Internal versus external tocodynamometry during induced or augmented labour

Jannet JH Bakker; Petra F Janssen; Karlijn van Halem; Birgit Y van der Goes; Dimitri N.M. Papatsonis; Joris AM van der Post; Ben Willem J Mol

doi:10.1002/14651858.CD006947.pub2

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Analysis 1.1

Comparison 1 Monitoring of contractions with internal tocodynamometry compared to external tocodynamometry, Outcome 1 Uterine rupture.

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Analysis 1.2

Comparison 1 Monitoring of contractions with internal tocodynamometry compared to external tocodynamometry, Outcome 2 Hyperstimulation.

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Analysis 1.3

Comparison 1 Monitoring of contractions with internal tocodynamometry compared to external tocodynamometry, Outcome 3 Apgar score less than seven at five minutes.

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Analysis 1.4

Comparison 1 Monitoring of contractions with internal tocodynamometry compared to external tocodynamometry, Outcome 4 Umbilical artery pH < 7.15.

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Analysis 1.5

Comparison 1 Monitoring of contractions with internal tocodynamometry compared to external tocodynamometry, Outcome 5 Umbilical artery pH < 7.05.

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Analysis 1.6

Comparison 1 Monitoring of contractions with internal tocodynamometry compared to external tocodynamometry, Outcome 6 Umbilical artery pH < 7.16.

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Analysis 1.7

Comparison 1 Monitoring of contractions with internal tocodynamometry compared to external tocodynamometry, Outcome 7 Admission to neonatal intensive care.

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Analysis 1.8

Comparison 1 Monitoring of contractions with internal tocodynamometry compared to external tocodynamometry, Outcome 8 Neonatal admission > 48 hours.

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Analysis 1.9

Comparison 1 Monitoring of contractions with internal tocodynamometry compared to external tocodynamometry, Outcome 9 Perinatal mortality.

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Analysis 1.10

Comparison 1 Monitoring of contractions with internal tocodynamometry compared to external tocodynamometry, Outcome 10 Serious maternal outcomes (defined as death, coma, cardiac arrest, respiratory arrest, use of a mechanical ventilator, admission to intensive care unit).

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Analysis 1.11

Comparison 1 Monitoring of contractions with internal tocodynamometry compared to external tocodynamometry, Outcome 11 Instrumental delivery.

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Analysis 1.12

Comparison 1 Monitoring of contractions with internal tocodynamometry compared to external tocodynamometry, Outcome 12 Instrumental vaginal delivery.

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Analysis 1.13

Comparison 1 Monitoring of contractions with internal tocodynamometry compared to external tocodynamometry, Outcome 13 Caesarean section.

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Analysis 1.14

Comparison 1 Monitoring of contractions with internal tocodynamometry compared to external tocodynamometry, Outcome 14 Mean time to delivery.

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Analysis 1.15

Comparison 1 Monitoring of contractions with internal tocodynamometry compared to external tocodynamometry, Outcome 15 Placental or fetal vessel damage.

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Analysis 1.16

Comparison 1 Monitoring of contractions with internal tocodynamometry compared to external tocodynamometry, Outcome 16 Indication of infection up to three weeks postpartum in mother or child.

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Analysis 1.17

Comparison 1 Monitoring of contractions with internal tocodynamometry compared to external tocodynamometry, Outcome 17 Signs intrauterine infection during labor.

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Summary of findings for the main comparison. Monitoring of contractions with internal tocodynamometry compared to external tocodynamometry

Monitoring of contractions with internal tocodynamometry compared to external tocodynamometry
Patient or population: Settings: Intervention: Monitoring of contractions with internal tocodynamometry compared to external tocodynamometry Comparison:
Outcomes	*Illustrative comparative risks (95% CI)**		Relative effect (95% CI)	No of Participants (studies)	Quality of the evidence (GRADE)	Comments
	Assumed risk	Corresponding risk
		Monitoring of contractions with internal tocodynamometry to external tocodynamometry
Hyperstimulation	Study population		RR 1.21 (0.78 to 1.88)	489 (2 studies)	⊕⊕⊕⊝ moderate^1,2
	122 per 1000	148 per 1000 (95 to 229)
	Moderate
	121 per 1000	146 per 1000 (94 to 227)
Apgar score less than seven at five minutes	Study population		RR 1.78 (0.83 to 3.83)	1945 (3 studies)	⊕⊕⊕⊝ moderate^1,3
	10 per 1000	18 per 1000 (9 to 40)
	Moderate
	8 per 1000	14 per 1000 (7 to 31)
Umbilical artery pH < 7.15	Study population		RR 1.31 (0.95 to 1.79)	1456 (1 study)	⊕⊕⊕⊝ moderate¹
	84 per 1000	111 per 1000 (80 to 151)
	Moderate
	85 per 1000	111 per 1000 (81 to 152)
Umbilical artery pH < 7.16	Study population		RR 1.23 (0.39 to 3.92)	239 (1 study)	⊕⊕⊕⊝ moderate^1,2
	41 per 1000	51 per 1000 (16 to 162)
	Moderate
	41 per 1000	50 per 1000 (16 to 161)
Admission to neonatal intensive care	Study population		RR 0.34 (0.07 to 1.67)	489 (2 studies)	⊕⊕⊕⊝ moderate^1,2
	24 per 1000	8 per 1000 (2 to 41)
	Moderate
	25 per 1000	9 per 1000 (2 to 42)
Instrumental vaginal delivery	Study population		RR 1.06 (0.85 to 1.32)	1945 (3 studies)	⊕⊕⊕⊝ moderate^1,3
	131 per 1000	139 per 1000 (112 to 173)
	Moderate
	133 per 1000	141 per 1000 (113 to 176)
Caesarean section	Study population		RR 1.04 (0.85 to 1.29)	1945 (3 studies)	⊕⊕⊕⊝ moderate^1,3
	148 per 1000	154 per 1000 (126 to 191)
	Moderate
	140 per 1000	146 per 1000 (119 to 181)
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 Unclear risk of bias for not blinding patients and caregivers. ² No report of allocation concealment ³ No report of allocation concealment in two of the three trials.

