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'Risk of bias' graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.
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Figure 1

'Risk of bias' graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.

'Risk of bias' summary: review authors' judgements about each risk of bias item for each included study.
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Figure 2

'Risk of bias' summary: review authors' judgements about each risk of bias item for each included study.

Comparison 1 Fetal ECG plus CTG versus CTG alone, Outcome 1 Caesarean section.
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Analysis 1.1

Comparison 1 Fetal ECG plus CTG versus CTG alone, Outcome 1 Caesarean section.

Comparison 1 Fetal ECG plus CTG versus CTG alone, Outcome 2 Cord pH < 7.05 + base deficit > 12 mmol/L.
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Analysis 1.2

Comparison 1 Fetal ECG plus CTG versus CTG alone, Outcome 2 Cord pH < 7.05 + base deficit > 12 mmol/L.

Comparison 1 Fetal ECG plus CTG versus CTG alone, Outcome 3 Neonatal encephalopathy.
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Analysis 1.3

Comparison 1 Fetal ECG plus CTG versus CTG alone, Outcome 3 Neonatal encephalopathy.

Comparison 1 Fetal ECG plus CTG versus CTG alone, Outcome 4 Fetal blood sampling.
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Analysis 1.4

Comparison 1 Fetal ECG plus CTG versus CTG alone, Outcome 4 Fetal blood sampling.

Comparison 1 Fetal ECG plus CTG versus CTG alone, Outcome 5 Operative vaginal delivery.
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Analysis 1.5

Comparison 1 Fetal ECG plus CTG versus CTG alone, Outcome 5 Operative vaginal delivery.

Comparison 1 Fetal ECG plus CTG versus CTG alone, Outcome 6 Apgar score < 7 at 5 minutes.
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Analysis 1.6

Comparison 1 Fetal ECG plus CTG versus CTG alone, Outcome 6 Apgar score < 7 at 5 minutes.

Comparison 1 Fetal ECG plus CTG versus CTG alone, Outcome 7 Neonatal intubation.
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Analysis 1.7

Comparison 1 Fetal ECG plus CTG versus CTG alone, Outcome 7 Neonatal intubation.

Comparison 1 Fetal ECG plus CTG versus CTG alone, Outcome 8 Admission neonatal special care unit.
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Analysis 1.8

Comparison 1 Fetal ECG plus CTG versus CTG alone, Outcome 8 Admission neonatal special care unit.

Comparison 1 Fetal ECG plus CTG versus CTG alone, Outcome 9 Perinatal death.
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Analysis 1.9

Comparison 1 Fetal ECG plus CTG versus CTG alone, Outcome 9 Perinatal death.

Summary of findings for the main comparison. Fetal electrocardiogram (ECG) (ST analysis) plus cardiotocography (CTG) versus CTG alone for fetal monitoring during labour

Fetal ECG (ST analysis) plus CTG versus CTG alone for fetal monitoring during labour

Patient or population: Pregnant women (and their fetuses) in labour, with a perceived need for continuous electronic fetal heart rate monitoring
Settings: Sweden, USA, Finland, France, The Netherlands, UK.
Intervention: Fetal ECG (ST analysis) plus CTG
Comparison: CTG alone

Outcomes

Anticipated absolute effects* (95% CI)

Relative effect
(95% CI)

№ of participants
(studies)

Quality of the evidence
(GRADE)

Comments

Risk with CTG alone

Risk with Fetal ECG plus CTG

Caesarean section ‐ ST analysis

Study population

RR 1.02
(0.96 to 1.08)

26,446
(6 RCTs)

⊕⊕⊕⊕
high

135 per 1000

137 per 1000
(129 to 145)

Moderate

119 per 1000

121 per 1000
(114 to 128)

Cord pH less than 7.05 and base deficit greater than 12 mmol/L ‐ ST analysis

Study population

RR 0.72
(0.43 to 1.20)

25,682
(6 RCTs)

⊕⊕⊕⊝
moderate1

9 per 1000

7 per 1000
(4 to 11)

Moderate

11 per 1000

8 per 1000
(5 to 13)

Neonatal encephalopathy ‐ ST analysis

Study population

RR 0.61
(0.30 to 1.22)

26,410
(6 RCTs)

⊕⊕⊕⊕
high

2 per 1000

1 per 1000
(0 to 2)

Moderate

2 per 1000

1 per 1000
(1 to 2)

Fetal blood sampling ‐ ST analysis

Study population

RR 0.61
(0.41 to 0.91)

9671
(4 RCTs)

⊕⊕⊕⊕
high

154 per 1000

94 per 1000
(63 to 140)

Moderate

131 per 1000

80 per 1000
(54 to 119)

Operative vaginal delivery ‐ ST analysis

Study population

RR 0.92
(0.86 to 0.99)

26,446
(6 RCTs)

⊕⊕⊕⊕
high

113 per 1000

104 per 1000
(97 to 112)

Moderate

133 per 1000

122 per 1000
(114 to 131)

Admission to neonatal special care unit ‐ ST analysis

Study population

RR 0.96
(0.89 to 1.04)

26410
(6 RCTs)

⊕⊕⊕⊕
high

88 per 1000

84 per 1000
(78 to 91)

Moderate

55 per 1000

53 per 1000
(49 to 57)

Perinatal death ‐ ST analysis

Study population

RR 1.71
(0.67 to 4.33)

26,446
(6 RCTs)

⊕⊕⊕⊕
high

0 per 1000

1 per 1000
(0 to 2)

Moderate

0 per 1000

1 per 1000
(0 to 2)

*The risk in the intervention group (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).

