Intermittent auscultation (IA) of fetal heart rate in labour for fetal well‐being

Ruth Martis; Ova Emilia; Detty S Nurdiati; Julie Brown

doi:10.1002/14651858.CD008680.pub2

Cochrane Database of Systematic Reviews

Auscultación intermitente (AI) de la frecuencia cardíaca fetal durante el trabajo de parto para el bienestar fetal

Información

DOI:

https://doi.org/10.1002/14651858.CD008680.pub2 Copiar DOI

Base de datos:

Cochrane Database of Systematic Reviews

Versión publicada:

13 febrero 2017see what's new

Tipo:

Intervention

Etapa:

Review

Grupo Editorial Cochrane:

Grupo Cochrane de Embarazo y parto

Copyright:

Copyright © 2017 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

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Autores

Ruth Martis

Correspondencia a: Liggins Institute, The University of Auckland, Auckland, New Zealand

[email protected]

[email protected]
Ova Emilia

Department of Obstetrics and Gynaecology, Faculty of Medicine, Universitas Gadjah Mada, Yogyakarta, Indonesia
Detty S Nurdiati

Department of Obstetrics and Gynaecology, Faculty of Medicine, Universitas Gadjah Mada, Yogyakarta, Indonesia
Julie Brown

Liggins Institute, The University of Auckland, Auckland, New Zealand

Contributions of authors

Ruth Martis wrote the protocol with Ova Emilia and Detty Nurdiati providing feedback. Julie Brown joined the review team during the editorial process for this review to assist with data extractions of the newly added studies and finalising the review for publication. All review authors contributed to data extraction, presentation and interpretation of the results, and approved the final version of the review.

Sources of support

Internal sources

Christchurch Polytechnic Institute of Technology, CPIT, New Zealand.

The Department of Health Science and Allied Health, ARC committee, provided financial support for Ruth Martis to travel to Australia to finish the review.
The Faculty of Medicine, Universitas Gadjah Mada, Yogyakarta, Indonesia.

provided financial support for Ova Emilia and Detty Nurdiati to travel to Australia to finish the review.
Liggins Institute, Univeristy of Auckland, New Zealand.

External sources

Australasian Cochrane Centre, Monash University, Melbourne, Australia.

Technical support from the Australasian Cochrane Centre, which included an accommodation grant for OE and DN to stay in Melbourne for a week to complete the review.
UNDP‐UNFPA‐UNICEF‐WHO‐World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Reproductive Health and Research (RHR), World Health Organization, Switzerland.

Declarations of interest

Ruth Martis: received support from Cochrane Health Promotion and Public Health Field in the form of a bursary supporting travel to meet with review authors for review progress and data analysis. The bursary was administrated by the SeaOrchid project.

Ova Emilia: received support (for travel and accommodation) from the SeaOrchid Project to be trained in preparing Cochrane Systematic Review in Australia.

Detty S Nurdiati: received support (for travel and accommodation) from the SeaOrchid Project to be trained in preparing Cochrane Systematic Review in Australia. She also received support from the Faculty of Medicine, Universitas Gadjah Mada, Yogyakarta, Indonesia to attend a workshop on completing systematic reviews.

Julie Brown: none known.

Acknowledgements

The review authors would like to thank the staff from the Australasian Cochrane Centre for technical support. We also sincerely acknowledge Steve McDonald, Philippa Middleton and Miranda Cumpston for their editorial assistance and support. The Department of Health Science and Allied Health, ARC committee, Christchurch Polytechnic Institute of Technology provided support for Ruth Martis to travel to Australia to finish the review. The Faculty of Medicine, Universitas Gadjah Mada, Yogyakarta, Indonesia, provided support for Ova Emilia and Detty Nurdiati to travel to Australia to finish the review.

We also would like to acknowledge and thank Associate Professor Malinee Laopaiboon, Department of Biostatistics and Demography, Faculty of Public Health, Khon Kaen University, Khon Kaen, Thailand, for her invaluable statistical guidance.

As part of the pre‐publication editorial process, this review has been commented on by four peers (an editor and three referees who are external to the editorial team), a member of the Pregnancy and Childbirth Group's international panel of consumers and the Group's Statistical Adviser.

This project was supported by the National Institute for Health research, via Cochrane Infrastructure funding to Cochrane Pregnancy and Childbirth. The views and opinions expressed therein are those of the authors and do not necessarily reflect those of the Systematic Reviews Programme, NIHR, NHS or the Department of Health.

