Predicting umbilical artery pH during labour: Development and validation of a nomogram using fetal heart rate...

Nomograms are statistical models that combine variables to obtain the most accurate and reliable prediction for a particular risk. Fetal heart rate (FHR) interpretation alone has been found to be poorly predictive for fetal acidosis while other clinical risk factors exist. The aim of this study was to create and validate a nomogram based on FHR patterns and relevant clinical parameters to provide a non-invasive individualized prediction of umbilical artery pH during labour.

A retrospective observational study was conducted on 4071 patients in labour presenting singleton pregnancies at >34 gestational weeks and delivering vaginally. Clinical characteristics, FHR patterns and umbilical cord gas of 1913 patients were used to construct a nomogram predicting an umbilical artery (Ua) pH <7.18 (10th centile of the study population) after an univariate and multivariate stepwise logistic regression analysis. External validation was obtained from an independent cohort of 2158 patients. Area under the receiver operating characteristics (ROC) curve, sensitivity, specificity, positive and negative predictive values of the nomogram were determined.

Upon multivariate analysis, parity (p < 0.01), induction of labour (p = 0.01), a prior uterine scar (p = 0.02), maternal fever (p = 0.02) and the type of FHR (p < 0.01) were significantly associated with an Ua pH <7.18 (p < 0.05). Apgar score at 1, 5 and 10 min were significantly lower in the group with an Ua pH <7.18 (p < 0.01). The nomogram constructed had a Concordance Index of 0.75 (area under the curve) with a sensitivity of 57%, a specificity of 91%, a negative predictive value of 5% and a positive predictive value of 99%. Calibration found no difference between the predicted probabilities and the observed rate of Ua pH <7.18 (p = 0.63). The validation set had a Concordance Index of 0.72 and calibration with a p < 0.77.

We successfully developed and validated a nomogram to predict Ua pH by combining easily available clinical variables and FHR. Discrimination and calibration of the model were statistically good. This mathematical tool can help clinicians in the management of labour by predicting umbilical artery pH based on FHR tracings.