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{{Infobox diagnostic
| name = Fetal scalp blood testing
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| purpose = assess fetal oxygenation
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'''Fetal scalp blood testing''' is a technique used in [[obstetrics]] during active [[childbirth|labor]] to confirm whether a fetus is receiving enough oxygen. This is a supplementary procedure used to determine if fetal [[Acidosis|acidemia]] has occurred following fetal cardiac distress.<ref name="Bohiltea_2022">{{cite journal | vauthors = Bohiltea RE, Mihai BM, Ducu I, Cioca AM, Bohiltea AT, Iordache AM, Iordache SM, Grigorescu CE, Marinescu S | display-authors = 6 | title = Current Innovative Methods of Fetal pH Monitoring-A Brief Review | journal = Diagnostics | volume = 12 | issue = 11 | pages = 2675 | date = November 2022 | pmid = 36359522 | pmc = 9689968 | doi = 10.3390/diagnostics12112675 | doi-access = free }}</ref> While continuous fetal heart rate monitoring is the primary method for assessing fetal wellbeing during labor, a change in fetal heart rate is not indicative of fetal acidemia.<ref name="Bohiltea_2022" /><ref>{{Cite web |title=Fetal scalp pH testing Information {{!}} Mount Sinai - New York |url=https://www.mountsinai.org/health-library/tests/fetal-scalp-ph-testing |access-date=2023-08-01 |website=Mount Sinai Health System |language=en-US}}</ref> Some of the signs and symptoms of oxygen deprivation are pH in the umbilical cord, abnormal fetal heartbeat and abnormal coloration of amniotic fluid.<ref>{{cite journal | vauthors = van Tetering AA, van de Ven J, Fransen AF, Dieleman JP, van Runnard Heimel PJ, Oei SG | title = Risk factors of incomplete Apgar score and umbilical cord blood gas analysis: a retrospective observational study | journal = The Journal of Maternal-Fetal & Neonatal Medicine | volume = 30 | issue = 21 | pages = 2539–2544 | date = November 2017 | pmid = 27884069 | doi = 10.1080/14767058.2016.1256985 | s2cid = 744955 | url = https://pure.tue.nl/ws/files/96700588/teterisk2017.pdf }}</ref><ref name=":0" /> This correlation can only be concluded by sampling fetal scalp blood and measuring acid status.<ref name="Bohiltea_2022" /> Therefore, fetal scalp blood testing could be used to reduce the number of unnecessary emergency caesarean sections made on the decision of fetal heart rate alone.<ref name="Bohiltea_2022" />

Fetal blood sampling is a useful procedure that can diagnose, treat, or monitor different fetal problems. With the help of a small needle, various providers and specialists can remove small amounts of blood from the fetus. This procedure is used to help determine blood type, diagnose genetic abnormalities, identify fetal infections, fetal anemia, and low platelet count. With the help of continuous ultrasound guidance to place the needle in the abdomen into the tiny fetal blood vessel, the blood sample gets obtained and sent for testing.<ref>{{Cite web | vauthors = McMacken M |title=Fetal Blood Sampling |url=https://www.hopkinsmedicine.org/gynecology_obstetrics/specialty_areas/fetal_therapy/fetal-interventions-procedures/fetal_blood_sampling.html |access-date=2023-07-28 |website=www.hopkinsmedicine.org |language=en}}</ref> Therefore, due to limitation in adding value, fetal scalp testing can serve as second line test to provide and strengthen the information on fetal acidosis and hypoxia status obtained from [[Cardiotocography|cardiocotography (CTG)]].<ref>{{cite journal | vauthors = Urdal J, Engan K, Eftestøl T, Haaland SH, Kamala B, Mdoe P, Kidanto H, Ersdal H | display-authors = 6 | title = Fetal heart rate development during labour | journal = BioMedical Engineering OnLine | volume = 20 | issue = 1 | pages = 26 | date = March 2021 | pmid = 33726745 | pmc = 7962212 | doi = 10.1186/s12938-021-00861-z | doi-access = free }}</ref><ref>{{cite journal | vauthors = Hilal Z, Mrkvicka J, Rezniczek GA, Dogan A, Tempfer CB | title = Accuracy of intrapartum fetal blood gas analysis by scalp sampling: A retrospective cohort study | journal = Medicine | volume = 96 | issue = 49 | pages = e8839 | date = December 2017 | pmid = 29245247 | pmc = 5728862 | doi = 10.1097/MD.0000000000008839 }}</ref> Cardiocotography is the primary means of monitorning a fetus during pregnancy as well as labour.<ref name=":0">{{cite journal | vauthors = Alarcón-Rodríguez R, Martín-Álvarez MP, García-González J, Requena-Mullor M, Rodríguez-García MC, Zheng R, Rey RR | title = Determination of Foetal Scalp Blood Sampling pH as an Indicator of Loss of Foetal Well-Being in Women Undergoing Caesarean Section | journal = Healthcare | volume = 11 | issue = 5 | pages = 725 | date = March 2023 | pmid = 36900730 | pmc = 10001157 | doi = 10.3390/healthcare11050725 | doi-access = free }}</ref>

