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Fetal size at birth in relation to quality of blood glucose control in pregnancies complicated by pregestational diabetes mellitus

Sic The recent paper by Gulmezoglu et al. (Vol 103, June 1996)' compared the use of a newly developed suction fetal scalp electrode with the traditional double helix spiral electrode. The advantages of this less invasive electrode are promising, with the prospect of less fetal scalp infection, less viral transmission and less pain to the fetus. In particular, with the increasing incidence of human immunodeficiency virus (HIV) infection worldwide, there may be increasing demand for such a device in monitoring the fetal heart in labour. However, a number of points with respect to this paper need to be addressed. First, the authors calculated that a sample size of 118 was required to demonstrate a difference between the electrodes, assuming a success rate of 90% with the suction electrode, with a power of 80%. The reported success rate with the suction electrode was actually much lower at 70%. Although acknowledged by the authors, the number recruited in the study was only 100, due to limited time. It is a pity that they did not pursue their goal for the sake of the extra 18 patients or so, and unfortunate that time constraints have limited the statistical validity of the results of a small but important trial. Second, it is not stated whether those examining the infants 24 h after delivery were blinded to the type of electrode used. Such information is important with regard to potential bias. Finally, the results indicate a much lower rate of meconium passage in the suction electrode group, 10% versus 28%. While it is suggested that no firm conclusion should be drawn from this observation, the authors postulate that the lower rate could be due to less scalp irritation or pain from the suction electrode than with the spiral electrode, and should be further investigated. In this context, it would be more relevant to know the rate of meconium at membrane rupture and then ascertain if new development of meconium after application of the electrode is different between the two groups. Without this information, and because of the small numbers studied, the reported difference is most likely due to chance. Overall, the authors should be commended for highlighting this relatively new device, which clearly has a role in the future of fetal heart rate monitoring.