Version history

Published

Title

Stage

Authors

Version

2017 Feb 13

Intermittent auscultation (IA) of fetal heart rate in labour for fetal well‐being

Review

Ruth Martis, Ova Emilia, Detty S Nurdiati, Julie Brown

https://doi.org/10.1002/14651858.CD008680.pub2

2010 Sep 08

Intermittent auscultation (IA) of fetal heart rate in labour for fetal well‐being

Protocol

Ruth Martis, Ova Emilia, Detty S Nurdiati

https://doi.org/10.1002/14651858.CD008680

Differences between protocol and review

The methods section has been updated to reflect the latest guidance in the Cochrane Handbook for Systematic Reviews of Interventions (Higgins 2011) and the Cochrane Pregnancy and Childbirth Group's methodological guidelines. The electronic searches section was updated to include Embase and email alerts.

We did not anticipate that one trial (Mahomed 1994) would include electronic fetal monitoring (EFM) with a cardiotocograph (CTG) as an intermittent auscultation (IA) modality. After discussion, we decided to include this arm of the intervention as well, as it appears that only the fetal heart rate (FHR) was used for clinical management decisions, rather than interpreting the paper tracing. This trial reported Apgar score < six at five minutes as a measure of newborn condition; although our prespecified outcome was Apgar score < seven, we decided to use the data from this trial, as overall only two studies are included in the review and we wanted to use all available data.

Two secondary outcomes for the mother have been removed, as recommended by the peer reviewers. These were: (5) Types of induction of labour, e.g. prostaglandin gel, oxytocin infusion, amniotomy and (6) Spontaneous onset of labour. The reasons provided for this request were that participants are in labour already therefore neither intervention could affect the outcome.

The maternal secondary outcome, 'length of ruptured membranes' was edited to 'duration of ruptured membranes'.

Spontaneous onset of labour versus induction of labour (3) was replaced with first stage versus second stage of labour for subgroup analysis and investigation of heterogeneity.

In this version of the review, we have included a new infant outcome: mortality or serious morbidity, and this outcome is included in our 'Summary of findings' tables.

The GRADE approach to examine the quality of the body of evidence was added to this review.

Keywords

MeSH

Medical Subject Headings (MeSH) Keywords

Medical Subject Headings Check Words

Female; Humans; Infant, Newborn; Pregnancy;

PICO

Population

Intervention

Comparison

Outcome

El uso y la enseñanza del modelo PICO están muy extendidos en el ámbito de la atención sanitaria basada en la evidencia para formular preguntas y estrategias de búsqueda y para caracterizar estudios o metanálisis clínicos. PICO son las siglas en inglés de cuatro posibles componentes de una pregunta de investigación: paciente, población o problema; intervención; comparación; desenlace (outcome).

Para saber más sobre el uso del modelo PICO, puede consultar el Manual Cochrane.

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 trial.

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Figure 3

'Risk of bias' graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.

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Analysis 1.1

Comparison 1 Intermittent electronic fetal monitoring (CTG) versus routine Pinard, Outcome 1 Apgar < 7 at 5 minutes after birth.

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Analysis 1.2

Comparison 1 Intermittent electronic fetal monitoring (CTG) versus routine Pinard, Outcome 2 Caesarean section for fetal distress.

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Analysis 1.3

Comparison 1 Intermittent electronic fetal monitoring (CTG) versus routine Pinard, Outcome 3 Perinatal mortality.

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Analysis 1.4

Comparison 1 Intermittent electronic fetal monitoring (CTG) versus routine Pinard, Outcome 4 Fetal heart rate abnormality detected.

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Analysis 1.5

Comparison 1 Intermittent electronic fetal monitoring (CTG) versus routine Pinard, Outcome 5 Early and late fetal heart rate decelerations detected.

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Analysis 1.6

Comparison 1 Intermittent electronic fetal monitoring (CTG) versus routine Pinard, Outcome 6 Admission to NICU/NNU.

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Analysis 1.7

Comparison 1 Intermittent electronic fetal monitoring (CTG) versus routine Pinard, Outcome 7 Seizures in the neonatal period.

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Analysis 1.8

Comparison 1 Intermittent electronic fetal monitoring (CTG) versus routine Pinard, Outcome 8 Hypoxic ischaemic encephalopathy.

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Analysis 1.9

Comparison 1 Intermittent electronic fetal monitoring (CTG) versus routine Pinard, Outcome 9 Caesarean section.