Fetal blood sampling is a complex procedure and performed when other tests are not possible. It can be done for pregnancies that are 18 weeks or later. The procedure has many benefits such as providing specific information about the baby's health and the ability to treat babies with any severe blood diseases before birth. Potential risks include bleeding from the fetal blood sampling site, infection, changes to heart rate, and death.<ref>{{Cite web |title=default - Stanford Medicine Children's Health |url=https://www.stanfordchildrens.org/en/topic/default?id=fetal-blood-sampling-90-P02447 |access-date=2023-07-31 |website=www.stanfordchildrens.org}}</ref>

== History ==
The use of fetal scalp blood testing originated in Germany in 1961 and required 0.25 mL of blood drawn from the fetus.<ref name="Bohiltea_2022" /> As one of the first methods of monitoring fetal wellbeing during labor, there were many disadvantages including the need for at least 3&nbsp;cm dilation of the mother and extreme precision from the physician performing the procedure.<ref name="Cummins_2018">{{cite journal | vauthors = Cummins G, Kremer J, Bernassau A, Brown A, Bridle HL, Schulze H, Bachmann TT, Crichton M, Denison FC, Desmulliez MP | display-authors = 6 | title = Sensors for Fetal Hypoxia and Metabolic Acidosis: A Review | journal = Sensors | volume = 18 | issue = 8 | pages = 2648 | date = August 2018 | pmid = 30104478 | pmc = 6111374 | doi = 10.3390/s18082648 | bibcode = 2018Senso..18.2648C | doi-access = free }}</ref> Now, fetal scalp blood testing requires a considerable less amount of blood depending if testing pH or lactate.

One safer alternative to fetal scalp blood testing is what is called fetal scalp stimulation. It is a diagnostic test that helps detect metabolic acidemia. Fetal scalp stimulation is a second-line test that helps provide specialists reassurance that the labor process can safely continue.<ref>{{cite journal | vauthors = Murphy DJ, Devane D, Molloy E, Shahabuddin Y | title = Fetal scalp stimulation for assessing fetal well-being during labour | journal = The Cochrane Database of Systematic Reviews | volume = 1 | issue = 1 | pages = CD013808 | date = January 2023 | pmid = 36625680 | pmc = 9831024 | doi = 10.1002/14651858.CD013808.pub2 | collaboration = Cochrane Pregnancy and Childbirth Group }}</ref> In complicated pregnancies, it is recommended that there is continuous monitoring of the baby's heart rate using an electronic recorder, or CTG. During labor, babies can show abnormal readings on the CTG and, in some cases, this warrants an emergency caesarean section. To avoid this emergency C-section, the baby's scalp is stimulated vaginally to cause an increase in heart rate. This response is indicative that the baby is healthy and receiving enough oxygen and this test also provides a safe alternative as opposed to taking a small blood sample from the baby's scalp and testing the acid-base levels in the blood. This test is beneficial because it reduces the need to have to perform an emergency C-section when it may not be needed.<ref>{{Cite journal |title=Stimulating the baby's scalp as a test of the baby's well-being in labour |url=https://www.cochrane.org/CD013808/PREG_stimulating-babys-scalp-test-babys-well-being-labour |access-date=2023-07-30 |journal=The Cochrane Database of Systematic Reviews |date=2023 |doi=10.1002/14651858.CD013808.pub2 |pmid=36625680 |language=en |last1=Murphy |first1=D. J. |last2=Devane |first2=D. |last3=Molloy |first3=E. |last4=Shahabuddin |first4=Y. |volume=1 |issue=1 |pages=CD013808 |pmc=9831024 }}</ref>

