urge to push.
The Statistical Package for Social Sciences (SPSS)
for Windows, version 15.0, was used (SPSS, Inc.,
Chicago, IL, USA). To compare group distributions
the chi-squared test or Fishers exact test were
applied and the Mann
Whitney U-test or t-test for
continuous variables. A p-value B0.05 was considered to indicate a significant difference.
Since most of the variables entered in the univariate analysis are interrelated a multivariate logistic
regression analysis was done to identify independent
risk factors for acidemia. Variables entered in the
multivariate analysis were age, postterm pregnancy,
oxytocin use ]6 contractions/10 minutes, cord
entanglement, occipito-posterior position and bearing down ]45 minutes. Odds Ratios (OR) with
95% confidence interval were calculated.
The study was approved by the Research Ethics
Committee at the University of Uppsala.
Results
There were a total of 28,486 deliveries at the two
units. Umbilical artery blood gas sampling was
obtained in 83% of deliveries, 349 (1.2%) had a
pH value B7.05 of which 305 remained by the
inclusion criteria. The majority of neonates born
with acidemia had a normal Apgar score, 252/305
(82.6%). Among cases 53% displayed a metabolic
component to the acidemia. Of paired pH and pCO2
sample results, 4.6% appeared to be taken from the

Neonatal acidemia and association to uterine contraction frequency

same vessel. In the control group 32 (5.2%) had a
pH value of 7.05
7.10, and 174 (28.5%) had a pH
value between 7.11
7.20.
There were no differences between the case and
the control groups in terms of gestational length,
complications of pregnancy or intercurrent disease,
birthweight or gender but a difference in age and
post-term pregnancy was observed (Table I). Methods of analgesia during labor did not differ between
cases and controls (Table II). Duration of bearing
down was longer in the case group (pB0.001) and
cord entanglement at delivery was more common
among cases (p B0.001). Cases were significantly
more often delivered by vacuum extraction (27.9%
vs. 8.9%) and in occipito-posterior position (7.5%
vs. 3.6%). Admission of the newborn to the NICU
differed between cases (31.9%) and controls (2.6%).
Among the cases 13.8% stayed in the NICU for 2
days compared to 1.0% of controls (p B0.001). Of
infants with metabolic acidemia NICU admission
was 45.6%.
Table III shows that the use of oxytocin infusion
during the last two hours of labor was more common
among cases, 61.2% vs. 41.7% (pB0.001). The
median duration of oxytocin treatment (total time)
was 120 minutes (25th percentile: 60 minutes, 75th
percentile: 300 minutes) in the case and 180 minutes
(25th percentile: 63 minutes, 75th percentile: 332
minutes) in the control group (not-significant (ns)).
Mean maximal infusion rate was 18913 mU/min
vs.16913 mU/min (ns).
Hyperactive labor occurred in 38.9% of cases vs.
11.3% of controls (p B0.001). In cases of hyperactive labor 75% (63/84) were treated with oxytocin
(Table III). Pathological cardiotocographic patterns
occurred in 68.8% of cases and 26.1% of controls
(pB0.001). About 16% of CTG tracings were

missing, in 12.1% of cases and 20.3% of controls

(p B0.05). Tracings missing were evenly distributed
in the intervals of pH B7.15. In the higher pH
intervals the proportion of missing tracings was more
marked. An adequate tocographic registration was
not achieved in 34.4% (28% of cases and 37.6% of
controls) (pB0.001). Of patients receiving oxytocin
treatment, CTG tracings were missing in 11% (8.1%
cases, 13.4% controls) and 22% were not adequately
supervised with regard to uterine contraction frequency (18% cases, 25% controls ns). Oxytocin
infusion was started despite an abnormal CTG
tracing in 11%, cases 16.6% vs. controls 6.3%.
The results of the multivariate analysis demonstrated that significant risk factors associated with
pH B7.05 were ]6 contractions/10 minutes, oxytocin use and cord entanglement (Table IV). Duration
of bearing down and occipito-posterior position were
significantly more common but reduced and not
significant in the multivariate analysis. Among cases,
a subanalysis on neonates with metabolic acidemia
compared with neonates without metabolic acidemia
showed that mean pH was 6.9790.07 compared to
7.0290.03 and base deficit 15.593.7 compared to
9.292.05 in neonates with no metabolic acidemia
(p B0.001). There was no difference in the use of
oxytocin, hyperactive uterine activity or overstimulated labor during the last two hours of labor. The
median duration of oxytocin treatment (total time)
was 120 minutes (25th percentile: 65 minutes, 75th
percentile:324 minutes) in the group with metabolic
acidemia and 106 minutes (25th percentile:
60 minutes, 75th percentile: 300 minutes) in
the group without (ns). Mean maximal infusion
rates were 17914 mU/min vs. 18912.5 mU/min,
respectively (ns).

