Cardiotocography versus intermittent auscultation of fetal heart on admission to labour ward for assessment of fetal wellbeing

Declan Devane; Joan G Lalor; Sean Daly; William McGuire; Anna Cuthbert; Valerie Smith

doi:10.1002/14651858.CD005122.pub5

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Figure 1

Study flow diagram

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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 Admission cardiotocography versus Intermittent auscultation (low‐risk women), Outcome 1 Caesarean section.

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Analysis 1.2

Comparison 1 Admission cardiotocography versus Intermittent auscultation (low‐risk women), Outcome 2 Instrumental vaginal birth.

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Analysis 1.3

Comparison 1 Admission cardiotocography versus Intermittent auscultation (low‐risk women), Outcome 3 Continuous EFM during labour.

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Analysis 1.4

Comparison 1 Admission cardiotocography versus Intermittent auscultation (low‐risk women), Outcome 4 Amniotomy.

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Analysis 1.5

Comparison 1 Admission cardiotocography versus Intermittent auscultation (low‐risk women), Outcome 5 Oxytocin for augmentation of labour.

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Analysis 1.6

Comparison 1 Admission cardiotocography versus Intermittent auscultation (low‐risk women), Outcome 6 Epidural.

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Analysis 1.7

Comparison 1 Admission cardiotocography versus Intermittent auscultation (low‐risk women), Outcome 7 Fetal blood sampling.

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Analysis 1.8

Comparison 1 Admission cardiotocography versus Intermittent auscultation (low‐risk women), Outcome 8 Fetal and neonatal deaths.

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Analysis 1.9

Comparison 1 Admission cardiotocography versus Intermittent auscultation (low‐risk women), Outcome 9 Evidence of fetal multi‐organ compromise within the first 24 hours after birth.

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Analysis 1.10

Comparison 1 Admission cardiotocography versus Intermittent auscultation (low‐risk women), Outcome 10 Admission to neonatal intensive care.

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Analysis 1.11

Comparison 1 Admission cardiotocography versus Intermittent auscultation (low‐risk women), Outcome 11 Apgar score < 7 at or after 5 minutes.

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Analysis 1.12

Comparison 1 Admission cardiotocography versus Intermittent auscultation (low‐risk women), Outcome 12 Hypoxic ischaemic encephalopathy.

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Analysis 1.13

Comparison 1 Admission cardiotocography versus Intermittent auscultation (low‐risk women), Outcome 13 Neonatal seizures.

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Analysis 1.14

Comparison 1 Admission cardiotocography versus Intermittent auscultation (low‐risk women), Outcome 14 Length of stay in neonatal intensive care (days).

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Analysis 1.15

Comparison 1 Admission cardiotocography versus Intermittent auscultation (low‐risk women), Outcome 15 Length of stay in neonatal intensive care (hours).

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Summary of findings for the main comparison. Admission cardiotocography compared to Intermittent auscultation (low‐risk women) for assessment of fetal wellbeing