== Procedure ==
During a fetal scalp blood testing procedure, a small incision on the fetal scalp is made and blood is collected using a capillary tube.<ref name="Cummins_2018" /><ref>{{Cite web |title=Nail abnormalities: MedlinePlus Medical Encyclopedia |url=https://medlineplus.gov/ency/article/003247.htm |access-date=2023-08-01 |website=medlineplus.gov |language=en}}</ref> An amnioscope with a light source is used to expose the scalp of the fetus, and the procedure requires at least 3 to 4&nbsp;cm of cervical dilation to visualize the fetal scalp.<ref name="Cummins_2018" /><ref name="Carbonne_2016">{{cite journal |vauthors=Carbonne B, Pons K, Maisonneuve E |date=January 2016 |title=Foetal scalp blood sampling during labour for pH and lactate measurements |journal=Best Practice & Research. Clinical Obstetrics & Gynaecology |series=Intrapartum Fetal Surveillance |volume=30 |pages=62–67 |doi=10.1016/j.bpobgyn.2015.05.006 |pmid=26253238|doi-access=free }}</ref> After blood collection, pH and/or lactate levels are tested requiring up to 25 minutes per sample.<ref name="Cummins_2018" />

Fetal scalp blood testing is associated with a relatively high failure rate of up to 20% due to variables such as sample contamination with air or amniotic fluid, or inadequate sample volume.<ref name="Cummins_2018" /><ref name="Carbonne_2016" /> Moreover, this process may be invasive, time-consuming, and painful for mother during labour.<ref name="Cummins_2018" /> Rare complications have also been reported including infection, excessive bleeding, and leakage of cerebral spinal fluid.<ref name="Cummins_2018" /> Fetal scalp blood testing should be avoided when there is a potential risk of infection (e.g. HIV, Hepatitis B, Hepatitis C) or any suspicions of rare bleeding disorders in newborns, known as [[Haemophilia|hemophilia]].<ref name="Cummins_2018" /><ref name="Carbonne_2016" /><ref>{{cite journal | vauthors = Murphy DJ, Devane D, Molloy E, Shahabuddin Y | title = Fetal scalp stimulation for assessing fetal well-being during labour | journal = The Cochrane Database of Systematic Reviews | volume = 1 | issue = 1 | pages = CD013808 | date = January 2023 | pmid = 36625680 | pmc = 9831024 | doi = 10.1002/14651858.CD013808.pub2 | collaboration = Cochrane Pregnancy and Childbirth Group }}</ref>

The procedure is contraindicated in the case of pregnancies less than 34 weeks, abnormal fetal heart rate, abnormal fetal blood status, and maternal infection.<ref>{{Cite book | vauthors = Young C, Ryce A |url=http://www.ncbi.nlm.nih.gov/books/NBK532205/ |title=Fetal Scalp Lactate Testing During Intrapartum Pregnancy with Abnormal Fetal Heart Rate: A Review of Clinical Effectiveness, Cost-Effectiveness, and Guidelines | date=2018 |publisher=Canadian Agency for Drugs and Technologies in Health |series=CADTH Rapid Response Reports |location=Ottawa (ON) |pmid=30329245}}</ref>

== Fetal Monitoring Parameters ==
Two components that are commonly tested using this method are [[pH]]<ref name="urlFetal scalp pH testing: MedlinePlus Medical Encyclopedia">{{cite encyclopedia |title=Fetal scalp pH testing |url=https://www.nlm.nih.gov/medlineplus/ency/article/003408.htm |access-date=2010-01-17 |encyclopedia=MedlinePlus Medical Encyclopedia |publisher=U.S. National Library of Medicine}}</ref> and [[Lactic acid|lactate]], both being indicators of [[acid base homeostasis]]. A low pH and high level of lactate indicate that there is [[acidosis]], which in turn is associated with [[hypoxia (medical)|hypoxia]]. The two different types of fetal acidosis are respiratory acidosis or metabolic acidosis. Respiratory acidosis occurs when carbon dioxide accumulates due to decreased placental elimination. This is caused by an increase in pressure on the umbilical cord, but is quickly corrected upon childbirth as carbon dioxide levels return to normal once the baby begins breathing.<ref name="Demaegd_2020">{{cite journal | vauthors = Demaegd H, Bauters E, Page GH | title = Foetal scalp blood sampling and ST-analysis of the foetal ECG for intrapartum foetal monitoring: a restricted systematic review | journal = Facts, Views & Vision in ObGyn | volume = 11 | issue = 4 | pages = 337–346 | date = March 2020 | pmid = 32322830 | pmc = 7162663 }}</ref> Metabolic acidosis is caused by anaerobic cell metabolism due to hypoxia. Anaerobic metabolism results in the production of lactate, which breaks down and lowers blood pH.<ref name="Abdul Halim_2022">{{cite journal | vauthors = Abdul Halim SF, Zakaria Z, Pusppanathan J, Mohd Noor A, Norali AN, Fazalul Rahiman MH, Mohd Muji SZ, Abdul Rahim R, Engku-Husna EI, Ali Hassan MK, Aziz Safar MJ, Salleh AF, Mat Som MH | display-authors = 6 | title = A Review on Magnetic Induction Spectroscopy Potential for Fetal Acidosis Examination | journal = Sensors | volume = 22 | issue = 4 | pages = 1334 | date = February 2022 | pmid = 35214235 | pmc = 8963069 | doi = 10.3390/s22041334 | bibcode = 2022Senso..22.1334A | doi-access = free }}</ref> Even after correction, metabolic acidosis can persist for several hours before correction after childbirth.<ref name="Demaegd_2020" />

