Scolaris Content Display Scolaris Content Display

Study flow diagram.
Figures and Tables -
Figure 1

Study flow diagram.

'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 2

'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 3

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

Comparison 1 Planned early delivery versus expectant management, Outcome 1 Perinatal mortality.
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Analysis 1.1

Comparison 1 Planned early delivery versus expectant management, Outcome 1 Perinatal mortality.

Comparison 1 Planned early delivery versus expectant management, Outcome 2 Major neonatal morbidity.
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Analysis 1.2

Comparison 1 Planned early delivery versus expectant management, Outcome 2 Major neonatal morbidity.

Comparison 1 Planned early delivery versus expectant management, Outcome 3 Neurodevelopmental disability/impairment.
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Analysis 1.3

Comparison 1 Planned early delivery versus expectant management, Outcome 3 Neurodevelopmental disability/impairment.

Comparison 1 Planned early delivery versus expectant management, Outcome 4 Maternal mortality.
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Analysis 1.4

Comparison 1 Planned early delivery versus expectant management, Outcome 4 Maternal mortality.

Comparison 1 Planned early delivery versus expectant management, Outcome 5 Major maternal morbidity.
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Analysis 1.5

Comparison 1 Planned early delivery versus expectant management, Outcome 5 Major maternal morbidity.

Comparison 1 Planned early delivery versus expectant management, Outcome 6 Neonatal seizures.
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Analysis 1.6

Comparison 1 Planned early delivery versus expectant management, Outcome 6 Neonatal seizures.

Comparison 1 Planned early delivery versus expectant management, Outcome 7 Necrotising enterocolitis.
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Analysis 1.7

Comparison 1 Planned early delivery versus expectant management, Outcome 7 Necrotising enterocolitis.

Comparison 1 Planned early delivery versus expectant management, Outcome 8 Respiratory distress syndrome.
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Analysis 1.8

Comparison 1 Planned early delivery versus expectant management, Outcome 8 Respiratory distress syndrome.

Comparison 1 Planned early delivery versus expectant management, Outcome 9 Meconium aspiration.
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Analysis 1.9

Comparison 1 Planned early delivery versus expectant management, Outcome 9 Meconium aspiration.

Comparison 1 Planned early delivery versus expectant management, Outcome 10 Gestational age at birth (days).
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Analysis 1.10

Comparison 1 Planned early delivery versus expectant management, Outcome 10 Gestational age at birth (days).

Comparison 1 Planned early delivery versus expectant management, Outcome 11 Gestational age ≥ 40 weeks (not pre‐specified).
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Analysis 1.11

Comparison 1 Planned early delivery versus expectant management, Outcome 11 Gestational age ≥ 40 weeks (not pre‐specified).

Comparison 1 Planned early delivery versus expectant management, Outcome 12 Apgar score < 7 at 5 minutes.
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Analysis 1.12

Comparison 1 Planned early delivery versus expectant management, Outcome 12 Apgar score < 7 at 5 minutes.

Comparison 1 Planned early delivery versus expectant management, Outcome 13 Resuscitation required.
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Analysis 1.13

Comparison 1 Planned early delivery versus expectant management, Outcome 13 Resuscitation required.

Comparison 1 Planned early delivery versus expectant management, Outcome 14 Requirement for mechanical ventilation.
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Analysis 1.14

Comparison 1 Planned early delivery versus expectant management, Outcome 14 Requirement for mechanical ventilation.

Comparison 1 Planned early delivery versus expectant management, Outcome 15 Birthweight < 10 centile.
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Analysis 1.15

Comparison 1 Planned early delivery versus expectant management, Outcome 15 Birthweight < 10 centile.

Comparison 1 Planned early delivery versus expectant management, Outcome 16 Birthweight < 2.3 centile (not pre‐specified).
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Analysis 1.16

Comparison 1 Planned early delivery versus expectant management, Outcome 16 Birthweight < 2.3 centile (not pre‐specified).