Summary of findings for the main comparison. Monitoring of contractions with internal tocodynamometry compared to external tocodynamometry

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Table 1. Median time to delivery

Outcome	No of participants (studies)	External tocodynamometry	Internal tocodynamometry	RR	CI	P value

Time to delivery after induction (minutes ± SD)	1195 (2 studies)	358 ± 247 (n = 474) 363 ± 212 (n = 121)	313 ± 299 (n = 482) 337 ± 180 (n = 118)			ns
Time to delivery after augmentation (minutes ± SD)	750 (2 studies)	386 ± 280 (n = 248) 273 ± 228 (n = 125)	299 ± 239 (n = 252) 269 ± 158 (125)
Time to delivery is presented as median time in minutes SD = standard deviation

Table 1. Median time to delivery

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Comparison 1. Monitoring of contractions with internal tocodynamometry compared to external tocodynamometry

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Uterine rupture Show forest plot	3	1945	Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]

2 Hyperstimulation Show forest plot	2	489	Risk Ratio (M‐H, Fixed, 95% CI)	1.21 [0.78, 1.88]

3 Apgar score less than seven at five minutes Show forest plot	3	1945	Risk Ratio (M‐H, Fixed, 95% CI)	1.78 [0.83, 3.83]

4 Umbilical artery pH < 7.15 Show forest plot	1	1456	Risk Ratio (M‐H, Fixed, 95% CI)	1.31 [0.95, 1.79]

5 Umbilical artery pH < 7.05 Show forest plot	1	1456	Risk Ratio (M‐H, Fixed, 95% CI)	0.90 [0.40, 2.03]

6 Umbilical artery pH < 7.16 Show forest plot	1	239	Risk Ratio (M‐H, Fixed, 95% CI)	1.23 [0.39, 3.92]

7 Admission to neonatal intensive care Show forest plot	2	489	Risk Ratio (M‐H, Fixed, 95% CI)	0.34 [0.07, 1.67]

8 Neonatal admission > 48 hours Show forest plot	1	1456	Risk Ratio (M‐H, Fixed, 95% CI)	0.92 [0.71, 1.20]

9 Perinatal mortality Show forest plot	3	1945	Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]

10 Serious maternal outcomes (defined as death, coma, cardiac arrest, respiratory arrest, use of a mechanical ventilator, admission to intensive care unit) Show forest plot	3	1945	Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]

11 Instrumental delivery Show forest plot	3	1945	Risk Ratio (M‐H, Fixed, 95% CI)	1.05 [0.91, 1.21]

11.1 Induced labour	2	1195	Risk Ratio (M‐H, Fixed, 95% CI)	0.91 [0.75, 1.10]
11.2 Augmented labour	2	750	Risk Ratio (M‐H, Fixed, 95% CI)	1.25 [1.02, 1.53]
12 Instrumental vaginal delivery Show forest plot	3	1945	Risk Ratio (M‐H, Fixed, 95% CI)	1.06 [0.85, 1.32]

12.1 Induced labour	2	1195	Risk Ratio (M‐H, Fixed, 95% CI)	0.90 [0.66, 1.24]
12.2 Augmented labour	2	750	Risk Ratio (M‐H, Fixed, 95% CI)	1.25 [0.91, 1.73]
13 Caesarean section Show forest plot	3	1945	Risk Ratio (M‐H, Fixed, 95% CI)	1.04 [0.85, 1.29]

13.1 Induced labour	2	1195	Risk Ratio (M‐H, Fixed, 95% CI)	0.91 [0.68, 1.21]
13.2 Augmented labour	2	750	Risk Ratio (M‐H, Fixed, 95% CI)	1.25 [0.91, 1.71]
14 Mean time to delivery Show forest plot	1	1456	Mean Difference (IV, Fixed, 95% CI)	‐15.60 [‐40.99, 9.79]

14.1 induced labour	1	956	Mean Difference (IV, Fixed, 95% CI)	‐25.78 [‐58.57, 7.01]
14.2 Augmented labour	1	500	Mean Difference (IV, Fixed, 95% CI)	‐0.35 [‐40.47, 39.77]
15 Placental or fetal vessel damage Show forest plot	3	1945	Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]

16 Indication of infection up to three weeks postpartum in mother or child Show forest plot	1	1435	Risk Ratio (M‐H, Fixed, 95% CI)	0.84 [0.61, 1.16]

17 Signs intrauterine infection during labor Show forest plot	1	1456	Risk Ratio (M‐H, Fixed, 95% CI)	0.69 [0.44, 1.08]

Comparison 1. Monitoring of contractions with internal tocodynamometry compared to external tocodynamometry

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