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Analysis 1.10

Comparison 1 Intermittent electronic fetal monitoring (CTG) versus routine Pinard, Outcome 10 Instrumental vaginal birth.

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Analysis 1.11

Comparison 1 Intermittent electronic fetal monitoring (CTG) versus routine Pinard, Outcome 11 Length of labour (hours).

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Analysis 2.1

Comparison 2 Doppler versus routine Pinard, Outcome 1 Apgar < 7 at 5 minutes after birth.

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Analysis 2.2

Comparison 2 Doppler versus routine Pinard, Outcome 2 Caesarean section for fetal distress.

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Analysis 2.3

Comparison 2 Doppler versus routine Pinard, Outcome 3 Perinatal mortality.

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Analysis 2.4

Comparison 2 Doppler versus routine Pinard, Outcome 4 Fetal heart rate abnormality detected.

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Analysis 2.5

Comparison 2 Doppler versus routine Pinard, Outcome 5 Early and late fetal heart rate decelerations detected.

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Analysis 2.6

Comparison 2 Doppler versus routine Pinard, Outcome 6 Admission to NICU/NNU.

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Analysis 2.7

Comparison 2 Doppler versus routine Pinard, Outcome 7 Seizures in the neonatal period.

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Analysis 2.8

Comparison 2 Doppler versus routine Pinard, Outcome 8 Hypoxic ischaemic encephalopathy.

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Analysis 2.9

Comparison 2 Doppler versus routine Pinard, Outcome 9 Caesarean section.

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Analysis 2.10

Comparison 2 Doppler versus routine Pinard, Outcome 10 Instrumental vaginal birth.

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Analysis 2.11

Comparison 2 Doppler versus routine Pinard, Outcome 11 Length of labour (hours).

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Analysis 3.1

Comparison 3 Intensive Pinard versus routine Pinard, Outcome 1 Apgar < 7 at 5 minutes after birth.

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Analysis 3.2

Comparison 3 Intensive Pinard versus routine Pinard, Outcome 2 Caesarean section for fetal distress.

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Analysis 3.3

Comparison 3 Intensive Pinard versus routine Pinard, Outcome 3 Perintal mortality.

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Analysis 3.4

Comparison 3 Intensive Pinard versus routine Pinard, Outcome 4 Fetal heart rate abnormality detected.

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Analysis 3.5

Comparison 3 Intensive Pinard versus routine Pinard, Outcome 5 Early and late fetal heart rate decelerations detected.

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Analysis 3.6

Comparison 3 Intensive Pinard versus routine Pinard, Outcome 6 Admission to NICU/NNU.

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Analysis 3.7

Comparison 3 Intensive Pinard versus routine Pinard, Outcome 7 Seizures in the neonatal period.

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Analysis 3.8

Comparison 3 Intensive Pinard versus routine Pinard, Outcome 8 Hypoxic ischaemic encephalopathy.

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Analysis 3.9

Comparison 3 Intensive Pinard versus routine Pinard, Outcome 9 Caesarean section.

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Analysis 3.10

Comparison 3 Intensive Pinard versus routine Pinard, Outcome 10 Instrumental vaginal birth.

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Analysis 3.11

Comparison 3 Intensive Pinard versus routine Pinard, Outcome 11 Length of labour (hours).

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Summary of findings for the main comparison. Intermittent ausculation of fetal heart rate in labour for fetal well‐being ‐ Intermittent electronic fetal monitoring (CTG) versus routine Pinard (outcomes for the baby)

