Continuous cardiotocography (CTG) as a form of electronic fetal monitoring (EFM) for fetal assessment during labour

Zarko Alfirevic; Declan Devane; Gillian ML Gyte

doi:10.1002/14651858.CD006066.pub2

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Figure 1

Methodological quality summary: review authors' judgements about each methodological quality item for each included study.

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Figure 2

Funnel plot of comparison: 1 Continuous CTG versus intermittent auscultation, outcome: 1.1 Perinatal mortality (primary outcome).

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Figure 3

Funnel plot of comparison: 1 Continuous CTG versus intermittent auscultation, outcome: 1.2 Neonatal seizures (primary outcome).

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Figure 4

Funnel plot of comparison: 1 Continuous CTG versus intermittent auscultation, outcome: 1.4 Caesarean section (primary outcome).

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Figure 5

Funnel plot of comparison: 1 Continuous CTG versus intermittent auscultation, outcome: 1.5 Instrumental vaginal birth (primary outcome).

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Analysis 1.1

Comparison 1 Continuous CTG versus intermittent auscultation, Outcome 1 Perinatal mortality (primary outcome).

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Analysis 1.2

Comparison 1 Continuous CTG versus intermittent auscultation, Outcome 2 Neonatal seizures (primary outcome).

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Analysis 1.3

Comparison 1 Continuous CTG versus intermittent auscultation, Outcome 3 Cerebral palsy (primary outcome).

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Analysis 1.4

Comparison 1 Continuous CTG versus intermittent auscultation, Outcome 4 Caesarean section (primary outcome).

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Analysis 1.5

Comparison 1 Continuous CTG versus intermittent auscultation, Outcome 5 Instrumental vaginal birth (primary outcome).

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Analysis 1.6

Comparison 1 Continuous CTG versus intermittent auscultation, Outcome 6 Cord blood acidosis (primary outcome).

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Analysis 1.7

Comparison 1 Continuous CTG versus intermittent auscultation, Outcome 7 Any pharmacological analgesia (primary outcome).

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Analysis 1.8

Comparison 1 Continuous CTG versus intermittent auscultation, Outcome 8 Hypoxic ischaemic encephalopathy.

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Analysis 1.9

Comparison 1 Continuous CTG versus intermittent auscultation, Outcome 9 Neurodevelopmental disability at at least 12 months of age.

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Analysis 1.10

Comparison 1 Continuous CTG versus intermittent auscultation, Outcome 10 Apgar score < 7 at 5 minutes.

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Analysis 1.11

Comparison 1 Continuous CTG versus intermittent auscultation, Outcome 11 Apgar score < 4 at 5 minutes.

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Analysis 1.12

Comparison 1 Continuous CTG versus intermittent auscultation, Outcome 12 Neonatal ICU admissions.

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Analysis 1.13

Comparison 1 Continuous CTG versus intermittent auscultation, Outcome 13 Fetal blood sampling.

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Analysis 1.14

Comparison 1 Continuous CTG versus intermittent auscultation, Outcome 14 Damage/infection from scalp electrode or scalp sampling.

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Analysis 1.15

Comparison 1 Continuous CTG versus intermittent auscultation, Outcome 15 Caesarean section for abnormal FHR pattern and/or acidosis.

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Analysis 1.16

Comparison 1 Continuous CTG versus intermittent auscultation, Outcome 16 Instrumental vaginal birth for abnormal CTG or fetal acidosis.

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Analysis 1.17

Comparison 1 Continuous CTG versus intermittent auscultation, Outcome 17 Spontaneous vaginal birth.

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Analysis 1.18

Comparison 1 Continuous CTG versus intermittent auscultation, Outcome 18 Epidural analgesia.

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Analysis 1.21

Comparison 1 Continuous CTG versus intermittent auscultation, Outcome 21 Oxytocin during 1st and/or 2nd stage of labour.

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Analysis 1.27

Comparison 1 Continuous CTG versus intermittent auscultation, Outcome 27 Length of stay on NICU.

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Analysis 2.1

Comparison 2 Continuous CTG versus IA (pregnancy risk status ‐ high/low), Outcome 1 Perinatal mortality.

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Analysis 2.2

Comparison 2 Continuous CTG versus IA (pregnancy risk status ‐ high/low), Outcome 2 Neonatal seizures.

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Analysis 2.3

Comparison 2 Continuous CTG versus IA (pregnancy risk status ‐ high/low), Outcome 3 Cerebral palsy.

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Analysis 2.4

Comparison 2 Continuous CTG versus IA (pregnancy risk status ‐ high/low), Outcome 4 Caesarean section.

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Analysis 2.5

Comparison 2 Continuous CTG versus IA (pregnancy risk status ‐ high/low), Outcome 5 Instrumental vaginal birth.

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Analysis 2.6

Comparison 2 Continuous CTG versus IA (pregnancy risk status ‐ high/low), Outcome 6 Cord blood acidosis.

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Analysis 2.7

Comparison 2 Continuous CTG versus IA (pregnancy risk status ‐ high/low), Outcome 7 Any pharmacological analgesia.

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Analysis 3.1

Comparison 3 Continuous CTG versus IA (onset of labour ‐ spontaneous/induced), Outcome 1 Perinatal mortality.

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Analysis 3.2

Comparison 3 Continuous CTG versus IA (onset of labour ‐ spontaneous/induced), Outcome 2 Neonatal seizures.

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Analysis 3.3

Comparison 3 Continuous CTG versus IA (onset of labour ‐ spontaneous/induced), Outcome 3 Cerebral palsy.

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Analysis 3.4

Comparison 3 Continuous CTG versus IA (onset of labour ‐ spontaneous/induced), Outcome 4 Caesarean section.

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Analysis 3.5

Comparison 3 Continuous CTG versus IA (onset of labour ‐ spontaneous/induced), Outcome 5 Instrumental vaginal birth.

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Analysis 3.6

Comparison 3 Continuous CTG versus IA (onset of labour ‐ spontaneous/induced), Outcome 6 Cord blood acidosis.

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Analysis 3.7

Comparison 3 Continuous CTG versus IA (onset of labour ‐ spontaneous/induced), Outcome 7 Any pharmacological analgesia.

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Analysis 4.1

Comparison 4 Continuous CTG versus IA (preterm/term labour), Outcome 1 Perinatal mortality.

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Analysis 4.2

Comparison 4 Continuous CTG versus IA (preterm/term labour), Outcome 2 Neonatal seizures.

