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Meta-Analysis
. 2014 Oct 7;2014(10):CD004075.
doi: 10.1002/14651858.CD004075.pub4.

Fetal pulse oximetry for fetal assessment in labour

Christine E East  1 , Lisa Begg, Paul B Colditz, Rosalind Lau
Affiliations
Meta-Analysis

Fetal pulse oximetry for fetal assessment in labour

Christine E East et al. Cochrane Database Syst Rev. .

Abstract

Background: The use of conventional cardiotocographic (CTG) monitoring of fetal well-being during labour is associated with an increased caesarean section rate, compared with intermittent auscultation of the fetal heart rate, resulting in a reduction in neonatal seizures, although no differences in other neonatal outcomes. To improve the sensitivity of this test and therefore reduce the number of caesarean sections performed for nonreassuring fetal status, several additional measures of evaluating fetal well-being have been considered. These have demonstrated some effect on reducing caesarean section rates, for example, fetal scalp blood sampling for pH estimation/lactate measurement. The adaptation of pulse oximetry for use in the unborn fetus could potentially contribute to improved evaluation during labour and therefore lead to a reduction in caesarean sections for nonreassuring fetal status, without any change in neonatal outcomes.

Objectives: To compare the effectiveness and safety of fetal intrapartum pulse oximetry with other surveillance techniques.

Search methods: We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 May 2014), contacted experts in the field and searched reference lists of retrieved studies. In previous versions of this review, we performed additional searches of MEDLINE, Embase and Current Contents. These searches were discontinued for this review update, as they consistently failed to identify any trials that were not shown in the Cochrane Pregnancy and Childbirth Group's Trials Register.

Selection criteria: All published and unpublished randomised controlled trials that compared maternal and fetal outcomes when fetal pulse oximetry was used in labour, (i) with or without concurrent use of conventional fetal surveillance, that is, cardiotocography (CTG), compared with using CTG alone or (ii) with or without concurrent use of both CTG and other method(s) of fetal surveillance, such as fetal electrocardiography (ECG) plus CTG.

Data collection and analysis: At least two independent review authors performed data extraction. We sought additional information from the investigators of three of the reported trials.

Main results: We included seven published trials: six comparing fetal pulse oximetry and CTG with CTG alone (or when fetal pulse oximetry values were blinded) and one comparing fetal pulse oximetry plus CTG with fetal ECG plus CTG. The published trials, with some unpublished data, were at high risk of bias in terms of the impractical nature of blinding participants and clinicians, as well as high risk or unclear risk of bias for outcome assessor for all but one report. Selection bias, attrition bias, reporting bias and other sources of bias were of low or unclear risk. The trials reported on a total of 8013 pregnancies. Differing entry criteria necessitated separate analyses, rather than meta-analysis of all trials.Systematic review of four trials from 34 weeks not requiring fetal blood sampling (FBS) prior to study entry showed no evidence of differences in the overall caesarean section rate between those monitored with fetal oximetry and those not monitored with fetal pulse oximetry or for whom the fetal pulse oximetry results were masked (average risk ratio (RR) 0.99 using random-effects, 95% confidence intervals (CI) 0.86 to 1.13, n = 4008, I² = 45%). There was evidence of a higher risk of caesarean section in the group with fetal oximetry plus CTG than in the group with fetal ECG plus CTG (one study, n = 180, RR 1.56, 95% CI 1.06 to 2.29). Neonatal seizures and neonatal encephalopathy were rare in both groups. No studies reported details of long-term disability.There was evidence of a decrease in caesarean section for nonreassuring fetal status in the fetal pulse oximetry plus CTG group compared to the CTG group, gestation from 34 weeks (average RR (random-effects) 0.65, 95% CI 0.46 to 0.90, n = 4008, I² = 63%). There was no evidence of differences between groups in caesarean section for dystocia, although the overall incidence rates varied between the trials.

Authors' conclusions: The addition of fetal pulse oximetry does not reduce overall caesarean section rates. One study found a higher caesarean section rate in the group monitored with fetal pulse oximetry plus CTG, compared with fetal ECG plus CTG. The data provide limited support for the use of fetal pulse oximetry when used in the presence of a nonreassuring CTG, to reduce caesarean section for nonreassuring fetal status. A better method than pulse oximetry is required to enhance the overall evaluation of fetal well-being in labour.

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Conflict of interest statement

Three authors (C East, FY Chan, P Colditz) were chief investigators in the Australian multicentre randomised controlled trial of fetal intrapartum pulse oximetry (East 2006). That trial was supported in part by a research grant and equipment loan from Nellcor Inc, manufacturers of a fetal pulse oximetry system. An additional co‐author who was not an investigator in that trial, L Begg, joined the review team to evaluate that trial for incorporation in the 2007 update of the review.

