Relation between umbilical cord blood pH, base deficit, lactate, 5-minute Apgar score and development of hypoxic ischemic encephalopathy
Open accessAbstract
OBJECTIVE: Umbilical cord acid-base analysis is fundamental for assessing intrapartum hypoxia. The accuracy of arterial umbilical cord blood lactate, pH and base deficit to reflect a low 5-minute Apgar score and hypoxic ischemic encephalopathy (HIE) stage 2-3 was assessed, and new gestational age-adjusted reference standards were compared with traditional stationary reference values. DESIGN AND SAMPLE: A total of 13,735 pH-validated routine cord acid-base values from singleton deliveries were tested with stationary and gestational age-adjusted reference values using receiver operating characteristic curves and calculation of area under curve. SETTING: University hospital. MAIN OUTCOME MEASURES: Accuracy of low pH, high base deficit and high lactate, alone or in combination, to imply 5-minute Apgar score < 7 or < 4 or HIE. RESULTS: Gestational age-adjusted values were for all parameters significantly better than crude values to indicate Apgar score < 7. For Apgar score < 4, the differences were not significant. The frequency of HIE was 0.046%, making statistical analyses pointless. Gestational age-adjusted lactate had the overall best accuracy and among combinations; a low age-adjusted pH plus high age-adjusted lactate was slightly better than a low age-adjusted pH plus high age-adjusted base deficit. The sensitivity and positive predictive value were low for all parameters. CONCLUSIONS: Lactate in cord arterial blood at birth is at least as good as base deficit to reflect an impaired condition at birth, and best when gestational age-adjusted values are used. Due to methodological confounding involved in calculation of base deficit, lactate may replace base deficit as an acid-base outcome parameter at birth.
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In a study of 13,735 deliveries, gestational age-adjusted reference standards were significantly better than stationary ROCC-optimal values for all blood gas and lactate parameters in indicating an Apgar score <7, but for Apgar score <4 there were no significant differences.
“Gestational age-adjusted values were significantly better than the stationary ROCC-optimal values for all blood gas and lactate parameters in indicating an Apgar score <7, but for Apgar score <4 there were no significant differences.”
From Umbilical cord pH, blood gases, and lactate at birth: normal values, interpretation, and clinical utility. (2023) · cites this paper as [59]
In the same study of 13,735 deliveries, there were only 6 neonates with HIE stages 2 to 3 (0.046%); only 3 had a pH <7.10 and none a pH <7.00.
“there were only 6 ajog.org Expert Review neonates with HIE stages 2 to 3 (0.046%);only 3 of them had a pH <7.10 and none a pH <7.00.”
From Umbilical cord pH, blood gases, and lactate at birth: normal values, interpretation, and clinical utility. (2023) · cites this paper as [59]
In the authors' own unselected series of 13,735 newborns, 6 neonates (0.046%) developed HIE stages 2 and 3 despite all of them having a cord artery pH >7.00.
“Such a poor agreement between cord blood pH and clinical signs of encephalopathy was also demonstrated in our own unselected series of 13,735 newborns, where altogether 6 neonates (0.046%) developed HIE stages 2 and 3 despite all of them having a cord artery pH >7.00.59”
From Umbilical cord pH, blood gases, and lactate at birth: normal values, interpretation, and clinical utility. (2023) · cites this paper as [59]
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MethodThe significance of base deficit in acidemic term neonates
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ResultUmbilical Cord Venous Lactate for Predicting Arterial Lactic Acidemia and Neonatal Morbidity at Term
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“In a recent study, we found that lactic acid (lactate) had a better accuracy than BDblood to reflect a five minute Apgar score < 7, both with regard to crude values and to gestational age-adjusted values (24).”
Can biochemical markers predict the severity of hypoxic-ischemic encephalopathy?
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ResultHypoxic-ischemic encephalopathy following intrapartum asphyxia: is it avoidable?
Tarvonen, M. J., Jernman, R. M., Stefanović, V., Tuppurainen, V., Karikoski, R., Haataja, L., & Andersson, S. (2025) · American Journal of Obstetrics and Gynecology · doi:10.1016/j.ajog.2025.04.073 · Cited by 15 · see citing works
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“For those children where only the pH from the umbilical vein was registered (n¼ 72), we withdrew 0.03 from the pH value to get an estimated arterial value (Westgate et al. 1994; Wiberg et al. 2010).”