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Analysis 4.3

Comparison 4 Continuous CTG versus IA (preterm/term labour), Outcome 3 Cerebral palsy.

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Analysis 4.4

Comparison 4 Continuous CTG versus IA (preterm/term labour), Outcome 4 Caesarean section.

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Analysis 4.5

Comparison 4 Continuous CTG versus IA (preterm/term labour), Outcome 5 Instrumental vaginal birth.

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Analysis 4.6

Comparison 4 Continuous CTG versus IA (preterm/term labour), Outcome 6 Cord blood acidosis.

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Analysis 4.7

Comparison 4 Continuous CTG versus IA (preterm/term labour), Outcome 7 Any pharmacological analgesia.

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Analysis 5.1

Comparison 5 Continuous CTG versus IA (singleton/twin pregnancy), Outcome 1 Perinatal mortality.

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Analysis 5.2

Comparison 5 Continuous CTG versus IA (singleton/twin pregnancy), Outcome 2 Neonatal seizures.

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Analysis 5.3

Comparison 5 Continuous CTG versus IA (singleton/twin pregnancy), Outcome 3 Cerebral palsy.

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Analysis 5.4

Comparison 5 Continuous CTG versus IA (singleton/twin pregnancy), Outcome 4 Caesarean section.

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Analysis 5.5

Comparison 5 Continuous CTG versus IA (singleton/twin pregnancy), Outcome 5 Instrumental vaginal birth.

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Analysis 5.6

Comparison 5 Continuous CTG versus IA (singleton/twin pregnancy), Outcome 6 Cord blood acidosis.

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Analysis 5.7

Comparison 5 Continuous CTG versus IA (singleton/twin pregnancy), Outcome 7 Any pharmacological analgesia.

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Analysis 6.1

Comparison 6 Continuous CTG versus IA (access to FBS during labour ‐ yes/no), Outcome 1 Perinatal mortality.

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Analysis 6.2

Comparison 6 Continuous CTG versus IA (access to FBS during labour ‐ yes/no), Outcome 2 Neonatal seizures.

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Analysis 6.3

Comparison 6 Continuous CTG versus IA (access to FBS during labour ‐ yes/no), Outcome 3 Cerebral palsy.

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Analysis 6.4

Comparison 6 Continuous CTG versus IA (access to FBS during labour ‐ yes/no), Outcome 4 Caesarean section.

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Analysis 6.5

Comparison 6 Continuous CTG versus IA (access to FBS during labour ‐ yes/no), Outcome 5 Instrumental vaginal birth.

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Analysis 6.6

Comparison 6 Continuous CTG versus IA (access to FBS during labour ‐ yes/no), Outcome 6 Cord blood acidosis.

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Analysis 6.7

Comparison 6 Continuous CTG versus IA (access to FBS during labour ‐ yes/no), Outcome 7 Any pharmacological analgesia.

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Analysis 7.1

Comparison 7 Continuous CTG versus IA (primiparous/multiparous women), Outcome 1 Perinatal mortality.

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Analysis 7.2

Comparison 7 Continuous CTG versus IA (primiparous/multiparous women), Outcome 2 Neonatal seizures.

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Analysis 7.3

Comparison 7 Continuous CTG versus IA (primiparous/multiparous women), Outcome 3 Cerebral palsy.

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Analysis 7.4

Comparison 7 Continuous CTG versus IA (primiparous/multiparous women), Outcome 4 Caesarean section.

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Analysis 7.5

Comparison 7 Continuous CTG versus IA (primiparous/multiparous women), Outcome 5 Instrumental vaginal birth.

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Analysis 7.6

Comparison 7 Continuous CTG versus IA (primiparous/multiparous women), Outcome 6 Cord blood acidosis.

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Analysis 7.7

Comparison 7 Continuous CTG versus IA (primiparous/multiparous women), Outcome 7 Any pharmacological analgesia.

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Analysis 8.1

Comparison 8 Continuous CTG versus IA (high‐quality studies vs lower‐quality studies), Outcome 1 Perinatal mortality.

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Analysis 8.2

Comparison 8 Continuous CTG versus IA (high‐quality studies vs lower‐quality studies), Outcome 2 Neonatal seizures.

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Analysis 8.3

Comparison 8 Continuous CTG versus IA (high‐quality studies vs lower‐quality studies), Outcome 3 Cerebral palsy.

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Analysis 8.4

Comparison 8 Continuous CTG versus IA (high‐quality studies vs lower‐quality studies), Outcome 4 Caesarean section.

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Analysis 8.5

Comparison 8 Continuous CTG versus IA (high‐quality studies vs lower‐quality studies), Outcome 5 Instrumental vaginal birth.

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Analysis 8.6

Comparison 8 Continuous CTG versus IA (high‐quality studies vs lower‐quality studies), Outcome 6 Cord blood acidosis.

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Analysis 8.7

Comparison 8 Continuous CTG versus IA (high‐quality studies vs lower‐quality studies), Outcome 7 Any pharmacological analgesia.

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Analysis 9.4

Comparison 9 Continuous CTG versus intermittent CTG, Outcome 4 Caesarean section (primary outcome).

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Analysis 9.5

Comparison 9 Continuous CTG versus intermittent CTG, Outcome 5 Instrumental vaginal birth (primary outcome).

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Analysis 9.6

Comparison 9 Continuous CTG versus intermittent CTG, Outcome 6 Cord blood acidosis (primary outcome).

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Analysis 9.10

Comparison 9 Continuous CTG versus intermittent CTG, Outcome 10 Apgar score < 7 at 5 minutes.

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Analysis 9.12

Comparison 9 Continuous CTG versus intermittent CTG, Outcome 12 Neonatal ICU admissions.

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Analysis 9.15

Comparison 9 Continuous CTG versus intermittent CTG, Outcome 15 Caesarean section for abnormal FHR pattern and/or acidosis.

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Analysis 9.17

Comparison 9 Continuous CTG versus intermittent CTG, Outcome 17 Spontaneous vaginal birth.

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Analysis 9.18

Comparison 9 Continuous CTG versus intermittent CTG, Outcome 18 Epidural analgesia.