Comparison 1 Planned early delivery versus expectant management, Outcome 17 Admission to NICU.
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Analysis 1.17

Comparison 1 Planned early delivery versus expectant management, Outcome 17 Admission to NICU.

Comparison 1 Planned early delivery versus expectant management, Outcome 18 Admission to intermediate care nursery (not pre‐specified).
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Analysis 1.18

Comparison 1 Planned early delivery versus expectant management, Outcome 18 Admission to intermediate care nursery (not pre‐specified).

Comparison 1 Planned early delivery versus expectant management, Outcome 19 Length of stay in NICU/SCN (days).
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Analysis 1.19

Comparison 1 Planned early delivery versus expectant management, Outcome 19 Length of stay in NICU/SCN (days).

Comparison 1 Planned early delivery versus expectant management, Outcome 20 Interval (days) between randomisation and delivery.
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Analysis 1.20

Comparison 1 Planned early delivery versus expectant management, Outcome 20 Interval (days) between randomisation and delivery.

Comparison 1 Planned early delivery versus expectant management, Outcome 21 Neonatal sepsis.
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Analysis 1.21

Comparison 1 Planned early delivery versus expectant management, Outcome 21 Neonatal sepsis.

Comparison 1 Planned early delivery versus expectant management, Outcome 22 Caesarean section.
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Analysis 1.22

Comparison 1 Planned early delivery versus expectant management, Outcome 22 Caesarean section.

Comparison 1 Planned early delivery versus expectant management, Outcome 23 Placental abruption.
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Analysis 1.23

Comparison 1 Planned early delivery versus expectant management, Outcome 23 Placental abruption.

Comparison 1 Planned early delivery versus expectant management, Outcome 24 Pre‐eclampsia.
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Analysis 1.24

Comparison 1 Planned early delivery versus expectant management, Outcome 24 Pre‐eclampsia.

Comparison 1 Planned early delivery versus expectant management, Outcome 25 Induction of labour.
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Analysis 1.25

Comparison 1 Planned early delivery versus expectant management, Outcome 25 Induction of labour.

Comparison 1 Planned early delivery versus expectant management, Outcome 26 Vaginal birth.
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Analysis 1.26

Comparison 1 Planned early delivery versus expectant management, Outcome 26 Vaginal birth.

Comparison 1 Planned early delivery versus expectant management, Outcome 27 Assisted vaginal birth.
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Analysis 1.27

Comparison 1 Planned early delivery versus expectant management, Outcome 27 Assisted vaginal birth.

Comparison 1 Planned early delivery versus expectant management, Outcome 28 Breastfeeding.
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Analysis 1.28

Comparison 1 Planned early delivery versus expectant management, Outcome 28 Breastfeeding.

Comparison 1 Planned early delivery versus expectant management, Outcome 29 Breastfeeding (weeks).
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Analysis 1.29

Comparison 1 Planned early delivery versus expectant management, Outcome 29 Breastfeeding (weeks).

Comparison 1 Planned early delivery versus expectant management, Outcome 30 Maternal hospital stay (days) (not pre‐specified).
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Analysis 1.30

Comparison 1 Planned early delivery versus expectant management, Outcome 30 Maternal hospital stay (days) (not pre‐specified).

Summary of findings for the main comparison. Planned early delivery compared with expectant management for improving outcomes of the term suspected compromised baby

Planned early delivery compared with expectant management for improving outcomes of the term suspected compromised baby

Patient or population: pregnant women with a term suspected compromised baby
Settings: studies took place in The Netherlands and Sweden
Intervention: planned early delivery
Comparison: expectant management

Outcomes

Illustrative comparative risks* (95% CI)

Relative effect
(95% CI)

No of participants
(studies)

Quality of the evidence
(GRADE)

Comments

Assumed risk

Corresponding risk

Expectant management

Planned early delivery

Perinatal mortality
(stillbirth ‐ death of fetus prior to birth; neonatal death ‐ death within the first 28 days of birth; or infant death ‐ death after the first 28 days)