InfluentialBlood gas measures as predictors for neonatal encephalopathy severity
Sakpichaisakul, K., Supapannachart, K. J., El‐Dib, M., Szakmár, E., Yang, E., Walsh, B. H., Robinson, J. N., Cherkerzian, S., Volpe, J. J., & Inder, T. E. (2021) · Journal of Perinatology · doi:10.1038/s41372-021-01075-w · Cited by 11 · see citing works
“In general higher aUCG lactate has been found to predict neonatal morbidity, but controversy remains in determining what cutoff values would adequately identify infants at risk for adverse neurological outcomes [13, 14].”
BackgroundAshoori, M., O’Toole, J. M., Garvey, A. A., O’Halloran, K. D., Walsh, B. H., Moore, M., Pavel, A. M., Boylan, G. B., Murray, D. M., Dempsey, E. M., et al. (2024) · The Journal of Physiology · doi:10.1113/jp287001 · Cited by 10 · see citing works
“A combination of clinical data, commonly used for the early identification of infants at risk of HIE (Wiberg et al., 2010), were analysed for predictive value.”
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“This is in accordance with earlier studies of fetal lactate concentration in the antepartum period and at delivery [2,4].”
BackgroundResultDetermination of base excess in umbilical cord blood at birth: accessory or excess?
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Umbilical Artery Lactate Correlates with Brain Lactate in Term Infants
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Sundberg, T.-M., Wiberg, N., Källén, K., & Zaigham, M. (2023) · BMC Pregnancy and Childbirth · doi:10.1186/s12884-023-05487-8 · Cited by 8 · see citing works
“On the other hand, Wiberg and colleagues [29] found that umbilical cord lactate values were as good as cord pH or base deficit in predicting depressed neonatal condition at birth.”
BackgroundAmmitzbøll, I. L. A., Andersen, B. R., Lange, K. H. W., Clausen, T. D., & Løkkegaard, E. C. L. (2023) · European Journal of Obstetrics & Gynecology and Reproductive Biology · doi:10.1016/j.ejogrb.2023.02.012 · Cited by 8 · see citing works
Long-term neurodevelopmental effects of exclusively high cord lactate levels in term newborn
Yılmaz, A., Çebi, M. N., Yılmaz, G., Karacaoglu, G., Aydın, S. N., Perk, Y., & Vural, M. (2023) · The Journal of Maternal-Fetal & Neonatal Medicine · doi:10.1080/14767058.2023.2284115 · Cited by 7 · see citing works
“The most sensitive blood gas parameter was reported to be the lactate level when it was adjusted for the gestational week in the same survey [35].”
BackgroundZaigham, M., Källén, K., & Olofsson, P. (2018) · Acta Obstetricia Et Gynecologica Scandinavica · doi:10.1111/aogs.13384 · Cited by 6 · see citing works
Peripartum events associated with severe neurologic morbidity and mortality among acidemic neonates
Zuarez-Easton, S., Hosary, S., Zafran, N., Garmi, G., Felszer, C., & Salim, R. (2018) · Archives of Gynecology and Obstetrics · doi:10.1007/s00404-018-4657-0 · Cited by 6 · see citing works
“Umbilical artery blood pH and base deficit values are objective tools obtained immediately after birth to assess fetal well-being during the course of labor [7].”
BackgroundYılmaz, A., Kaya, N., Ülkersoy, İ., Taner, H. E., Çulpan, H. C., Kaymak, D., Perk, Y., & Vural, M. (2022) · Turkish Archives of Pediatrics · doi:10.5152/turkarchpediatr.2022.22079 · Cited by 5 · see citing works
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“Furthermore, our model holds the potential for broader applicability across different geographical regions and populations, especially in low-income and middle-income countries.”
BackgroundBadmus, O. M., Adenaya, O. R., Aderinwale, O. A., Ewuoso, D. B. O., Awolaja, B. S., & Ade-Onojobi, A. O. (2024) · Journal of Taibah University Medical Sciences · doi:10.1016/j.jtumed.2024.08.027 · Cited by 4 · see citing works
“Thesensitivity obtained in the present study was similar to Allanson et al. 24 and higher than that obtained by Wiberg et al. 28 and Hamed 27 in Egypt.”