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Summary of findings for the main comparison. Continuous CTG versus intermittent auscultation for fetal assessment during labour

Continuous CTG versus intermittent auscultation for fetal assessment during labour
Patient or population: Women undergoing fetal assessment during labour Settings: Intervention: Continuous CTG versus intermittent auscultation
Outcomes	*Illustrative comparative risks (95% CI)**		Relative effect (95% CI)	No of Participants (studies)	Quality of the evidence (GRADE)	Comments
	Assumed risk	Corresponding risk
	Control	Continuous CTG versus intermittent auscultation
Perinatal mortality (primary outcome)	Study population		RR 0.86 (0.59 to 1.24)	33513 (11 studies)	⊕⊕⊝⊝ low^1,2
	3 per 1000	3 per 1000 (2 to 4)
	Moderate
	4 per 1000	3 per 1000 (2 to 5)
Neonatal seizures (primary outcome)	Study population		RR 0.5 (0.31 to 0.8)	32386 (9 studies)	⊕⊕⊕⊝ moderate³
	3 per 1000	1 per 1000 (1 to 2)
	Moderate
	4 per 1000	2 per 1000 (1 to 3)
Cerebral palsy (primary outcome)	Study population		RR 1.75 (0.84 to 3.63)	13252 (2 studies)	⊕⊕⊝⊝ low^4,5
	3 per 1000	4 per 1000 (2 to 9)
	Moderate
	39 per 1000	68 per 1000 (33 to 142)
Caesarean section (primary outcome)	Study population		RR 1.63 (1.29 to 2.07)	18861 (11 studies)	⊕⊕⊝⊝ low^6,7
	36 per 1000	59 per 1000 (47 to 75)
	Moderate
	66 per 1000	108 per 1000 (85 to 137)
Instrumental vaginal birth (primary outcome)	Study population		RR 1.15 (1.01 to 1.33)	18615 (10 studies)	⊕⊕⊝⊝ low^8,9
	102 per 1000	118 per 1000 (103 to 136)
	Moderate
	222 per 1000	255 per 1000 (224 to 295)
Cord blood acidosis (primary outcome)	Study population		RR 0.92 (0.27 to 3.11)	2494 (2 studies)	⊕⊝⊝⊝ very low^10,11,12
	24 per 1000	22 per 1000 (6 to 74)
	Moderate
	24 per 1000	22 per 1000 (6 to 75)
Any pharmacological analgesia (primary outcome)	Study population		RR 0.98 (0.88 to 1.09)	1677 (3 studies)	⊕⊕⊝⊝ low^13,14
	754 per 1000	739 per 1000 (663 to 822)
	Moderate
	805 per 1000	789 per 1000 (708 to 877)
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 Limitations in design: Most of the pooled effect provided by studies “B” or “C” without a substantial proportion (i.e. < 40% (actual 33% weight) from studies “C”. ² 95% confidence interval around the pooled or best estimate of effect includes both 1) no effect and 2) appreciable benefit favouring CTG. ³ Limitations in design: Most of the pooled effect provided by studies “B” or “C” without a substantial proportion (i.e. < 40% (actual 5.2% weight) from studies “C” ⁴ Limitations in design: Most of the pooled effect provided by studies “B” or “C” without a substantial proportion (i.e. < 40% (actual 0% weight) from studies “C” ⁵ 95% confidence interval around the pooled or best estimate of effect includes both 1) no effect and 2) appreciable benefit favouring IA. ⁶ Limitations in design: Most of the pooled effect provided by studies “B” or “C” without a substantial proportion (i.e. < 40% (actual 20.9% weight) from studies “C” ⁷ Severe heterogeneity (I² = 60% & Chi² P = 0.005) ⁸ Limitations in design: Most of the pooled effect provided by studies “B” or “C” without a substantial proportion (i.e. < 40% (actual 17.3% weight) from studies “C” ⁹ Severe heterogeneity (I² = 60% & Chi² P = 0.008) ¹⁰ Limitations in design: Most of the pooled effect provided by studies “C” (i.e. > 40%, actual 56.4%) ¹¹ Severe heterogeneity (I² = 77% & Chi² P = 0.04) ¹² 95% confidence interval around the pooled or best estimate of effect includes both 1) no effect and 2) appreciable benefit and appreciable harm. ¹³ Limitations in design: Most of the pooled effect provided by studies “B” or “C” without a substantial proportion (i.e. < 40% (actual 0% weight) from studies “C” ¹⁴ Severe heterogeneity (I² = 72% & Chi² P = 0.03)

Summary of findings for the main comparison. Continuous CTG versus intermittent auscultation for fetal assessment during labour

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Table 1. Methods of fetal heart rate monitoring

Method	Description
Fetal stethoscope (Pinard) ‐ for intermittent monitoring (IA)	This is a trumpet‐shaped device, which is placed on the mother's abdomen and the caregiver listens for the heart beat at the other end. This is a simple instrument of relatively low cost.
Hand‐held Doppler ultrasound monitor ‐ for intermittent monitoring (IA)	The device is placed on the mother's abdomen with gel smeared on the underside of the ultrasound transducer. This allows the ultrasound beam to travel from the fetal heart to the transducer without interruption.
External cardiotocography ‐ for continuous or intermittent monitoring	The fetal heart rate and the activity of the uterine muscle are detected by two transducers placed on the mother's abdomen (one above the fetal heart and the other at the fundus). Doppler ultrasound provides the information which is recorded on a paper strip known as a cardiotocograph (CTG).
Internal cardiotocography ‐ for continuous monitoring	An electrode is placed directly on the baby's presenting part to detect the fetal ECG signal. Again the signals are recorded on a paper strip (CTG). This method can only be used if membranes (fore‐waters) have ruptured either spontaneously or artificially.

Table 1. Methods of fetal heart rate monitoring

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Table 2. Additional descriptive information from included studies