See comment

See comment

Not estimable

459
(1 study)

⊕⊕⊕⊝
moderate1

Major neonatal morbidity
one or more of the following: hypoxic ischaemic encephalopathy (HIE) ‐ grade II or III, necrotising enterocolitis (NEC), need for ongoing ventilation, meconium aspiration syndrome, seizures, need for therapeutic hypothermia
Follow‐up: 0‐22 days

Study population

RR 0.15
(0.01 to 2.81)

459
(1 study)

⊕⊕⊝⊝
low2,3

13 per 1000

2 per 1000
(0 to 36)

Neurodevelopmental disability/impairment
CBCL, Ages and Stages Questionnaire
Follow‐up: mean 2 years

Study population

RR 2.04
(0.62 to 6.69)

459
(1 study)

⊕⊕⊝⊝
low2,3

17 per 1000

35 per 1000
(11 to 115)

Maternal mortality
Follow‐up: 0‐10 days

Study population

RR 3.07
(0.13 to 74.87)

459
(1 study)

⊕⊕⊝⊝
low2,3

0 per 1000

0 per 1000
(0 to 0)

Significant maternal morbidity
one or more of the following: significant postpartum haemorrhage requiring blood transfusion; maternal admission to intensive care unit; uterine rupture; hysterectomy

Study population

RR 0.92
(0.38 to 2.22)

459
(1 study)

⊕⊕⊝⊝
low2,3

43 per 1000

40 per 1000
(16 to 96)

Admission to NICU

Study population

RR 0.88
(0.35 to 2.23)

545
(3 studies)

⊕⊝⊝⊝
very low2,3,4

33 per 1000

29 per 1000
(11 to 73)

Moderate

26 per 1000

23 per 1000
(9 to 58)

Caesarean section

Study population

RR 1.02
(0.65 to 1.59)

546
(3 studies)

⊕⊕⊝⊝
low5,6

124 per 1000

126 per 1000
(80 to 197)

Moderate

154 per 1000

157 per 1000
(100 to 245)

*The basis for the assumed risk (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (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: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality: We are very uncertain about the estimate.

1 There were no events for this outcome.
2 Few total events (< 30).
3 Wide CI crossing line of no effect and RR > 25%.
4 Although all studies address outcome of NICU admission, 2 studies included additional outcome of intermediate nursery admission. Overall this may have compromised the total number of events comparatively.
5 One study did not give outcomes for elective C/S, only emergency C/S assessed.
6 Two out of three studies had wide CIs crossing the line of no effect.

CBCL: child behaviour checklist
NICU: neonatal intensive care unit

Figures and Tables -
Summary of findings for the main comparison. Planned early delivery compared with expectant management for improving outcomes of the term suspected compromised baby
Comparison 1. Planned early delivery versus expectant management

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Perinatal mortality Show forest plot

1

459

Risk Ratio (M‐H, Fixed, 95% CI)

0.0 [0.0, 0.0]

2 Major neonatal morbidity Show forest plot

1

459

Risk Ratio (M‐H, Fixed, 95% CI)

0.15 [0.01, 2.81]

3 Neurodevelopmental disability/impairment Show forest plot

1

459

Risk Ratio (M‐H, Fixed, 95% CI)

2.04 [0.62, 6.69]

4 Maternal mortality Show forest plot

1

459

Risk Ratio (M‐H, Fixed, 95% CI)

3.07 [0.13, 74.87]

5 Major maternal morbidity Show forest plot

1

459

Risk Ratio (M‐H, Fixed, 95% CI)

0.92 [0.38, 2.22]

6 Neonatal seizures Show forest plot

1

336

Risk Ratio (M‐H, Fixed, 95% CI)

0.0 [0.0, 0.0]

7 Necrotising enterocolitis Show forest plot

1

333

Risk Ratio (M‐H, Fixed, 95% CI)

