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.

Apgar < 7 at 5 minutes

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

not estimable

(0 studies)

No data reported for cord blood acidosis in the included studies.

Neonatal seizures

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

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

not estimable

(0 studies)

No data reported for a composite of mortality and serious morbidity in the included studies.

Cerebral palsy

not estimable

(0 studies)

No data reported for cerebral palsy in the included studies.

Neurosensory disability

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

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.

Caesarean section for fetal distress and/or fetal acidosis

RR 2.92
(1.78 to 4.80)

633
(1 RCT)

⊕⊕⊕⊝ MODERATE ^1,

Instrumental vaginal birth

RR 1.46
(0.86 to 2.49)

633
(1 RCT)

⊕⊕⊝⊝ LOW ^1,2,

Maternal mortality

not estimable

(0 studies)

No data reported for maternal mortality in the included studies.

Any pharmacological or non‐pharmacological analgesia use excluding epidural

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

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

not estimable

(0 studies)

No data reported for mobility or restriction during labour in the included studies.

Postnatal depression

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

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.

Apgar < 7 at 5 minutes

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

not estimable

(0 studies)

No data reported for cord blood acidosis in the included studies.

Seizures in the neonatal period

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

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

not estimable

(0 studies)

No data reported for a composite of mortality and serious morbidity in the included studies.

Cerebral palsy

not estimable

(0 studies)

No data reported for cerebral palsy in the included studies.

Neurosensory disability

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

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.

Caesarean section for fetal distress and/or fetal acidosis

RR 2.71
(1.64 to 4.48)

627
(1 RCT)

⊕⊕⊕⊝
MODERATE ^1,

Instrumental vaginal birth

RR 1.35
(0.78 to 2.32)

627
(1 RCT)

⊕⊕⊝⊝
LOW ^1,2

Maternal mortality

not estimable

(0 studies)

No data reported for maternal mortality in the included studies.

Any pharmacological or non‐pharmacological analgesia use excluding epidural

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

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

not estimable

(0 studies)

No data reported for mobility or restriction during labour in the included studies.

Postnatal depression

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

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.

Apgar < 7 at 5 minutes

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

not estimable

(0 studies)

No data reported for cord blood acidosis in the included studies.

Neonatal seizures

RR 0.68
(0.24 to 1.88)

625
(1 RCT)

⊕⊝⊝⊝
VERY LOW ^1,2

Perinatal mortality

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

not estimable

(0 studies)

No data reported for a composite of mortality and serious morbidity in the included studies.

Cerebral palsy

not estimable

(0 studies)

No data reported for cerebral palsy in the included studies.

Neurosensory disability

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

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.

Caesarean section for fetal distress and/or fetal acidosis

RR 0.70
(0.35 to 1.38)

625
(1 RCT)

⊕⊕⊝⊝
LOW ^1,2

Instrumental vaginal birth

RR 1.21
(0.69 to 2.11)

625
(1 RCT)

⊕⊕⊝⊝
LOW ^1,2

Maternal morbidity

not estimable

(0 studies)

No data reported for maternal morbidity in the included studies.

Any pharmacological or non‐pharmacological analgesia use excluding epidural

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

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

not estimable

(0 studies)

No data reported for mobility or restriction during labour in the included studies.

Postnatal depression

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