Study	1 carer to 1 woman	Induction	ARM	Oxytocin	Mobility	Birth positions	Women's views	Social context	Experience of staff
Athens 1993	Yes	Induction ‐ 11% overall	No information	Augmentation ‐ 46% overall	No mobility ‐ all women with IV line inserted	Semi‐Fowler or lateral	No information	No information	IA standard practice, EFM intensive training provided
Copenhagen 1985	No information	No information	No information	No information	EFM only applied when women no longer wished to walk around.	No information	No information	No information	No information
Dallas 1986	2 women : 1 nurse	Excluded women whose labours were induced	No information	Excluded women	No information	No information	No information	No information	No information
Denver 1976	IA: yes CTG: no information	Included women whose labours were induced	No information	Included women given oxytocin for augmentation	No information	No information	No information	No information	No information
Denver 1979	Yes	No specific information	No information	29% of women given oxytocin for augmentation	No information	No information	No information	No information	No information
Dublin 1985	Yes	Included women whose labours were induced	ARM within an hour of admission to check liquor	23% of women given oxytocin for augmentation	IA, probably more mobile	No information	Women's views sought and published separately.	No information	No information
Lund 1994	No information	Included women whose labours were induced	No information	48% of women were given ocytocin for induction or acceleration	Women in CTG group offered telemetry if wished mobility	No information	No information	No information	No information
Melbourne 1976	No information	Induction ‐ 42% overall	No information	63% of women given oxytocin in labour	No information	No information	No information	No information	Exp staff.
Melbourne 1981	No information	No information	ARM when in established labour or for obstetric reasons	No information	No information	No information	No information	No information	No information
Pakistan 1989	No information	No information	No information	No information	No information	No information	No information	No information	No information
New Delhi 2006	No information	No information	No information	No information	No information	No information	No information	No information	No information
Seattle 1987	Yes	No information	ARM at 7 cm unless clinically indicated prior to 7 cm	Included women given oxytocin	No information	No information	Women's views sought and published separately.	No information	No information
Sheffield 1978	No information	Included women whose labours were induced	Augmentation with ARM alone or in combination with oxytocin if progress fell below nomogram.	Oxytocin was administered to all women as indicated	No information	No information	No information	No information	No information
ARM: artificial rupture of membranes CTG: cardiotocography EFM: electronic fetal monitoring IA: intermittent auscultation IV: intravenous

Table 2. Additional descriptive information from included studies

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Comparison 1. Continuous CTG versus intermittent auscultation

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Perinatal mortality (primary outcome) Show forest plot	11	33513	Risk Ratio (M‐H, Fixed, 95% CI)	0.86 [0.59, 1.24]

2 Neonatal seizures (primary outcome) Show forest plot	9	32386	Risk Ratio (M‐H, Fixed, 95% CI)	0.50 [0.31, 0.80]

3 Cerebral palsy (primary outcome) Show forest plot	2	13252	Risk Ratio (M‐H, Random, 95% CI)	1.75 [0.84, 3.63]

4 Caesarean section (primary outcome) Show forest plot	11	18861	Risk Ratio (M‐H, Random, 95% CI)	1.63 [1.29, 2.07]

5 Instrumental vaginal birth (primary outcome) Show forest plot	10	18615	Risk Ratio (M‐H, Random, 95% CI)	1.15 [1.01, 1.33]

6 Cord blood acidosis (primary outcome) Show forest plot	2	2494	Risk Ratio (M‐H, Random, 95% CI)	0.92 [0.27, 3.11]

7 Any pharmacological analgesia (primary outcome) Show forest plot	3	1677	Risk Ratio (M‐H, Random, 95% CI)	0.98 [0.88, 1.09]

8 Hypoxic ischaemic encephalopathy Show forest plot	1	1428	Risk Ratio (M‐H, Fixed, 95% CI)	0.46 [0.04, 5.03]

9 Neurodevelopmental disability at at least 12 months of age Show forest plot	1	173	Risk Ratio (M‐H, Fixed, 95% CI)	3.88 [0.83, 18.17]

10 Apgar score < 7 at 5 minutes Show forest plot	6	4137	Risk Ratio (M‐H, Fixed, 95% CI)	0.95 [0.71, 1.27]

11 Apgar score < 4 at 5 minutes Show forest plot	3	1919	Risk Ratio (M‐H, Fixed, 95% CI)	1.80 [0.71, 4.59]

12 Neonatal ICU admissions Show forest plot	10	33167	Risk Ratio (M‐H, Random, 95% CI)	1.01 [0.86, 1.18]

13 Fetal blood sampling Show forest plot	2	13929	Risk Ratio (M‐H, Fixed, 95% CI)	1.24 [1.05, 1.47]

14 Damage/infection from scalp electrode or scalp sampling Show forest plot	1	200	Risk Ratio (M‐H, Fixed, 95% CI)	3.0 [0.12, 72.77]

15 Caesarean section for abnormal FHR pattern and/or acidosis Show forest plot	11	33379	Risk Ratio (M‐H, Fixed, 95% CI)	2.38 [1.89, 3.01]

16 Instrumental vaginal birth for abnormal CTG or fetal acidosis Show forest plot	1	12964	Risk Ratio (M‐H, Fixed, 95% CI)	2.54 [1.95, 3.31]

17 Spontaneous vaginal birth Show forest plot	11	18861	Risk Ratio (M‐H, Random, 95% CI)	0.91 [0.86, 0.96]

18 Epidural analgesia Show forest plot	8	17630	Risk Ratio (M‐H, Fixed, 95% CI)	1.00 [0.90, 1.12]

19 Use of non pharmacological methods of coping with labour	0	0	Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
20 Amniotomy	0	0	Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
21 Oxytocin during 1st and/or 2nd stage of labour Show forest plot	5	3683	Risk Ratio (M‐H, Random, 95% CI)	1.08 [0.86, 1.37]

22 Perineal trauma needing repair	0	0	Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
23 Inability to adopt preferred position in labour	0	0	Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
24 Dissatisifaction with labour and/or perceived loss of control	0	0	Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
25 Postpartum depression	0	0	Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
26 Exclusive breastfeeding at discharge	0	0	Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
27 Length of stay on NICU Show forest plot	1	206	Mean Difference (IV, Fixed, 95% CI)	0.20 [‐1.17, 1.57]

Comparison 1. Continuous CTG versus intermittent auscultation

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Comparison 2. Continuous CTG versus IA (pregnancy risk status ‐ high/low)

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Perinatal mortality Show forest plot	11	33513	Risk Ratio (M‐H, Fixed, 95% CI)	0.86 [0.59, 1.24]

1.1 High risk	5	1974	Risk Ratio (M‐H, Fixed, 95% CI)	1.04 [0.62, 1.74]
1.2 Low risk	3	16049	Risk Ratio (M‐H, Fixed, 95% CI)	0.87 [0.29, 2.58]
1.3 Risk status ‐ mixed or not specified	3	15490	Risk Ratio (M‐H, Fixed, 95% CI)	0.68 [0.38, 1.24]
2 Neonatal seizures Show forest plot	9	32386	Risk Ratio (M‐H, Fixed, 95% CI)	0.50 [0.31, 0.80]

2.1 High risk	5	4805	Risk Ratio (M‐H, Fixed, 95% CI)	0.67 [0.36, 1.24]
2.2 Low risk	3	25175	Risk Ratio (M‐H, Fixed, 95% CI)	0.36 [0.16, 0.79]
2.3 Risk status ‐ mixed or not specified	2	2406	Risk Ratio (M‐H, Fixed, 95% CI)	0.18 [0.01, 3.80]
3 Cerebral palsy Show forest plot	2	13252	Risk Ratio (M‐H, Fixed, 95% CI)	1.74 [0.97, 3.11]