ResultBowe, S., Staff, A. C., & Sugulle, M. (2020) · Acta Obstetricia Et Gynecologica Scandinavica · doi:10.1111/aogs.13922 · Cited by 4 · see citing works
Ekengård, F., Cardell, M., & Herbst, A. (2022) · The Journal of Maternal-Fetal & Neonatal Medicine · doi:10.1080/14767058.2022.2157717 · Cited by 3 · see citing works
Bhat, J. A., Sheikh, S. A., & Ara, R. (2020) · Paediatrica Indonesiana · doi:10.14238/pi60.1.2020.24-30 · Cited by 3 · see citing works
The effects of time and temperature on umbilical cord gas analysis
Fan, I. Y., Hiersch, L., Belov, Y., Amikam, U., Tzur, Y., Hershkovitz, G., Sindel, O., Alpern, S., Segal, R., Dangot, A., et al. (2020) · The Journal of Maternal-Fetal & Neonatal Medicine · doi:10.1080/14767058.2020.1849118 · Cited by 3 · see citing works
Fetal Heart Rate Analysis with Gaussian Processes
Feng, G., Quirk, J. G., Heiselman, C. J., & Djurić, P. M. (2023) · Springer eBooks · doi:10.1007/978-3-031-32625-7_10 · Cited by 3 · see citing works
Pitfalls in Interpreting Umbilical Cord Blood Gases and Lactate at Birth
Mokarami, P. (2013) · Lund University Publications (Lund University) · Cited by 3 · see citing works
Tarvonen, M. J., Georgieva, A., Lear, C. A., Ugwumadu, A. H. N., Stefanović, V., Jernman, R. M., Haataja, L., Gunn, A., & Andersson, S. (2026) · American Journal of Obstetrics and Gynecology · doi:10.1016/j.ajog.2026.08.009 · Cited by 2 · see citing works
S3-Leitlinie „Vaginale Geburt am Termin“ aus anästhesiologischer Sicht
Helmer, P., Skazel, T., Wenk, M., von Kaisenberg, C., Abou‐Dakn, M., Papsdorf, M., Hmeidan, F. A., Kehl, S., Meybohm, P., & Kranke, P. (2021) · Der Anaesthesist · doi:10.1007/s00101-021-01024-4 · Cited by 2 · see citing works
Khan, S., Qamar, S., Ansari, M., & Mohapatra, J. (2023) · Journal of Acute Disease · doi:10.4103/2221-6189.379275 · Cited by 2 · see citing works
Mönkkönen, A., Rajala, K., Backman, H., & Keski‐Nisula, L. (2024) · Journal of obstetrics and gynaecology research · doi:10.1111/jog.15875 · Cited by 2 · see citing works
Neurological problems in the newborn
Rennie, J. M., Huertas‐Ceballos, A., Boylan, G. B., Shah, D. K., Robertson, N. J., Groenendaal, F., Dyet, L. E., Barth, P. G., Manzur, A. Y., Robb, S. A., et al. (2012) · Elsevier eBooks · doi:10.1016/b978-0-7020-3479-4.00041-6 · Cited by 2 · see citing works
Saling, E., & Schmidt, S. (2016) · Gynécologie Obstétrique & Fertilité · doi:10.1016/j.gyobfe.2016.10.009 · Cited by 2 · see citing works
Shi, C., Rao, W., Huang, W., Ma, T., & Wei, W. (2023) · Medicine · doi:10.1097/md.0000000000036227 · Cited by 2 · see citing works
“[15] Therefore, we believe that blood gas analysis using this collection method can be used as an indicator to evaluate fetal acidemia and neonatal asphyxia.”