Uterine contractions during labor and delivery decrease placental blood flow, therefore the fetus is at an increased risk of hypoxia.<ref>{{Cite web |title=Fetal scalp blood sampling |url=https://acutecaretesting.org/en/articles/fetal-scalp-blood-sampling |access-date=2023-08-01 |website=acutecaretesting.org}}</ref> This is considered as one of the causes of acute fetal hypoxia among the likes of umbilical cord compression and myometrial contractures.<ref>{{cite journal | vauthors = Giussani DA | title = The fetal brain sparing response to hypoxia: physiological mechanisms | journal = The Journal of Physiology | volume = 594 | issue = 5 | pages = 1215–1230 | date = March 2016 | pmid = 26496004 | pmc = 4721497 | doi = 10.1113/JP271099 }}</ref>

Changes in fetal blood acidity can result in a shift in blood flow away from critical organs, particularly the brain.<ref name="Abdul Halim_2022" /> Conditions which have been reported in newborns who suffered fetal acidemia include [[Cerebral hypoxia|hypoxic-ischemic encephalopathy]] and [[periventricular leukomalacia]].<ref name="Abdul Halim_2022" />

Scalp pH and lactate testing appear to have similar [[sensitivity and specificity|sensitivity]] in predicting umbilical artery acidemia.<ref name="Wiberg-Itzel2008">{{cite journal | vauthors = Wiberg-Itzel E, Lipponer C, Norman M, Herbst A, Prebensen D, Hansson A, Bryngelsson AL, Christoffersson M, Sennström M, Wennerholm UB, Nordström L | display-authors = 6 | title = Determination of pH or lactate in fetal scalp blood in management of intrapartum fetal distress: randomised controlled multicentre trial | journal = BMJ | volume = 336 | issue = 7656 | pages = 1284–1287 | date = June 2008 | pmid = 18503103 | pmc = 2413392 | doi = 10.1136/bmj.39553.406991.25 }}</ref> Analysis of pH requires a relatively large amount of blood (30–50 μl), and sampling failure rates of 11–20% have been reported.<ref name="Wiberg-Itzel2008" /> Analysis of lactate only requires 5 μl of blood and can more accurately identify the cause of acidosis if metabolically induced.<ref name="Wiberg-Itzel2008" /><ref name="Demaegd_2020" /> Based on clinical literature, there has been discordance between scalp pH and lactate measurements, especially when the cervix was fully dilated. Using lactate values rather than pH or both could result in an increase in obstetric interventions without decreasing severe acidosis. Fetal scalp lactate measurements also require a much smaller volume of blood whereas fetal blood sampling is more invasive. A smaller volume of blood is required for testing of fetal blood sampling for lactate estimation. This test can help determine an abnormal fetal heart rate pattern. Also, this test requires a smaller volume of blood compared to a pH estimation.<ref>{{cite journal | vauthors = East CE, Leader LR, Sheehan P, Henshall NE, Colditz PB, Lau R | title = Intrapartum fetal scalp lactate sampling for fetal assessment in the presence of a non-reassuring fetal heart rate trace | journal = The Cochrane Database of Systematic Reviews | issue = 5 | pages = CD006174 | date = May 2015 | pmid = 25929461 | doi = 10.1002/14651858.CD006174.pub3 | editor-last = Cochrane Pregnancy and Childbirth Group | doi-access = free | pmc = 10823414 }}</ref>