3.1 High risk	1	173	Risk Ratio (M‐H, Fixed, 95% CI)	2.54 [1.10, 5.86]
3.2 Low risk	0	0	Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
3.3 Risk status ‐ mixed or not specified	1	13079	Risk Ratio (M‐H, Fixed, 95% CI)	1.20 [0.52, 2.79]
4 Caesarean section Show forest plot	11	18861	Risk Ratio (M‐H, Random, 95% CI)	1.63 [1.29, 2.07]

4.1 High risk	6	2069	Risk Ratio (M‐H, Random, 95% CI)	1.91 [1.39, 2.61]
4.2 Low risk	2	1431	Risk Ratio (M‐H, Random, 95% CI)	2.06 [1.24, 3.45]
4.3 Risk status ‐ mixed or not specified	3	15361	Risk Ratio (M‐H, Random, 95% CI)	1.14 [0.95, 1.36]
5 Instrumental vaginal birth Show forest plot	10	18615	Risk Ratio (M‐H, Random, 95% CI)	1.15 [1.01, 1.33]

5.1 High risk	5	1823	Risk Ratio (M‐H, Random, 95% CI)	1.02 [0.82, 1.27]
5.2 Low risk	2	1431	Risk Ratio (M‐H, Random, 95% CI)	1.09 [0.77, 1.54]
5.3 Risk status ‐ mixed or not specified	3	15361	Risk Ratio (M‐H, Random, 95% CI)	1.33 [1.20, 1.49]
6 Cord blood acidosis Show forest plot	2	2494	Risk Ratio (M‐H, Fixed, 95% CI)	1.16 [0.72, 1.89]

6.1 High risk	0	0	Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
6.2 Low risk	0	0	Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
6.3 Risk status ‐ mixed or not specified	2	2494	Risk Ratio (M‐H, Fixed, 95% CI)	1.16 [0.72, 1.89]
7 Any pharmacological analgesia Show forest plot	3	1677	Risk Ratio (M‐H, Fixed, 95% CI)	0.99 [0.93, 1.04]

7.1 High risk	2	1173	Risk Ratio (M‐H, Fixed, 95% CI)	1.01 [0.96, 1.06]
7.2 Low risk	1	504	Risk Ratio (M‐H, Fixed, 95% CI)	0.92 [0.79, 1.07]
7.3 Risk status ‐ mixed or not specified	0	0	Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]

Comparison 2. Continuous CTG versus IA (pregnancy risk status ‐ high/low)

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Comparison 3. Continuous CTG versus IA (onset of labour ‐ spontaneous/induced)

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Perinatal mortality Show forest plot	11	33513	Risk Ratio (M‐H, Fixed, 95% CI)	0.86 [0.59, 1.24]

1.1 Spontaneous labour	0	0	Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
1.2 Induction of labour	0	0	Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
1.3 Onset of labour ‐ not specified	11	33513	Risk Ratio (M‐H, Fixed, 95% CI)	0.86 [0.59, 1.24]
2 Neonatal seizures Show forest plot	9	32386	Risk Ratio (M‐H, Fixed, 95% CI)	0.50 [0.31, 0.80]

2.1 Spontaneous labour	0	0	Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
2.2 Induction of labour	0	0	Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
2.3 Onset of labour ‐ not specified	9	32386	Risk Ratio (M‐H, Fixed, 95% CI)	0.50 [0.31, 0.80]
3 Cerebral palsy Show forest plot	2	13252	Risk Ratio (M‐H, Fixed, 95% CI)	1.74 [0.97, 3.11]

3.1 Spontaneous labour	0	0	Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
3.2 Induction of labour	0	0	Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
3.3 Onset of labour ‐ not specified	2	13252	Risk Ratio (M‐H, Fixed, 95% CI)	1.74 [0.97, 3.11]
4 Caesarean section Show forest plot	11	18861	Risk Ratio (M‐H, Fixed, 95% CI)	1.43 [1.25, 1.64]

4.1 Spontaneous labour	0	0	Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
4.2 Induction of labour	0	0	Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
4.3 Onset of labour ‐ not specified	11	18861	Risk Ratio (M‐H, Fixed, 95% CI)	1.43 [1.25, 1.64]
5 Instrumental vaginal birth Show forest plot	10	18615	Risk Ratio (M‐H, Fixed, 95% CI)	1.21 [1.12, 1.31]

5.1 Spontaneous labour	0	0	Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
5.2 Induction of labour	0	0	Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
5.3 Onset of labour ‐ not specified	10	18615	Risk Ratio (M‐H, Fixed, 95% CI)	1.21 [1.12, 1.31]
6 Cord blood acidosis Show forest plot	2	2494	Risk Ratio (M‐H, Fixed, 95% CI)	1.16 [0.72, 1.89]

6.1 Spontaneous labour	0	0	Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
6.2 Induction of labour	0	0	Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
6.3 Onset of labour ‐ not specified	2	2494	Risk Ratio (M‐H, Fixed, 95% CI)	1.16 [0.72, 1.89]
7 Any pharmacological analgesia Show forest plot	3	1677	Risk Ratio (M‐H, Fixed, 95% CI)	0.99 [0.93, 1.04]

7.1 Spontaneous labour	0	0	Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
7.2 Induction of labour	0	0	Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
7.3 Onset of labour ‐ not specified	3	1677	Risk Ratio (M‐H, Fixed, 95% CI)	0.99 [0.93, 1.04]

Comparison 3. Continuous CTG versus IA (onset of labour ‐ spontaneous/induced)

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Comparison 4. Continuous CTG versus IA (preterm/term labour)

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Perinatal mortality Show forest plot	11	33513	Risk Ratio (M‐H, Fixed, 95% CI)	0.86 [0.59, 1.24]

1.1 Preterm labour	1	246	Risk Ratio (M‐H, Fixed, 95% CI)	0.96 [0.52, 1.77]
1.2 Term labour	3	2409	Risk Ratio (M‐H, Fixed, 95% CI)	0.82 [0.22, 3.03]
1.3 Both or gestation not specified	7	30858	Risk Ratio (M‐H, Fixed, 95% CI)	0.81 [0.50, 1.32]
2 Neonatal seizures Show forest plot	9	32386	Risk Ratio (M‐H, Fixed, 95% CI)	0.50 [0.31, 0.80]

