title: Protocol for a randomised controlled trial of fetal scalp blood lactate measurement to reduce caesarean sections during labour: the Flamingo trial [ACTRN12611000172909].
abstract: BACKGROUND
  The rate of caesarean sections around the world is rising each year, reaching epidemic proportions. Although many caesarean sections are performed for concerns about fetal welfare on the basis of abnormal cardiotocography, the majority of babies are shown to be well at birth, meaning that the operation, with its inherent short and long term risks, could have been avoided without compromising the baby's health. Previously, fetal scalp blood sampling for pH estimation was performed in the context of an abnormal cardiotocograph, to improve the identification of babies in need of expedited delivery. This test has largely been replaced by lactate measurement, although its validity is yet to be established through a randomised controlled trial. This study aims to test the hypothesis that the performance of fetal scalp blood lactate measurement for women in labour with an abnormal cardiotocograph will reduce the rate of birth by caesarean section from 38 % to 25 % (a 35 % relative reduction).
  
  
  METHODS
  Prospective unblinded randomised controlled trial conducted at a single tertiary perinatal centre. Women labouring with a singleton fetus in cephalic presentation at 37 or more weeks' gestation with ruptured membranes and with an abnormal cardiotocograph will be eligible. Participants will be randomised to one of two groups: fetal monitoring by cardiotocography alone, or cardiotocography augmented by fetal scalp blood lactate analysis. Decisions regarding the timing and mode of delivery will be made by the treating team, in accordance with hospital protocols. The primary study endpoint is caesarean section with secondary outcomes collected from maternal, fetal and neonatal clinical course and morbidities. A cost effectiveness analysis will also be performed. A sample size of 600 will provide 90 % power to detect the hypothesised difference in the proportion of women who give birth by caesarean section.
  
  
  CONCLUSIONS
  This world-first trial is adequately powered to determine the impact of fetal scalp blood lactate measurement on rates of caesarean section. Preventing unnecessary caesarean sections will reduce the health and financial burdens associated with this operation, both in the index and any future pregnancies.
  
  
  BACKGROUND
  Australian New Zealand Clinical Trials Registry ACTRN12611000172909.
authors.affiliation: Department of Obstetrics and Gynaecology, University of Melbourne & School of Nursing and Midwifery, Monash University, Parkville, 3052, Australia. eastc@unimelb.edu.au.|Department of Perinatal Medicine, Pregnancy Research Centre, The Royal Women's Hospital, The University of Melbourne, Parkville, 3052, Australia. eastc@unimelb.edu.au.|Department of Obstetrics and Gynaecology, The University of Melbourne, Parkville, 3052, Australia. eastc@unimelb.edu.au.
authors.forename: Christine E
authors.initials: CE
authors.lastname: East
authors.affiliation: Department of Perinatal Medicine, The Royal Women's Hospital, Parkville, 3052, Australia. Stefan.Kane@thewomens.org.au.
authors.forename: Stefan C
authors.initials: SC
authors.lastname: Kane
authors.affiliation: Judith Lumley Centre (formerly Mother & Child Health Research), La Trobe University, 215 Franklin Street, Melbourne, VIC, 3000, Australia. M.Davey@latrobe.edu.au.
authors.forename: Mary-Ann
authors.initials: MA
authors.lastname: Davey
authors.affiliation: Neonatal Services, Royal Women's Hospital, Parkville, 3052, Australia. Omar.Kamlin@thewomens.org.au.
authors.forename: C Omar
authors.initials: CO
authors.lastname: Kamlin
authors.affiliation: Department of Perinatal Medicine, Pregnancy Research Centre, The Royal Women's Hospital, The University of Melbourne, Parkville, 3052, Australia. s.brennecke@unimelb.edu.au.|Department of Obstetrics and Gynaecology, The University of Melbourne, Parkville, 3052, Australia. s.brennecke@unimelb.edu.au.
authors.forename: Shaun P
authors.initials: SP
authors.lastname: Brennecke
mesh_terms: D000328:Adult; D015415:Biomarkers / Q000097:blood; D002585:Cesarean Section / Q000009:adverse effects / Q000706:statistics & numerical data*; D002985:Clinical Protocols; D005260:Female; D005312:Fetal Blood; D005323:Fetal Monitoring / Q000379:methods*; D005865:Gestational Age; D006801:Humans; D019344:Lactic Acid / Q000097:blood*; D007744:Obstetric Labor Complications / Q000097:blood* / Q000209:etiology / Q000517:prevention & control; D011247:Pregnancy; D011446:Prospective Studies; D012535:Scalp
chemical_list: D015415:Biomarkers; D019344:Lactic Acid