Intermittent ausculation of fetal heart rate in labour for fetal well‐being ‐ Intermittent electronic fetal monitoring (CTG) (inconsistent/ opportunistic paper tracing) versus routine Pinard (outcomes for the baby).
Patient or population: women in established labour and their babies. Setting: all studies were conducted in Africa (Zimbabwe and Uganda). Intervention: electronic fetal monitoring (CTG) without paper tracing. Comparison: routine Pinard.
Outcomes	*Anticipated absolute effects^ (95% CI)**		Relative effect (95% CI)	№ of participants (studies)	Quality of the evidence (GRADE)	Comments
Outcomes	Risk with routine Pinard	Risk with Intermittent electronic fetal monitoring	Relative effect (95% CI)	№ of participants (studies)	Quality of the evidence (GRADE)	Comments
Apgar < 7 at 5 minutes	29 per 1000	19 per 1000 (7 to 52)	RR 0.66 (0.24 to 1.83)	633 (1 RCT)	⊕⊕⊝⊝ VERY LOW ^1,2	Low event rate. Study reported Apgar score < 6 at 5 minutes.
Cord blood acidosis	0 per 1000	0 per 1000 (0 to 0)	not estimable	(0 studies)		No data reported for cord blood acidosis in the included studies.
Neonatal seizures	29 per 1000	1 per 1000 (0 to 25)	RR 0.05 (0.00 to 0.89)	633 (1 RCT)	⊕⊕⊝⊝ LOW ^1,3	Low event rates. Routine Pinard group (9/315) compared to the intermittent EFM (CTG) group (0/318).
Perinatal mortality	29 per 1000	25 per 1000 (10 to 64)	RR 0.88 (0.34 to 2.25)	633 (1 RCT)	⊕⊝⊝⊝ VERY LOW ^1,2	Neonatal deaths included, unable to separate out from reported data. Low event rates 8/318 for intermittent EFM (CTG) group and 9/315 for routine Pinard group.
Composite of mortality and serious morbidity	0 per 1000	0 per 1000 (0 to 0)	not estimable	(0 studies)		No data reported for a composite of mortality and serious morbidity in the included studies.
Cerebral palsy	0 per 1000	0 per 1000 (0 to 0)	not estimable	(0 studies)		No data reported for cerebral palsy in the included studies.
Neurosensory disability	0 per 1000	0 per 1000 (0 to 0)	not estimable	(0 studies)		No data reported for neurosensory disability in the included studies at either 6 months or 1 year.
*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 Blinding of participants and health professionals not possible; high risk of performance bias and it is unclear if outcome assessors were blinded. Downgraded one level. ² Evidence of imprecision; single trial with low event rate and wide 95% CI crossing the line of no effect. Downgraded two levels. ³ Evidence of imprecision, evidence based on a single trial with low event rates. Downgraded one level.

Summary of findings for the main comparison. Intermittent ausculation of fetal heart rate in labour for fetal well‐being ‐ Intermittent electronic fetal monitoring (CTG) versus routine Pinard (outcomes for the baby)

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Summary of findings 2. Intermittent ausculation of fetal heart rate in labour for fetal well‐being ‐ Intermittent electronic fetal monitoring (CTG) versus routine Pinard (outcomes for the mother)

Intermittent ausculation of fetal heart rate in labour for fetal well‐being ‐ Intermittent electronic fetal monitoring (CTG) (inconsistent/ opportunistic paper tracing) versus Routine Pinard (outcomes for the mother).
Patient or population: women in established labour and their babies. Setting: all studies were conducted in Africa (Zimbawe and Uganda). Intervention: electronic fetal monitoring (CTG) without paper tracing. Comparison: routine Pinard.
Outcomes	*Anticipated absolute effects^ (95% CI)**		Relative effect (95% CI)	№ of participants (studies)	Quality of the evidence (GRADE)	Comments
Outcomes	Risk with routine Pinard	Risk with Intermittent electronic fetal monitoring intensive Pinard	Relative effect (95% CI)	№ of participants (studies)	Quality of the evidence (GRADE)	Comments
Caesarean section for fetal distress and/or fetal acidosis	60 per 1000	176 per 1000 (107 to 290)	RR 2.92 (1.78 to 4.80)	633 (1 RCT)	⊕⊕⊕⊝ MODERATE ^1,
Instrumental vaginal birth	67 per 1000	97 per 1000 (57 to 166)	RR 1.46 (0.86 to 2.49)	633 (1 RCT)	⊕⊕⊝⊝ LOW ^1,2,
Maternal mortality	0 per 1000	0 per 1000 (0 to 0)	not estimable	(0 studies)		No data reported for maternal mortality in the included studies.
Any pharmacological or non‐pharmacological analgesia use excluding epidural	0 per 1000	0 per 1000 (0 to 0)	not estimable	(0 studies)		No data reported for any pharmacological or non‐ pharmacological analgesia use excluding epidural in the included studies.
Epidural anaesthesia for pain relief excluding for caesarean section	0 per 1000	0 per 1000 (0 to 0)	not estimable	(0 studies)		No data reported for epidural anaesthesia for pain relief excluding for caesarean section in the included studies. However, 1 trial reported that no epidural analgesia was available in the labour ward.
Mobility or restriction during labour	0 per 1000	0 per 1000 (0 to 0)	not estimable	(0 studies)		No data reported for mobility or restriction during labour in the included studies.
Postnatal depression	0 per 1000	0 per 1000 (0 to 0)	not estimable	(0 studies)		No data reported for postnatal depression in the included studies.
*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 Blinding of participants and health professionals not possible; high risk of performance bias and it is unclear if outcome assessors were blinded. Downgraded one level. ² Evidence of imprecision with wide confidence intervals. Downgraded one level.