CI: Confidence interval; RR: Risk ratio

GRADE Working Group grades of evidence
High quality: We are very confident that the true effect lies close to that of the estimate of the effect
Moderate quality: We are moderately confident in the effect estimate: The true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different
Low quality: Our confidence in the effect estimate is limited: The true effect may be substantially different from the estimate of the effect
Very low quality: We have very little confidence in the effect estimate: The true effect is likely to be substantially different from the estimate of effect

1 Some heterogeneity in findings (I2 55%)

Figures and Tables -
Summary of findings for the main comparison. Fetal electrocardiogram (ECG) (ST analysis) plus cardiotocography (CTG) versus CTG alone for fetal monitoring during labour
Comparison 1. Fetal ECG plus CTG versus CTG alone

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Caesarean section Show forest plot

7

Risk Ratio (M‐H, Fixed, 95% CI)

Subtotals only

1.1 ST analysis

6

26446

Risk Ratio (M‐H, Fixed, 95% CI)

1.02 [0.96, 1.08]

1.2 PR analysis

1

957

Risk Ratio (M‐H, Fixed, 95% CI)

0.79 [0.61, 1.04]

2 Cord pH < 7.05 + base deficit > 12 mmol/L Show forest plot

6

Risk Ratio (M‐H, Random, 95% CI)

Subtotals only

2.1 ST analysis

6

25682

Risk Ratio (M‐H, Random, 95% CI)

0.72 [0.43, 1.20]

2.2 PR analysis

0

0

Risk Ratio (M‐H, Random, 95% CI)

0.0 [0.0, 0.0]

3 Neonatal encephalopathy Show forest plot

6

Risk Ratio (M‐H, Fixed, 95% CI)

Subtotals only

3.1 ST analysis

6

26410

Risk Ratio (M‐H, Fixed, 95% CI)

0.61 [0.30, 1.22]

3.2 PR analysis

0

0

Risk Ratio (M‐H, Fixed, 95% CI)

0.0 [0.0, 0.0]

4 Fetal blood sampling Show forest plot

5

Risk Ratio (M‐H, Random, 95% CI)

Subtotals only

4.1 ST analysis

4

9671

Risk Ratio (M‐H, Random, 95% CI)

0.61 [0.41, 0.91]

4.2 PR analysis

1

957

Risk Ratio (M‐H, Random, 95% CI)

0.91 [0.69, 1.19]

5 Operative vaginal delivery Show forest plot

7

Risk Ratio (M‐H, Fixed, 95% CI)

Subtotals only

5.1 ST analysis

6

26446

Risk Ratio (M‐H, Fixed, 95% CI)

0.92 [0.86, 0.99]

5.2 PR analysis

1

957

Risk Ratio (M‐H, Fixed, 95% CI)

0.94 [0.75, 1.17]

6 Apgar score < 7 at 5 minutes Show forest plot

6

Risk Ratio (M‐H, Fixed, 95% CI)

Subtotals only

6.1 ST analysis

5

15302

Risk Ratio (M‐H, Fixed, 95% CI)

0.95 [0.73, 1.24]

6.2 PR analysis

1

957

Risk Ratio (M‐H, Fixed, 95% CI)

0.42 [0.11, 1.62]

7 Neonatal intubation Show forest plot

3

Risk Ratio (M‐H, Fixed, 95% CI)

Subtotals only

7.1 ST analysis

2

12544

Risk Ratio (M‐H, Fixed, 95% CI)

1.37 [0.89, 2.11]

7.2 PR analysis

1

957

Risk Ratio (M‐H, Fixed, 95% CI)

0.74 [0.26, 2.11]

8 Admission neonatal special care unit Show forest plot

7

Risk Ratio (M‐H, Fixed, 95% CI)

Subtotals only

8.1 ST analysis

6

26410

Risk Ratio (M‐H, Fixed, 95% CI)

0.96 [0.89, 1.04]

8.2 PR analysis

1

957

Risk Ratio (M‐H, Fixed, 95% CI)

0.77 [0.45, 1.33]

9 Perinatal death Show forest plot

7

Risk Ratio (M‐H, Fixed, 95% CI)

Subtotals only

9.1 ST analysis

6

26446

Risk Ratio (M‐H, Fixed, 95% CI)

1.71 [0.67, 4.33]

9.2 PR analysis

1

957

Risk Ratio (M‐H, Fixed, 95% CI)

2.96 [0.12, 72.39]

Figures and Tables -
Comparison 1. Fetal ECG plus CTG versus CTG alone