MethodGellert, S., Norrestam, S., Tidstedt, A., Ignell, C., Isberg, P., Wiberg, N., & Iorizzo, L. (2025) · Acta Obstetricia Et Gynecologica Scandinavica · doi:10.1111/aogs.70080 · Cited by 1 · see citing works
AI-Driven Quantitative Metabolomics for Early and Precise HIE Diagnosis: Challenges and Solutions
Panigrahi, A., Das, N. R., Yadav, N., Panda, S., Sethy, A. S., Panda, S. K., Mohakud, N. K., & Tiwari, V. (2025) · ACS Omega · doi:10.1021/acsomega.5c03256 · Cited by 1 · see citing works
Parsaei, M., Sadeghimoghadam, P., & Hantoushzadeh, S. (2025) · Maternal and Children s Health · doi:10.1159/000545497 · Cited by 1 · see citing works
“Additionally, recent studies have suggested that the current umbilical artery pH threshold used for predicting adverse neonatal outcomes may lack robustness and require further evaluation and re fi nement [29, 31].”
Aragón-Charris, J., Reyna‐Villasmil, E., Mejía-Montilla, J., Torres-Cepeda, D., Santos-Bolívar, J., & Reyna-Villasmil, N. (2013) · Progresos de Obstetricia y Ginecología · doi:10.1016/j.pog.2013.02.001 · Cited by 1 · see citing works
Negi, V., Simalti, A., Kumar, A., & Pramanik, S. K. (2020) · Acta Medica International · doi:10.4103/ami.ami_144_20 · Cited by 1 · see citing works
Jiang, T., Bai, R., Xie, C., Guo, H., Li, Z., & Ma, J. (2023) · Translational Pediatrics · doi:10.21037/tp-23-387 · Cited by 1 · see citing works
“In many of these studies, a 5-minute Apgar score was deemed a risk factor, with the risk threshold typically ranging between 4 and 7 (22,39).”
Paikaray, S., Jena, S. K., Balakrishnan, D., & Mohanty, P. K. (2024) · European Journal of Obstetrics & Gynecology and Reproductive Biology X · doi:10.1016/j.eurox.2024.100329 · Cited by 1 · see citing works
Chí, S. A. P., Peraza-López, E. E., & Zapata-Peraza, A. (2018) · Acta Pediátrica de México · doi:10.18233/apm39no5pp271-2821674 · Cited by 1 · see citing works
Nordström, L., & Holzmann, M. (2011) · Acta Obstetricia Et Gynecologica Scandinavica · doi:10.1111/j.1600-0412.2011.01342.x · Cited by 1 · see citing works
Umbilical Cord Venous Lactate for Predicting Arterial Lactic Acidemia and Neonatal Morbidity at Term
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Reyna‐Villasmil, E., Mejía-Montilla, J., Torres-Cepeda, D., Suárez-Torres, I., Santos-Bolívar, J., & Reyna-Villasmil, N. (2015) · Clínica e Investigación en Ginecología y Obstetricia · doi:10.1016/j.gine.2014.11.001
Interprétation des mesures de pH et de lactates à la naissance
Roth, G.-E. (2016) · Elsevier eBooks · doi:10.1016/b978-2-294-74722-9.00016-0
Base excess as a prognostic factor determining the perinatal outcome
Chandrakala, P., Lysander, S. D., & ., J. (2020) · International Journal of Contemporary Pediatrics · doi:10.18203/2349-3291.ijcp20200673
“In a study done by Wiberg N et al, lactate in cord arterial blood is at least as good as BD to indicate a depressed vitality at birth, particularly in combination with pH and best used with Gestational age‐adjusted values, but for any conclusion about the predictive value on long‐term outcome further studies are neede…”
BackgroundTariq, A., Afsheen, A., Iftikhar, B., Anwar, R., Kiani, R. B., & Mahboob, S. (2021) · Pakistan Armed Forces Medical Journal · doi:10.51253/pafmj.v71i3.5836
Helmer, P., Skazel, T., Wenk, M., von Kaisenberg, C., Abou‐Dakn, M., Papsdorf, M., Hmeidan, F. A., Kehl, S., Meybohm, P., & Kranke, P. (2021) · Der Anaesthesist
Interpreting blood gas results on venous, capillary, and umbilical cord blood
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Iorizzo, L., Carlsson, Y., Johansson, C., Berggren, R., Herbst, A., Wang, M., Leiding, M., Isberg, P., Kristensen, K. H., Wiberg‐Itzel, E., et al. (2021) · doi:10.22541/au.161557233.30984735/v1
Loverro, G., Cosmo, L. D., Loverro, M., & Mastrolia, S. A. (2017) · Springer eBooks · doi:10.1007/978-3-319-48732-8_21
Non-reassuring fetal heart rate patterns in association with umbilical artery acidosis
Eyisoy, Ö. G. (2024) · Zeynep Kamil Medical Journal · doi:10.14744/zkmj.2023.58219
“[18] Since the number of fetuses whose umbilical artery blood parameters meet the threshold values for fetal acidemia is only one, we could not determine an optimal cut-off level of lactate concentration for fetal acidosis.”