Summary of findings 2. Intermittent ausculation of fetal heart rate in labour for fetal well‐being ‐ Intermittent electronic fetal monitoring (CTG) versus routine Pinard (outcomes for the mother)

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Summary of findings 3. Intermittent ausculation of fetal heart rate in labour for fetal well‐being ‐ Doppler versus routine Pinard (outcomes for the baby)

Intermittent ausculation of fetal heart rate in labour for fetal well‐being ‐ Doppler versus Routine Pinard (outcomes for the baby)
Patient or population: women in established labour and their babies. Setting: all studies were conducted in Africa (Zimbabwe and Uganda). Intervention: Doppler. Comparison: routine Pinard.
Outcomes	*Anticipated absolute effects^ (95% CI)**		Relative effect (95% CI)	№ of participants (studies)	Quality of the evidence (GRADE)	Comments
Outcomes	Risk with Routine Pinard	Risk with Doppler	Relative effect (95% CI)	№ of participants (studies)	Quality of the evidence (GRADE)	Comments
Apgar < 7 at 5 minutes	20 per 1000	15 per 1000 (4 to 58)	RR 0.76 (0.20 to 2.87)	2598 (2 RCTs)	⊕⊝⊝⊝ VERY LOW ^{1,2, 3}	One of the studies contributing data reported Apgar score < 6.
Cord blood acidosis	0 per 1000	0 per 1000 (0 to 0)	not estimable	(0 studies)		No data reported for cord blood acidosis in the included studies.
Seizures in the neonatal period	29 per 1000	1 per 1000 (0 to 26)	RR 0.05 (0.00 to 0.91)	627 (1 RCT)	⊕⊝⊝⊝ VERY LOW ^{1, 4}	Event rates are low 0/312 for Doppler and 9/315 for routine Pinard.
Perinatal mortality	12 per 1000	8 per 1000 (1 to 63)	RR 0.69 (0.09 to 5.40)	2597 (2 RCTs)	⊕⊕⊝⊝ VERY LOW ^{1, 2, 5}	Event rates 13/1304 for Doppler and 15/1293 for routine Pinard. Neonatal deaths included, unable to separate out from reported data.
Composite of mortality and serious morbidity	0 per 1000	0 per 1000 (0 to 0)	not estimable	(0 studies)		No data reported for a composite of mortality and serious morbidity in the included studies.
Cerebral palsy	0 per 1000	0 per 1000 (0 to 0)	not estimable	(0 studies)		No data reported for cerebral palsy in the included studies.
Neurosensory disability	0 per 1000	0 per 1000 (0 to 0)	not estimable	(0 studies)		No data reported for neurosensory disability in the included studies.
*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 Blinding of participants and health professionals not possible; high risk of performance bias and it is unclear if outcome assessors were blinded. Downgraded one level. ² Evidence of imprecision with wide 95% CI crossing the line of no effect. Downgraded one level. ³ There was high heterogeneity for this outcome. ⁴ Evidence of imprecision, with wide 95% CI crossing the line of no effect and low event rate. Downgraded 2 levels. ⁵ There was high heterogeneity for this outcome. Downgraded one level.

Summary of findings 3. Intermittent ausculation of fetal heart rate in labour for fetal well‐being ‐ Doppler versus routine Pinard (outcomes for the baby)

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Summary of findings 4. Intermittent ausculation of fetal heart rate in labour for fetal well‐being ‐ Doppler versus routine Pinard (outcomes for the mother)