2.1 Preterm labour	1	246	Risk Ratio (M‐H, Fixed, 95% CI)	1.02 [0.37, 2.81]
2.2 Term labour	2	1482	Risk Ratio (M‐H, Fixed, 95% CI)	0.33 [0.01, 8.08]
2.3 Both or gestation not specified	6	30658	Risk Ratio (M‐H, Fixed, 95% CI)	0.42 [0.24, 0.72]
3 Cerebral palsy Show forest plot	2	13252	Risk Ratio (M‐H, Fixed, 95% CI)	1.74 [0.97, 3.11]

3.1 Preterm labour	1	173	Risk Ratio (M‐H, Fixed, 95% CI)	2.54 [1.10, 5.86]
3.2 Term labour	0	0	Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
3.3 Both or gestation not specified	1	13079	Risk Ratio (M‐H, Fixed, 95% CI)	1.20 [0.52, 2.79]
4 Caesarean section Show forest plot	11	18861	Risk Ratio (M‐H, Fixed, 95% CI)	1.43 [1.25, 1.64]

4.1 Preterm labour	1	246	Risk Ratio (M‐H, Fixed, 95% CI)	1.02 [0.57, 1.82]
4.2 Term labour	3	2400	Risk Ratio (M‐H, Fixed, 95% CI)	1.84 [1.25, 2.69]
4.3 Both or gestation not specified	7	16215	Risk Ratio (M‐H, Fixed, 95% CI)	1.41 [1.21, 1.63]
5 Instrumental vaginal birth Show forest plot	10	18615	Risk Ratio (M‐H, Fixed, 95% CI)	1.21 [1.12, 1.31]

5.1 Preterm labour	0	0	Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
5.2 Term labour	3	2400	Risk Ratio (M‐H, Fixed, 95% CI)	1.18 [1.01, 1.37]
5.3 Both or gestation not specified	7	16215	Risk Ratio (M‐H, Fixed, 95% CI)	1.22 [1.11, 1.34]
6 Cord blood acidosis Show forest plot	2	2494	Risk Ratio (M‐H, Fixed, 95% CI)	1.16 [0.72, 1.89]

6.1 Preterm labour	0	0	Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
6.2 Term labour	0	0	Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
6.3 Both or gestation not specified	2	2494	Risk Ratio (M‐H, Fixed, 95% CI)	1.16 [0.72, 1.89]
7 Any pharmacological analgesia Show forest plot	3	1677	Risk Ratio (M‐H, Fixed, 95% CI)	0.99 [0.93, 1.04]

7.1 Preterm labour	0	0	Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
7.2 Term labour	1	504	Risk Ratio (M‐H, Fixed, 95% CI)	0.92 [0.79, 1.07]
7.3 Both or gestation not specified	2	1173	Risk Ratio (M‐H, Fixed, 95% CI)	1.01 [0.96, 1.06]

Comparison 4. Continuous CTG versus IA (preterm/term labour)

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Comparison 5. Continuous CTG versus IA (singleton/twin pregnancy)

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Perinatal mortality Show forest plot	11	33513	Risk Ratio (M‐H, Fixed, 95% CI)	0.86 [0.59, 1.24]

1.1 Singleton	7	18406	Risk Ratio (M‐H, Fixed, 95% CI)	0.77 [0.49, 1.21]
1.2 Twins	0	0	Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
1.3 Both or singleton/twins not specified	4	15107	Risk Ratio (M‐H, Fixed, 95% CI)	1.04 [0.55, 1.97]
2 Neonatal seizures Show forest plot	9	32386	Risk Ratio (M‐H, Fixed, 95% CI)	0.50 [0.31, 0.80]

2.1 Singleton	5	17279	Risk Ratio (M‐H, Fixed, 95% CI)	0.69 [0.32, 1.46]
2.2 Twins	0	0	Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
2.3 Both or singleton/twins not specified	4	15107	Risk Ratio (M‐H, Fixed, 95% CI)	0.41 [0.22, 0.76]
3 Cerebral palsy Show forest plot	2	13252	Risk Ratio (M‐H, Fixed, 95% CI)	1.74 [0.97, 3.11]

3.1 Singleton	1	173	Risk Ratio (M‐H, Fixed, 95% CI)	2.54 [1.10, 5.86]
3.2 Twins	0	0	Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
3.3 Both or singleton/twins not specified	1	13079	Risk Ratio (M‐H, Fixed, 95% CI)	1.20 [0.52, 2.79]
4 Caesarean section Show forest plot	11	18861	Risk Ratio (M‐H, Fixed, 95% CI)	1.43 [1.25, 1.64]

4.1 Singleton	7	3888	Risk Ratio (M‐H, Fixed, 95% CI)	1.58 [1.30, 1.93]
4.2 Twins	0	0	Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
4.3 Both or singleton/twins not specified	4	14973	Risk Ratio (M‐H, Fixed, 95% CI)	1.33 [1.11, 1.59]
5 Instrumental vaginal birth Show forest plot	10	18615	Risk Ratio (M‐H, Fixed, 95% CI)	1.21 [1.12, 1.31]

5.1 Singleton	6	3642	Risk Ratio (M‐H, Fixed, 95% CI)	1.13 [1.00, 1.28]
5.2 Twins	0	0	Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
5.3 Both or singleton/twins not specified	4	14973	Risk Ratio (M‐H, Fixed, 95% CI)	1.25 [1.13, 1.38]
6 Cord blood acidosis Show forest plot	2	2494	Risk Ratio (M‐H, Fixed, 95% CI)	1.16 [0.72, 1.89]

6.1 Singleton	1	1419	Risk Ratio (M‐H, Fixed, 95% CI)	1.58 [0.89, 2.81]
6.2 Twins	0	0	Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
6.3 Both or singleton/twins not specified	1	1075	Risk Ratio (M‐H, Fixed, 95% CI)	0.45 [0.16, 1.29]
7 Any pharmacological analgesia Show forest plot	3	1677	Risk Ratio (M‐H, Fixed, 95% CI)	0.99 [0.93, 1.04]

7.1 Singleton	2	987	Risk Ratio (M‐H, Fixed, 95% CI)	0.93 [0.86, 1.01]
7.2 Twins	0	0	Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
7.3 Both or singleton/twins not specified	1	690	Risk Ratio (M‐H, Fixed, 95% CI)	1.06 [1.00, 1.12]

Comparison 5. Continuous CTG versus IA (singleton/twin pregnancy)

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Comparison 6. Continuous CTG versus IA (access to FBS during labour ‐ yes/no)