{| class="wikitable"
|+ Reference ranges<ref name="Abdul Halim_2022" />
! !! pH !! Lactate
|-
! Normal 
| ≥ 7.25 || ≤ 4.1&nbsp;mmol/L 
|-
! Pre-acidemia 
| 7.21–7.24 || 4.2–4.8&nbsp;mmol/L 
|-
! Acidemia 
| ≤ 7.20 || ≥ 4.9&nbsp;mmol/L 
|}
During pregnancy, placental gas-exchange is primarily responsible for fetus well-being. Placental dysfunction can results in fetal risks such as acidosis, hypoxia, and stillbirth. The normal arterial pH of the fetus is approximately 7.35 before labor.<ref name="Cummins_2018" /><ref name="Carbonne_2016" /> Furthermore, there is a declined in pH which has shown that the mean umbilical arterial pH at birth predicts a pH > 7.25.<ref>{{cite journal | vauthors = Baschat AA, Galan HL, Lee W, DeVore GR, Mari G, Hobbins J, Vintzileos A, Platt LD, Manning FA | display-authors = 6 | title = The role of the fetal biophysical profile in the management of fetal growth restriction | journal = American Journal of Obstetrics and Gynecology | volume = 226 | issue = 4 | pages = 475–486 | date = April 2022 | doi = 10.1016/j.ajog.2022.01.020 | pmid = 35369904 | s2cid = 247911334 }}</ref> An abnormal decreases in pH, on the other hand, is shown that there may be a potential risk of acidosis in fetus if the pH is below a threshold of 7.21.<ref name="Cummins_2018" /><ref name="Carbonne_2016" />

Fetal scalp blood testing for lactate became well-known in the 1990s.<ref name="Carbonne_2016" /> One study has shown that there is a correlation between both umbilical cord pH and lactate measurement in fetus arterial blood.<ref name="Carbonne_2016" /> From a physiological standpoint, lactate levels in tissues earlier increase before pH decreases in oxygenation deficiency. The advantages of lactate measurement is that it is required 5 μl of fetal blood for analysis and provided immediate results compared to pH scalp testing.<ref name="Carbonne_2016" /><ref name="Wiberg-Itzel2008" /> One of the observational studies suggested that a threshold of 4.8&nbsp;mmol/L of lactate scalp measurement was chosen to prevent acidemia in newborns, which is corresponding to fetal scalp pH of 7.21.<ref name="Cummins_2018" /><ref name="Carbonne_2016" />

Using scalp lactate measurements compared to pH helps provide an easier and more affordable method than continuous electronic fetal monitoring. Nevertheless, literature has shown that both methods has no significant difference in measuring oxygen deprivation as well as in fetal outcome after delivery.<ref>{{Cite journal |title=Use of fetal scalp blood lactate for assessing fetal well-being during labour |url=https://www.cochrane.org/CD006174/PREG_use-of-fetal-scalp-blood-lactate-for-assessing-fetal-well-being-during-labour |access-date=2023-08-04 |journal=The Cochrane Database of Systematic Reviews |date=2015 |doi=10.1002/14651858.CD006174.pub3 |pmid=25929461 |language=en |last1=East |first1=C. E. |last2=Leader |first2=L. R. |last3=Sheehan |first3=P. |last4=Henshall |first4=N. E. |last5=Colditz |first5=P. B. |last6=Lau |first6=R. |issue=5 |pages=CD006174 |doi-access=free |pmc=10823414 }}</ref>

== Advancements ==
Improvements to the fetal blood scalp test procedure have been attempted to decrease invasiveness. Researchers have created a portable oximeter device which attaches to the hand of a physician and allows for the measurement of fetal oxygenation status. This method does not require blood draw from the scalp of the fetus, but instead acts as a indirect measurement of fetal blood pH status by measuring oxygen saturation.<ref name="Bohiltea_2022" /> Furthermore, studies are being done to evaluate and compare between the fetal scalp blood test and digital fetal scalp blood test, an alternative to fetal scalp blood test that is less invasive, as a second-line test for fetal hypoxia and acid-base status.<ref>{{cite journal | vauthors = Murphy DJ, Shahabuddin Y, Yambasu S, O'Donoghue K, Devane D, Cotter A, Gaffney G, Burke LA, Molloy EJ, Boland F | display-authors = 6 | title = Digital fetal scalp stimulation (dFSS) versus fetal blood sampling (FBS) to assess fetal wellbeing in labour-a multi-centre randomised controlled trial: Fetal Intrapartum Randomised Scalp Stimulation Trial (FIRSST NCT05306756) | journal = Trials | volume = 23 | issue = 1 | pages = 848 | date = October 2022 | pmid = 36195894 | pmc = 9531493 | doi = 10.1186/s13063-022-06794-9 | doi-access = free }}</ref>

== See also ==
* [[Fetal scalp stimulation test]]

== References ==
{{reflist}}

{{Obstetrical procedures}}

[[Category:Tests during pregnancy]]