Intermittent ausculation of fetal heart rate in labour for fetal well‐being ‐ Doppler versus Routine Pinard (outcomes for the mother)
Patient or population: women in established labour and their babies. Setting: all studies were conducted in Africa (Zimbabwe and Uganda). Intervention: Doppler. Comparison: routine Pinard.
Outcomes	*Anticipated absolute effects^ (95% CI)**		Relative effect (95% CI)	№ of participants (studies)	Quality of the evidence (GRADE)	Comments
Outcomes	Risk with routine Pinard	Risk with Doppler	Relative effect (95% CI)	№ of participants (studies)	Quality of the evidence (GRADE)	Comments
Caesarean section for fetal distress and/or fetal acidosis	60 per 1000	163 per 1000 (99 to 270)	RR 2.71 (1.64 to 4.48)	627 (1 RCT)	⊕⊕⊕⊝ MODERATE ^1,
Instrumental vaginal birth	67 per 1000	90 per 1000 (52 to 155)	RR 1.35 (0.78 to 2.32)	627 (1 RCT)	⊕⊕⊝⊝ LOW ^1,2
Maternal mortality	0 per 1000	0 per 1000 (0 to 0)	not estimable	(0 studies)		No data reported for maternal mortality in the included studies.
Any pharmacological or non‐pharmacological analgesia use excluding epidural	0 per 1000	0 per 1000 (0 to 0)	not estimable	(0 studies)		No data reported for any pharmacological or non‐pharmacological use excluding epidural in the included studies.
Epidural anaesthesia for pain relief excluding for caesarean section	0 per 1000	0 per 1000 (0 to 0)	not estimable	(0 studies)		No data reported for epidural anaesthesia for pain relief excluding for caesarean section in the included studies. However, 1 trial reported that no epidural analgesia was available in the labour ward.
Mobility or restriction during labour	0 per 1000	0 per 1000 (0 to 0)	not estimable	(0 studies)		No data reported for mobility or restriction during labour in the included studies.
Postnatal depression	0 per 1000	0 per 1000 (0 to 0)	not estimable	(0 studies)		No data reported for postnatal depression in the included studies.
*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 Blinding of participants and health professionals not possible; high risk of performance bias and it is unclear if outcome assessors were blinded. Downgraded one level. ² Wide confidence interval. Downgraded one level.

Summary of findings 4. Intermittent ausculation of fetal heart rate in labour for fetal well‐being ‐ Doppler versus routine Pinard (outcomes for the mother)

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Summary of findings 5. Intermittent ausculation of fetal heart rate in labour for fetal well‐being ‐ Intensive Pinard versus routine Pinard (outcomes for the baby)

Intermittent ausculation of fetal heart rate in labour for fetal well‐being ‐ Intensive Pinard versus Routine Pinard (outcomes for the baby)
Patient or population: women in established labour and their babies. Setting: all studies were conducted in Africa (Zimbabwe and Uganda). Intervention: intensive Pinard. Comparison: routine Pinard.
Outcomes	*Anticipated absolute effects^ (95% CI)**		Relative effect (95% CI)	№ of participants (studies)	Quality of the evidence (GRADE)	Comments
Outcomes	Risk with routine Pinard	Risk with Intensive Pinard	Relative effect (95% CI)	№ of participants (studies)	Quality of the evidence (GRADE)	Comments
Apgar < 7 at 5 minutes	29 per 1000	26 per 1000 (10 to 66)	RR 0.90 (0.35 to 2.31)	625 (1 RCT)	⊕⊝⊝⊝ VERY LOW ^1,2	Study reported Apgar score < 6 at 5 minutes.
Cord blood acidosis	0 per 1000	0 per 1000 (0 to 0)	not estimable	(0 studies)		No data reported for cord blood acidosis in the included studies.
Neonatal seizures	29 per 1000	19 per 1000 (7 to 54)	RR 0.68 (0.24 to 1.88)	625 (1 RCT)	⊕⊝⊝⊝ VERY LOW ^1,2
Perinatal mortality	29 per 1000	16 per 1000 (5 to 48)	RR 0.56 (0.19 to 1.67)	625 (1 RCT)	⊕⊝⊝⊝ VERY LOW ^1,2	Neonatal deaths included, unable to separate out from reported data.
Composite of mortality and serious morbidity	0 per 1000	0 per 1000 (0 to 0)	not estimable	(0 studies)		No data reported for a composite of mortality and serious morbidity in the included studies.
Cerebral palsy	0 per 1000	0 per 1000 (0 to 0)	not estimable	(0 studies)		No data reported for cerebral palsy in the included studies.
Neurosensory disability	0 per 1000	0 per 1000 (0 to 0)	not estimable	(0 studies)		No data reported for neurosensory disability in the included trial.
*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 Blinding of participants and health professionals not possible; high risk of performance bias and it is unclear if outcome assessors were blinded. Downgraded 1 level. ² Evidence was imprecise; wide 95% CI crossing the line of no effect and low event rate. Downgraded 2 levels.