BackgroundPravin, R. R., Raveentheran, G., Sultana, R., & Haium, A. A. A. (2024) · Journal of Clinical Neonatology · doi:10.4103/jcn.jcn_59_24
PONDUS HYDROGENII (pH) OF MOTHERS AND NEWBORNS BLOOD BY DIFFERENT CONDITIONS AND TERMS OF DELIVERY
Leush, S. S. (2024) · Bulletin of Problems Biology and Medicine · doi:10.29254/2077-4214-2024-3-174-157-166
Bhandankar, M. R., Charantimath, U., Somannavar, M. S., Deepthy, & Goudar, S. (2025) · Journal of Neonatology · doi:10.1177/09732179251344680
Sundberg, T.-M., Wiberg, N., Källén, K., & Zaigham, M. (2023) · Figshare · doi:10.6084/m9.figshare.26574418
Agrawal, V., Taksande, A., & Meshram, R. (2026) · IEEE International Conference on Intelligent Technologies for a Sustainable and Inclusive Future (ICITSIF) · doi:10.1109/icitsif69060.2026.11608574
“Cord blood acid–base status captures the severity of perinatal compromise, and large datasets show that low cord pH and related metabolic measures are associated with neonatal depression and HIE-related outcomes [18].”
Timing Perinatal Hypoxic–Ischemic Brain Injury
Dhillon, S. K., Davidson, J. O., Bennet, L., & Gunn, A. J. (2026) · Cambridge University Press eBooks · doi:10.1017/9781009418034.023
Vida, B., Csetri-Barabasi, C., Lénárt, J., Molnár, Z., Molnár, S., Deli, T., & Krasznai, Z. T. (2026) · Diagnostics · doi:10.3390/diagnostics16213562
Rega, M. (2015) · UCL Discovery (University College London)
- Authors
- Wiberg, N., Källén, K., Herbst, A., & Olofsson, P.
- Affiliations
- Lund University (SE)
- Corresponding author
- Wiberg, Nana
- Herbst, Andreas
- Olofsson, Per
- Venue
- Acta Obstetricia Et Gynecologica Scandinavica
- Publisher
- Wiley
- Published
- 2010-10
- Volume
- 89
- Issue
- 10
- Pages
- 1263-1269
- ISSN
- 0001-6349 (ISSN-L)
- 1600-0412
- OpenAlex
- W1994324985
- Cited by
- 92
- References
- 29
- Citations by year
- 2026: 4 · 2025: 5 · 2024: 7 · 2023: 10 · 2022: 5 · 2021: 10 · 2020: 6 · 2019: 3 · 2018: 7 · 2017: 5 · 2016: 8 · 2015: 7 · 2014: 2 · 2013: 4 · 2012: 5
- FWCI
- 3.77
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Locations
- Acta Obstetricia Et Gynecologica Scandinavica (publishedVersion)
- PubMed (publishedVersion)
- Lund University Publications (Lund University) (submittedVersion)
- Funders
- Lunds Universitet
- Region Skåne
- Topics
- Health Sciences › Medicine › Pediatrics, Perinatology and Child Health › Neonatal and fetal brain pathology
- Health Sciences › Medicine › Obstetrics and Gynecology › Maternal and Perinatal Health Interventions
- Health Sciences › Medicine › Pediatrics, Perinatology and Child Health › Neonatal Health and Biochemistry
- Keywords
- umbilical cord blood, hypoxic-ischemic encephalopathy, base deficit, umbilical cord pH, 5-minute Apgar score, intrapartum hypoxia, acid-base analysis, neonatal acidosis
- MeSH terms
- Apgar Score, Carbon Dioxide, Female, Fetal Blood, Humans, Hydrogen-Ion Concentration, Infant, Newborn, Predictive Value of Tests, Pregnancy, ROC Curve, Lactic Acid, Hypoxia-Ischemia, Brain
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