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Perinatal mortality Show forest plot	11	33513	Risk Ratio (M‐H, Fixed, 95% CI)	0.85 [0.59, 1.23]

1.1 Continuous CTG plus FBS	7	16131	Risk Ratio (M‐H, Fixed, 95% CI)	0.97 [0.64, 1.47]
1.2 Continuous CTG alone ‐ no FBS	5	17382	Risk Ratio (M‐H, Fixed, 95% CI)	0.57 [0.26, 1.24]
2 Neonatal seizures Show forest plot	9	32386	Risk Ratio (M‐H, Fixed, 95% CI)	0.50 [0.31, 0.80]

2.1 Continuous CTG plus FBS	5	15004	Risk Ratio (M‐H, Fixed, 95% CI)	0.49 [0.29, 0.84]
2.2 Continuous CTG alone ‐ no FBS	5	17382	Risk Ratio (M‐H, Fixed, 95% CI)	0.51 [0.18, 1.44]
3 Cerebral palsy Show forest plot	2	13252	Risk Ratio (M‐H, Fixed, 95% CI)	1.74 [0.97, 3.11]

3.1 Continuous CTG plus FBS	2	13252	Risk Ratio (M‐H, Fixed, 95% CI)	1.74 [0.97, 3.11]
3.2 Continuous CTG alone ‐ no FBS	0	0	Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
4 Caesarean section Show forest plot	11	18861	Risk Ratio (M‐H, Fixed, 95% CI)	1.43 [1.25, 1.64]

4.1 Continuous CTG plus FBS	7	16001	Risk Ratio (M‐H, Fixed, 95% CI)	1.34 [1.14, 1.58]
4.2 Continuous CTG alone ‐ no FBS	5	2860	Risk Ratio (M‐H, Fixed, 95% CI)	1.63 [1.30, 2.06]
5 Instrumental vaginal birth Show forest plot	10	18615	Risk Ratio (M‐H, Fixed, 95% CI)	1.21 [1.12, 1.31]

5.1 Continuous CTG plus FBS	6	15755	Risk Ratio (M‐H, Fixed, 95% CI)	1.27 [1.16, 1.39]
5.2 Continuous CTG alone ‐ no FBS	5	2860	Risk Ratio (M‐H, Fixed, 95% CI)	1.05 [0.90, 1.22]
6 Cord blood acidosis Show forest plot	2	2494	Risk Ratio (M‐H, Fixed, 95% CI)	1.16 [0.72, 1.89]

6.1 Continuous CTG plus FBS	1	1075	Risk Ratio (M‐H, Fixed, 95% CI)	0.45 [0.16, 1.29]
6.2 Continuous CTG alone ‐ no FBS	1	1419	Risk Ratio (M‐H, Fixed, 95% CI)	1.58 [0.89, 2.81]
7 Any pharmacological analgesia Show forest plot	3	1677	Risk Ratio (M‐H, Fixed, 95% CI)	0.99 [0.93, 1.04]

7.1 Continuous CTG plus FBS	2	849	Risk Ratio (M‐H, Fixed, 95% CI)	0.98 [0.90, 1.07]
7.2 Continuous CTG alone ‐ no FBS	2	828	Risk Ratio (M‐H, Fixed, 95% CI)	0.99 [0.92, 1.05]

Comparison 6. Continuous CTG versus IA (access to FBS during labour ‐ yes/no)

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Comparison 7. Continuous CTG versus IA (primiparous/multiparous women)

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Perinatal mortality Show forest plot	11	33513	Risk Ratio (M‐H, Fixed, 95% CI)	0.86 [0.59, 1.24]

1.1 Primaparous women	0	0	Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
1.2 Multiparous women	0	0	Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
1.3 Both or parity not specified	11	33513	Risk Ratio (M‐H, Fixed, 95% CI)	0.86 [0.59, 1.24]
2 Neonatal seizures Show forest plot	9	32386	Risk Ratio (M‐H, Fixed, 95% CI)	0.50 [0.31, 0.80]

2.1 Primaparous women	0	0	Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
2.2 Multiparous women	0	0	Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
2.3 Both or parity not specified	9	32386	Risk Ratio (M‐H, Fixed, 95% CI)	0.50 [0.31, 0.80]
3 Cerebral palsy Show forest plot	2	13252	Risk Ratio (M‐H, Fixed, 95% CI)	1.74 [0.97, 3.11]

3.1 Primaparous women	0	0	Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
3.2 Multiparous women	0	0	Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
3.3 Both or parity not specified	2	13252	Risk Ratio (M‐H, Fixed, 95% CI)	1.74 [0.97, 3.11]
4 Caesarean section Show forest plot	11	18961	Risk Ratio (M‐H, Fixed, 95% CI)	1.44 [1.26, 1.64]

4.1 Primaparous women	0	0	Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
4.2 Multiparous women	1	100	Risk Ratio (M‐H, Fixed, 95% CI)	1.55 [0.81, 2.96]
4.3 Both or parity not specified	11	18861	Risk Ratio (M‐H, Fixed, 95% CI)	1.43 [1.25, 1.64]
5 Instrumental vaginal birth Show forest plot	10	18715	Risk Ratio (M‐H, Fixed, 95% CI)	1.21 [1.12, 1.30]

5.1 Primaparous women	0	0	Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
5.2 Multiparous women	1	100	Risk Ratio (M‐H, Fixed, 95% CI)	0.33 [0.04, 3.10]
5.3 Both or parity not specified	10	18615	Risk Ratio (M‐H, Fixed, 95% CI)	1.21 [1.12, 1.31]
6 Cord blood acidosis Show forest plot	2	2494	Risk Ratio (M‐H, Fixed, 95% CI)	1.16 [0.72, 1.89]

6.1 Primaparous women	0	0	Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
6.2 Multiparous women	0	0	Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
6.3 Both or parity not specified	2	2494	Risk Ratio (M‐H, Fixed, 95% CI)	1.16 [0.72, 1.89]
7 Any pharmacological analgesia Show forest plot	3	1677	Risk Ratio (M‐H, Fixed, 95% CI)	0.99 [0.93, 1.04]

7.1 Primaparous women	0	0	Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
7.2 Multiparous women	0	0	Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
7.3 Both or parity not specified	3	1677	Risk Ratio (M‐H, Fixed, 95% CI)	0.99 [0.93, 1.04]

Comparison 7. Continuous CTG versus IA (primiparous/multiparous women)

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Comparison 8. Continuous CTG versus IA (high‐quality studies vs lower‐quality studies)