Summary of findings 5. Intermittent ausculation of fetal heart rate in labour for fetal well‐being ‐ Intensive Pinard versus routine Pinard (outcomes for the baby)

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Summary of findings 6. Intermittent ausculation of fetal heart rate in labour for fetal well‐being ‐ Intensive Pinard versus routine Pinard (outcomes for the mother)

Intermittent ausculation of fetal heart rate in labour for fetal well‐being ‐ Intensive Pinard versus Routine Pinard (outcomes for the mother)
Patient or population: women in established labour and their babies. Setting: all studies were conducted in Africa (Zimbawe and Uganda). Intervention: intensive Pinard. Comparison: routine Pinard.
Outcomes	*Anticipated absolute effects^ (95% CI)**		Relative effect (95% CI)	№ of participants (studies)	Quality of the evidence (GRADE)	Comments
Outcomes	Risk with routine Pinard	Risk with Intensive Pinard	Relative effect (95% CI)	№ of participants (studies)	Quality of the evidence (GRADE)	Comments
Caesarean section for fetal distress and/or fetal acidosis	60 per 1000	42 per 1000 (21 to 83)	RR 0.70 (0.35 to 1.38)	625 (1 RCT)	⊕⊕⊝⊝ LOW ^1,2
Instrumental vaginal birth	67 per 1000	81 per 1000 (46 to 141)	RR 1.21 (0.69 to 2.11)	625 (1 RCT)	⊕⊕⊝⊝ LOW ^1,2
Maternal morbidity	0 per 1000	0 per 1000 (0 to 0)	not estimable	(0 studies)		No data reported for maternal morbidity in the included studies.
Any pharmacological or non‐pharmacological analgesia use excluding epidural	0 per 1000	0 per 1000 (0 to 0)	not estimable	(0 studies)		No reported data for any pharmacological or non‐pharmacological analgesia use excluding epidural.
Epidural anaesthesia for pain relief excluding caesarean section	0 per 1000	0 per 1000 (0 to 0)	not estimable	(0 studies)		No data reported for epidural anaesthesia for pain relief excluding caesarean section in the included studies. However, 1 trial reported that no epidural analgesia was available in the labour ward.
Mobility or restriction during labour	0 per 1000	0 per 1000 (0 to 0)	not estimable	(0 studies)		No data reported for mobility or restriction during labour in the included studies.
Postnatal depression	0 per 1000	0 per 1000 (0 to 0)	not estimable	(0 studies)		No data reported for post natal depression in the included studies.
*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 Blinding of participants and health professionals not possible; high risk of performance bias and it is unclear if outcome assessors were blinded. Downgraded one level. ² Some imprecision with wide CI crossing the line of no effect. Downgraded one level.

Summary of findings 6. Intermittent ausculation of fetal heart rate in labour for fetal well‐being ‐ Intensive Pinard versus routine Pinard (outcomes for the mother)

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Comparison 1. Intermittent electronic fetal monitoring (CTG) versus routine Pinard

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Apgar < 7 at 5 minutes after birth Show forest plot	1	633	Risk Ratio (M‐H, Fixed, 95% CI)	0.66 [0.24, 1.83]

2 Caesarean section for fetal distress Show forest plot	1	633	Risk Ratio (M‐H, Fixed, 95% CI)	2.92 [1.78, 4.80]

3 Perinatal mortality Show forest plot	1	633	Risk Ratio (M‐H, Fixed, 95% CI)	0.88 [0.34, 2.25]

4 Fetal heart rate abnormality detected Show forest plot	1	633	Risk Ratio (M‐H, Fixed, 95% CI)	6.08 [4.21, 8.79]

5 Early and late fetal heart rate decelerations detected Show forest plot	1	633	Risk Ratio (M‐H, Fixed, 95% CI)	2.84 [1.82, 4.45]

6 Admission to NICU/NNU Show forest plot	1	633	Risk Ratio (M‐H, Fixed, 95% CI)	0.89 [0.63, 1.25]

7 Seizures in the neonatal period Show forest plot	1	633	Risk Ratio (M‐H, Fixed, 95% CI)	0.05 [0.00, 0.89]

8 Hypoxic ischaemic encephalopathy Show forest plot	1	633	Risk Ratio (M‐H, Fixed, 95% CI)	0.20 [0.04, 0.90]

9 Caesarean section Show forest plot	1	633	Risk Ratio (M‐H, Fixed, 95% CI)	1.92 [1.39, 2.64]

10 Instrumental vaginal birth Show forest plot	1	633	Risk Ratio (M‐H, Fixed, 95% CI)	1.46 [0.86, 2.49]

11 Length of labour (hours) Show forest plot	1	633	Mean Difference (IV, Fixed, 95% CI)	0.90 [‐0.05, 1.85]

Comparison 1. Intermittent electronic fetal monitoring (CTG) versus routine Pinard

