Fetal electrocardiogram (ECG) for fetal monitoring during labour

James P Neilson

doi:10.1002/14651858.CD000116.pub5

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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.

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Figure 2

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

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Analysis 1.1

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

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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.

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Analysis 1.3

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

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Analysis 1.4

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

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Analysis 1.5

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

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Analysis 1.6

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

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Analysis 1.7

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

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Analysis 1.8

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

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Analysis 1.9

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

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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%)

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

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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]

Comparison 1. Fetal ECG plus CTG versus CTG alone

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