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Perinatal mortality Show forest plot	11	33513	Risk Ratio (M‐H, Fixed, 95% CI)	0.86 [0.59, 1.24]

1.1 High‐quality trials	2	13434	Risk Ratio (M‐H, Fixed, 95% CI)	1.00 [0.49, 2.05]
1.2 Low‐quality trials	4	17173	Risk Ratio (M‐H, Fixed, 95% CI)	0.58 [0.28, 1.18]
1.3 Quality of trials unclear	5	2906	Risk Ratio (M‐H, Fixed, 95% CI)	1.00 [0.58, 1.71]
2 Neonatal seizures Show forest plot	9	32386	Risk Ratio (M‐H, Fixed, 95% CI)	0.50 [0.31, 0.80]

2.1 High‐quality trials	2	13434	Risk Ratio (M‐H, Fixed, 95% CI)	0.40 [0.21, 0.77]
2.2 Low‐quality trials	2	16046	Risk Ratio (M‐H, Fixed, 95% CI)	0.26 [0.04, 1.60]
2.3 Quality of trials unclear	5	2906	Risk Ratio (M‐H, Fixed, 95% CI)	0.83 [0.38, 1.81]
3 Cerebral palsy Show forest plot	2	13252	Risk Ratio (M‐H, Fixed, 95% CI)	1.74 [0.97, 3.11]

3.1 High‐quality trials	1	13079	Risk Ratio (M‐H, Fixed, 95% CI)	1.20 [0.52, 2.79]
3.2 Low‐quality trials	0	0	Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
3.3 Quality of trials unclear	1	173	Risk Ratio (M‐H, Fixed, 95% CI)	2.54 [1.10, 5.86]
4 Caesarean section Show forest plot	11	18861	Risk Ratio (M‐H, Random, 95% CI)	1.63 [1.29, 2.07]

4.1 High‐quality trials	2	13314	Risk Ratio (M‐H, Random, 95% CI)	1.27 [0.88, 1.83]
4.2 Low‐quality trials	3	2555	Risk Ratio (M‐H, Random, 95% CI)	1.77 [0.92, 3.41]
4.3 Quality of trials unclear	6	2992	Risk Ratio (M‐H, Random, 95% CI)	1.81 [1.34, 2.44]
5 Instrumental vaginal birth Show forest plot	10	18615	Risk Ratio (M‐H, Fixed, 95% CI)	1.21 [1.12, 1.31]

5.1 High‐quality trials	2	13314	Risk Ratio (M‐H, Fixed, 95% CI)	1.26 [1.13, 1.42]
5.2 Low‐quality trials	3	2555	Risk Ratio (M‐H, Fixed, 95% CI)	1.39 [1.17, 1.64]
5.3 Quality of trials unclear	5	2746	Risk Ratio (M‐H, Fixed, 95% CI)	1.00 [0.87, 1.16]
6 Cord blood acidosis Show forest plot	2	2494	Risk Ratio (M‐H, Fixed, 95% CI)	1.16 [0.72, 1.89]

6.1 High‐quality trials	1	1075	Risk Ratio (M‐H, Fixed, 95% CI)	0.45 [0.16, 1.29]
6.2 Low‐quality trials	1	1419	Risk Ratio (M‐H, Fixed, 95% CI)	1.58 [0.89, 2.81]
6.3 Quality of trials unclear	0	0	Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
7 Any pharmacological analgesia Show forest plot	3	1677	Risk Ratio (M‐H, Fixed, 95% CI)	0.99 [0.93, 1.04]

7.1 High‐quality trials	0	0	Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
7.2 Low‐quality trials	0	0	Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
7.3 Quality of trials unclear	3	1677	Risk Ratio (M‐H, Fixed, 95% CI)	0.99 [0.93, 1.04]

Comparison 8. Continuous CTG versus IA (high‐quality studies vs lower‐quality studies)

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Comparison 9. Continuous CTG versus intermittent CTG

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Perinatal mortality (primary outcome)	0	0	Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
2 Neonatal seizures (primary outcome)	0	0	Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
3 Cerebral palsy (primary outcome)	0	0	Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
4 Caesarean section (primary outcome) Show forest plot	1	4044	Risk Ratio (M‐H, Fixed, 95% CI)	1.29 [0.84, 1.97]

5 Instrumental vaginal birth (primary outcome) Show forest plot	1	4044	Risk Ratio (M‐H, Fixed, 95% CI)	1.16 [0.92, 1.46]

6 Cord blood acidosis (primary outcome) Show forest plot	1	4044	Risk Ratio (M‐H, Fixed, 95% CI)	1.43 [0.95, 2.14]

7 Any pharmacological analgesia (primary outcome)	0	0	Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
8 Hypoxic ischaemic encephalopathy	0	0	Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
9 Neurodevelopmental disability at at least 12 months of age	0	0	Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
10 Apgar score < 7 at 5 minutes Show forest plot	1	4044	Risk Ratio (M‐H, Fixed, 95% CI)	2.65 [0.70, 9.97]

11 Apgar score < 4 at 5 minutes	0	0	Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
12 Neonatal ICU admissions Show forest plot	1	4044	Risk Ratio (M‐H, Fixed, 95% CI)	1.34 [0.91, 1.98]

13 Fetal blood sampling	0	0	Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
14 Damage/infection from scalp electrode or scalp sampling	0	0	Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
15 Caesarean section for abnormal FHR pattern and/or acidosis Show forest plot	1	4044	Risk Ratio (M‐H, Fixed, 95% CI)	1.19 [0.66, 2.15]

16 Instrumental vaginal birth for abnormal CTG or fetal acidosis	0	0	Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
17 Spontaneous vaginal birth Show forest plot	1	4044	Risk Ratio (M‐H, Fixed, 95% CI)	0.98 [0.96, 1.00]

18 Epidural analgesia Show forest plot	1	4044	Risk Ratio (M‐H, Fixed, 95% CI)	1.06 [0.92, 1.21]

19 Use of non pharmacological methods of coping with labour	0	0	Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
20 Amniotomy	0	0	Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
21 Oxytocin during 1st and/or 2nd stage of labour	0	0	Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
22 Perineal trauma needing repair	0	0	Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
23 Inability to adopt preferred position in labour	0	0	Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
24 Dissatisifaction with labour and/or perceived loss of control	0	0	Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
25 Postpartum depression	0	0	Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
26 Exclusive breastfeeding at discharge	0	0	Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
27 Length of stay on NICU	0	0	Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]

Comparison 9. Continuous CTG versus intermittent CTG

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