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Comparison 2. Doppler versus routine Pinard

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Apgar < 7 at 5 minutes after birth Show forest plot	2	2598	Risk Ratio (M‐H, Random, 95% CI)	0.76 [0.20, 2.87]

2 Caesarean section for fetal distress Show forest plot	1	627	Risk Ratio (M‐H, Fixed, 95% CI)	2.71 [1.64, 4.48]

3 Perinatal mortality Show forest plot	2	2597	Risk Ratio (M‐H, Random, 95% CI)	0.69 [0.09, 5.40]

4 Fetal heart rate abnormality detected Show forest plot	2	2598	Risk Ratio (M‐H, Random, 95% CI)	2.40 [1.09, 5.29]

5 Early and late fetal heart rate decelerations detected Show forest plot	1	627	Risk Ratio (M‐H, Fixed, 95% CI)	2.72 [1.73, 4.28]

6 Admission to NICU/NNU Show forest plot	2	2598	Risk Ratio (M‐H, Random, 95% CI)	0.89 [0.41, 1.91]

7 Seizures in the neonatal period Show forest plot	1	627	Risk Ratio (M‐H, Fixed, 95% CI)	0.05 [0.00, 0.91]

8 Hypoxic ischaemic encephalopathy Show forest plot	1	627	Risk Ratio (M‐H, Fixed, 95% CI)	0.10 [0.01, 0.78]

9 Caesarean section Show forest plot	2	2598	Risk Ratio (M‐H, Random, 95% CI)	1.29 [0.81, 2.05]

10 Instrumental vaginal birth Show forest plot	1	627	Risk Ratio (M‐H, Fixed, 95% CI)	1.35 [0.78, 2.32]

11 Length of labour (hours) Show forest plot	1	627	Mean Difference (IV, Fixed, 95% CI)	0.0 [‐1.07, 1.07]

Comparison 2. Doppler versus routine Pinard

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Comparison 3. Intensive Pinard versus routine Pinard

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Apgar < 7 at 5 minutes after birth Show forest plot	1	625	Risk Ratio (M‐H, Fixed, 95% CI)	0.90 [0.35, 2.31]

2 Caesarean section for fetal distress Show forest plot	1	625	Risk Ratio (M‐H, Fixed, 95% CI)	0.70 [0.35, 1.38]

3 Perintal mortality Show forest plot	1	625	Risk Ratio (M‐H, Fixed, 95% CI)	0.56 [0.19, 1.67]

4 Fetal heart rate abnormality detected Show forest plot	1	625	Risk Ratio (M‐H, Fixed, 95% CI)	1.71 [1.10, 2.65]

5 Early and late fetal heart rate decelerations detected Show forest plot	1	625	Risk Ratio (M‐H, Fixed, 95% CI)	1.33 [0.79, 2.23]

6 Admission to NICU/NNU Show forest plot	1	625	Risk Ratio (M‐H, Fixed, 95% CI)	0.84 [0.59, 1.19]

7 Seizures in the neonatal period Show forest plot	1	625	Risk Ratio (M‐H, Fixed, 95% CI)	0.68 [0.24, 1.88]

8 Hypoxic ischaemic encephalopathy Show forest plot	1	625	Risk Ratio (M‐H, Fixed, 95% CI)	0.71 [0.27, 1.84]

9 Caesarean section Show forest plot	1	625	Risk Ratio (M‐H, Fixed, 95% CI)	0.71 [0.46, 1.08]

10 Instrumental vaginal birth Show forest plot	1	625	Risk Ratio (M‐H, Fixed, 95% CI)	1.21 [0.69, 2.11]

11 Length of labour (hours) Show forest plot	1	625	Mean Difference (IV, Fixed, 95% CI)	0.5 [‐0.52, 1.52]

Comparison 3. Intensive Pinard versus routine Pinard

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Auscultación intermitente (AI) de la frecuencia cardíaca fetal durante el trabajo de parto para el bienestar fetal

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