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)
SGABmean
2 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

Cases n305 n (%)

Controls n610 n (%)

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

Bearing down efforts (minutes)

Vacuum extraction
Cesarean delivery
Breech presentation
Occipito-posterior
Cord entanglement
Epidural anesthesia
Petidine
PCB

PCBpara cervical blockade.

Values are given as n (%) and means9standard deviation (SD).
nsnon-significant.

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 (17
19).
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

]7.15, could possibly cause an underestimation of

the difference between cases and controls.
Findings on the association between occipitoposterior position and adverse neonatal outcomes
are contradictory (20
22). In a large retrospective
cohort study Cheng et al. reported an association of
umbilical cord gas acidemia and occipito-posterior
position. In that study, length of labor, but not
oxytocin use or uterine activity, was controlled for in
the multivariate analysis, which could explain why
the reported results are contradictory to results
presented here (22).
The last two hours of labor were evaluated to
cover the part of the second stage when pushing
efforts are actively used. There correct obstetric
management is of vital importance. During the first
stage of labor there is only a slight decline in fetal pH
in normal labor, which is of no clinical significance
(23
26), and lactic acid concentration is unchanged
(25). During the second stage of labor there is a
more marked decline in fetal pH, especially in the
pushing phase (23,27,28). During the pushing phase
of the second stage there is a decline in fetal pH
values and an increase in lactic acid, with hypoxic
effects on the fetus (2,4,29). In studies with a cut-off
value for acidemia comparable to that used in
the present study, the duration of the second stage
was no risk factor for acidemia at birth (10,14).

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)

Controls n610 n (%)

254
303
43
29

(41.6)
(80.1)
(11.3)
(7.4)

p-value
B0.001
0.001
B0.001
B0.001

Neonatal acidemia and association to uterine contraction frequency

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)

(3.25
7.49)
(1.66
2.92)
(1.88
3.73)
(1.19
3.98)
(1.31
2.38)

5.36
1.89
4.08
1.59
1.42

(3.32
8.65)
(1.21
2.97)
(2.49
6.67)
(0.60
4.18)
(0.91
2.22)

ORodds ratio; CIconfidence interval.

Therefore, according to the literature, the critical

factor impacting on fetal outcome is duration of
active bearing down rather than duration of the
second stage. However, we could not find an
association between duration of bearing down and
acidemia at birth when contraction pattern and
oxytocin use had been considered. This underlines
the importance of avoiding a hyperactive contraction
pattern during the bearing down period.
The association between hyperactive labor and
acidemia is in agreement with previous reports
(30,31). A notable finding was that hyperactive
contraction patterns were mostly combined with
oxytocin use. This indicated that guidelines were
not followed and that acidemia could have been
avoided to some extent. Too frequent uterine contractions are generally considered to be the cause of
fetal compromise in oxytocin-stimulated labors. To
our knowledge, the present study is the first to
demonstrate that oxytocin use is a risk factor for
acidemia after considering the influence of increased
uterine activity. In this study, 11% of the patients
(cases and controls) receiving oxytocin did not have
adequate fetal heart rate monitoring and 22% had no
monitoring of uterine activity. This is a cause for
concern and a clear deviation from labor ward
departmental guidelines for oxytocin use, which
stipulated that continuous CTG monitoring was
required with oxytocin administration. To give
oxytocin despite a non-reassuring CTG tracing is
also alarming and unwarranted.
Our results, demonstrating an association between
oxytocin use and acidemia, are in agreement with the
results from a study by Herbst et al. who also defined
acidemia as an umbilical artery pH B7.05 (14). Both
studies used data from clinical practice. By contrast,
several prospective studies on oxytocin induced or
augmented labor have not shown an increased risk of
acidemia (32
35). In those studies, strict protocols
limited the use of oxytocin and discontinuation or
decrease of the infusion was applied in situations of
hyperstimulation, resulting in improvement of the
fetal status. Consequently, results in studies regard-

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.

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