0.0 [0.0, 0.0]

8 Respiratory distress syndrome Show forest plot

1

333

Risk Ratio (M‐H, Fixed, 95% CI)

0.33 [0.01, 7.98]

9 Meconium aspiration Show forest plot

1

459

Risk Ratio (M‐H, Fixed, 95% CI)

0.34 [0.01, 8.32]

10 Gestational age at birth (days) Show forest plot

1

459

Mean Difference (IV, Fixed, 95% CI)

‐9.5 [‐10.82, ‐8.18]

11 Gestational age ≥ 40 weeks (not pre‐specified) Show forest plot

1

33

Risk Ratio (M‐H, Fixed, 95% CI)

0.10 [0.01, 0.67]

12 Apgar score < 7 at 5 minutes Show forest plot

3

546

Risk Ratio (M‐H, Fixed, 95% CI)

2.56 [0.50, 13.04]

13 Resuscitation required Show forest plot

1

459

Risk Ratio (M‐H, Fixed, 95% CI)

0.11 [0.01, 2.10]

14 Requirement for mechanical ventilation Show forest plot

1

337

Risk Ratio (M‐H, Fixed, 95% CI)

0.20 [0.01, 4.11]

15 Birthweight < 10 centile Show forest plot

2

491

Risk Ratio (M‐H, Fixed, 95% CI)

0.98 [0.88, 1.10]

16 Birthweight < 2.3 centile (not pre‐specified) Show forest plot

2

491

Risk Ratio (M‐H, Fixed, 95% CI)

0.51 [0.36, 0.73]

17 Admission to NICU Show forest plot

3

545

Risk Ratio (M‐H, Fixed, 95% CI)

0.88 [0.35, 2.23]

18 Admission to intermediate care nursery (not pre‐specified) Show forest plot

2

491

Risk Ratio (M‐H, Fixed, 95% CI)

1.28 [1.02, 1.61]

19 Length of stay in NICU/SCN (days) Show forest plot

1

459

Mean Difference (IV, Fixed, 95% CI)

0.0 [‐1.28, 1.28]

20 Interval (days) between randomisation and delivery Show forest plot

1

459

Mean Difference (IV, Fixed, 95% CI)

‐8.68 [‐10.04, ‐7.32]

21 Neonatal sepsis Show forest plot

2

366

Risk Ratio (M‐H, Fixed, 95% CI)

3.18 [0.14, 72.75]

22 Caesarean section Show forest plot

3

546

Risk Ratio (M‐H, Fixed, 95% CI)

1.02 [0.65, 1.59]

23 Placental abruption Show forest plot

1

459

Risk Ratio (M‐H, Fixed, 95% CI)

3.07 [0.13, 74.87]

24 Pre‐eclampsia Show forest plot

1

459

Risk Ratio (M‐H, Fixed, 95% CI)

0.63 [0.27, 1.49]

25 Induction of labour Show forest plot

1

459

Risk Ratio (M‐H, Fixed, 95% CI)

2.05 [1.78, 2.37]

26 Vaginal birth Show forest plot

3

546

Risk Ratio (M‐H, Fixed, 95% CI)

0.98 [0.90, 1.07]

27 Assisted vaginal birth Show forest plot

3

546

Risk Ratio (M‐H, Fixed, 95% CI)

1.19 [0.69, 2.04]

28 Breastfeeding Show forest plot

1

218

Risk Ratio (M‐H, Fixed, 95% CI)

1.09 [0.85, 1.40]

29 Breastfeeding (weeks) Show forest plot

1

124

Mean Difference (IV, Fixed, 95% CI)

1.74 [‐3.37, 6.85]

30 Maternal hospital stay (days) (not pre‐specified) Show forest plot

1

33

Mean Difference (IV, Fixed, 95% CI)

1.0 [0.68, 1.32]

Figures and Tables -
Comparison 1. Planned early delivery versus expectant management