Admission cardiotocography compared to Intermittent auscultation (low‐risk women) for assessment of fetal wellbeing
Patient or population: Low risk pregnant women. All of the women were in labour. Setting: Ireland and UK Intervention: Admission cardiotocography ‐ women received a routine 15‐minute (1 trial) or 20‐minute (3 trials) tracing. Comparison: Intermittent auscultation (low‐risk women) ‐ women received intermittent auscultation of the fetal heart for at least one full minute (4 trials), during and after a contraction (2 trials) or after a contraction only (2 trials).
Outcomes	*Anticipated absolute effects^ (95% CI)**		Relative effect (95% CI)	№ of participants (studies)	Quality of the evidence (GRADE)	Comments
	Risk with Intermittent auscultation (low‐risk women)	Risk with admission cardiotocography
Incidence of caesarean section	Study population		RR 1.20 (1.00 to 1.44)	11338 (4 RCTs)	⊕⊕⊕⊝ MODERATE ^{1 2}
	36 per 1000	44 per 1000 (36 to 52)
Incidence of operative vaginal birth	Study population		RR 1.10 (0.95 to 1.27)	11338 (4 RCTs)	⊕⊕⊝⊝ LOW ^{1 3}
	126 per 1000	139 per 1000 (120 to 160)
Perinatal mortality rate (fetal and neonatal deaths excluding lethal congenital anomalies)	Study population		RR 1.01 (0.30 to 3.47)	11339 (4 RCTs)	⊕⊕⊕⊝ MODERATE ^{4 5 6}
	1 per 1000	1 per 1000 (0 to 3)
Severe neurodevelopmental disability assessed ≥ 12 months of age	Study population		‐	(0 RCTs)	‐	None of the included studies reported data for the outcome
	see comment	see comment
Incidence of continuous electronic fetal monitoring during labour	Study population		RR 1.30 (1.14 to 1.48)	10753 (3 RCTs)	⊕⊕⊝⊝ LOW ^{1 7}
	417 per 1000	542 per 1000 (475 to 617)
Incidence and severity of hypoxic ischaemic encephalopathy (incidence only reported)	Study population		RR 1.19 (0.37 to 3.90)	2367 (1 RCT)	⊕⊝⊝⊝ VERY LOW ^{1 8}
	4 per 1000	5 per 1000 (2 to 17)
Incidence of seizures in the neonatal period	Study population		RR 0.72 (0.32 to 1.61)	8056 (1 RCT)	⊕⊕⊝⊝ LOW ^{1 9}
	3 per 1000	2 per 1000 (1 to 6)
*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; OR: Odds 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 Most studies contributing data had design limitations: outcome may have been affected by lack of blinding as all studies judged to be at high risk of performance bias (‐1) ² Good sample size (> 3000), no measurable heterogeneity (I² = 0%), however 95% confidence interval touches the line of no effect (not downgraded) ³ Good sample size (> 3000), though wide confidence intervals cross the line of no effect (‐1) ⁴ Studies contributing data had design limitations: unlikely this outcome was affected by lack of blinding (not downgraded) ⁵ Few events but good sample size (not downgraded) ⁶ Very wide confidence intervals crossing the line of no effect (‐1) ⁷ Statistical heterogeneity (I² = 79%) (‐1) ⁸ Wide confidence interval crossing the line of no effect, few events & small sample size (based on one study) (‐2) ⁹ Wide confidence intervals crossing the line of no effect, large sample size with data from one study (‐1)

Summary of findings for the main comparison. Admission cardiotocography compared to Intermittent auscultation (low‐risk women) for assessment of fetal wellbeing

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Comparison 1. Admission cardiotocography versus Intermittent auscultation (low‐risk women)

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Caesarean section Show forest plot	4	11338	Risk Ratio (M‐H, Random, 95% CI)	1.20 [1.00, 1.44]

2 Instrumental vaginal birth Show forest plot	4	11338	Risk Ratio (M‐H, Random, 95% CI)	1.10 [0.95, 1.27]

3 Continuous EFM during labour Show forest plot	3	10753	Risk Ratio (M‐H, Random, 95% CI)	1.30 [1.14, 1.48]

4 Amniotomy Show forest plot	2	2694	Risk Ratio (M‐H, Random, 95% CI)	1.04 [0.97, 1.12]

5 Oxytocin for augmentation of labour Show forest plot	4	11324	Risk Ratio (M‐H, Random, 95% CI)	1.05 [0.95, 1.17]

6 Epidural Show forest plot	3	10757	Risk Ratio (M‐H, Random, 95% CI)	1.11 [0.87, 1.41]

7 Fetal blood sampling Show forest plot	3	10757	Risk Ratio (M‐H, Random, 95% CI)	1.28 [1.13, 1.45]

8 Fetal and neonatal deaths Show forest plot	4	11339	Risk Ratio (M‐H, Random, 95% CI)	1.01 [0.30, 3.47]

9 Evidence of fetal multi‐organ compromise within the first 24 hours after birth Show forest plot	1	8056	Risk Ratio (M‐H, Random, 95% CI)	0.56 [0.19, 1.67]

10 Admission to neonatal intensive care Show forest plot	4	11331	Risk Ratio (M‐H, Random, 95% CI)	1.03 [0.86, 1.24]

11 Apgar score < 7 at or after 5 minutes Show forest plot	4	11324	Risk Ratio (M‐H, Random, 95% CI)	1.00 [0.54, 1.85]

12 Hypoxic ischaemic encephalopathy Show forest plot	1	2367	Risk Ratio (M‐H, Random, 95% CI)	1.19 [0.37, 3.90]

13 Neonatal seizures Show forest plot	1	8056	Risk Ratio (M‐H, Random, 95% CI)	0.72 [0.32, 1.61]

14 Length of stay in neonatal intensive care (days) Show forest plot	1	91	Mean Difference (IV, Random, 95% CI)	1.80 [‐0.59, 4.19]

15 Length of stay in neonatal intensive care (hours) Show forest plot	1	318	Mean Difference (IV, Random, 95% CI)	6.20 [‐8.70, 21.10]

Comparison 1. Admission cardiotocography versus Intermittent auscultation (low‐risk women)

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