Figures

1
1
'Risk of bias' graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.
2
2
'Risk of bias' summary: review authors' judgements about each risk of bias item for each included study.
1.1
1.1. Analysis
Comparison 1 Primary outcomes: FPO + CTG versus CTG only, Outcome 1 Caesarean section.
1.2
1.2. Analysis
Comparison 1 Primary outcomes: FPO + CTG versus CTG only, Outcome 2 Hypoxic‐ischaemic encephalopathy.
1.3
1.3. Analysis
Comparison 1 Primary outcomes: FPO + CTG versus CTG only, Outcome 3 Neonatal seizures.
2.1
2.1. Analysis
Comparison 2 Secondary outcomes: maternal: FPO + CTG versus CTG only, Outcome 1 Caesarean section for nonreassuring fetal status.
2.2
2.2. Analysis
Comparison 2 Secondary outcomes: maternal: FPO + CTG versus CTG only, Outcome 2 Caesarean section for dystocia.
2.3
2.3. Analysis
Comparison 2 Secondary outcomes: maternal: FPO + CTG versus CTG only, Outcome 3 Operative birth (caesarean section, forceps, vacuum extraction) for all indications.
2.4
2.4. Analysis
Comparison 2 Secondary outcomes: maternal: FPO + CTG versus CTG only, Outcome 4 Operative birth (caesarean section, forceps, vacuum) for nonreassuring fetal status.
2.5
2.5. Analysis
Comparison 2 Secondary outcomes: maternal: FPO + CTG versus CTG only, Outcome 5 Use of intrapartum antibiotics.
2.6
2.6. Analysis
Comparison 2 Secondary outcomes: maternal: FPO + CTG versus CTG only, Outcome 6 Overall antibiotic use.
2.7
2.7. Analysis
Comparison 2 Secondary outcomes: maternal: FPO + CTG versus CTG only, Outcome 7 Intrapartum haemorrhage.
2.8
2.8. Analysis
Comparison 2 Secondary outcomes: maternal: FPO + CTG versus CTG only, Outcome 8 Postpartum haemorrhage.
2.9
2.9. Analysis
Comparison 2 Secondary outcomes: maternal: FPO + CTG versus CTG only, Outcome 9 Chorioamnionitis.
2.10
2.10. Analysis
Comparison 2 Secondary outcomes: maternal: FPO + CTG versus CTG only, Outcome 10 Endometritis.
2.11
2.11. Analysis
Comparison 2 Secondary outcomes: maternal: FPO + CTG versus CTG only, Outcome 11 Uterine rupture.
2.12
2.12. Analysis
Comparison 2 Secondary outcomes: maternal: FPO + CTG versus CTG only, Outcome 12 Length of hospital stay (days).
2.13
2.13. Analysis
Comparison 2 Secondary outcomes: maternal: FPO + CTG versus CTG only, Outcome 13 Satisfaction with labour.
2.14
2.14. Analysis
Comparison 2 Secondary outcomes: maternal: FPO + CTG versus CTG only, Outcome 14 Satisfaction with fetal monitoring in labour.
2.15
2.15. Analysis
Comparison 2 Secondary outcomes: maternal: FPO + CTG versus CTG only, Outcome 15 Death.
3.1
3.1. Analysis
Comparison 3 Secondary outcomes: fetal/neonatal: FPO + CTG versus CTG only, Outcome 1 Apgar score less than 4 at 5 minutes.
3.2
3.2. Analysis
Comparison 3 Secondary outcomes: fetal/neonatal: FPO + CTG versus CTG only, Outcome 2 Apgar score less than 7 at 5 minutes.
3.3
3.3. Analysis
Comparison 3 Secondary outcomes: fetal/neonatal: FPO + CTG versus CTG only, Outcome 3 Length of hospital stay (days).
3.4
3.4. Analysis
Comparison 3 Secondary outcomes: fetal/neonatal: FPO + CTG versus CTG only, Outcome 4 Umbilical arterial pH less than 7.10.
3.5
3.5. Analysis
Comparison 3 Secondary outcomes: fetal/neonatal: FPO + CTG versus CTG only, Outcome 5 Umbilical arterial base excess less than ‐12.
3.6
3.6. Analysis
Comparison 3 Secondary outcomes: fetal/neonatal: FPO + CTG versus CTG only, Outcome 6 Admission to neonatal intensive care unit.
3.7
3.7. Analysis
Comparison 3 Secondary outcomes: fetal/neonatal: FPO + CTG versus CTG only, Outcome 7 Death.
3.8
3.8. Analysis
Comparison 3 Secondary outcomes: fetal/neonatal: FPO + CTG versus CTG only, Outcome 8 Death, hypoxic‐ischaemic encephalopathy, or both.
3.9
3.9. Analysis
Comparison 3 Secondary outcomes: fetal/neonatal: FPO + CTG versus CTG only, Outcome 9 Death, seizures, or both.
3.10
3.10. Analysis
Comparison 3 Secondary outcomes: fetal/neonatal: FPO + CTG versus CTG only, Outcome 10 Death, long‐term neurodevelopmental problem, or both.
3.11
3.11. Analysis
Comparison 3 Secondary outcomes: fetal/neonatal: FPO + CTG versus CTG only, Outcome 11 Skin trauma.
4.1
4.1. Analysis
Comparison 4 Subgroup: fetal blood sampling: primary outcomes, Outcome 1 Caesarean section.
4.2
4.2. Analysis
Comparison 4 Subgroup: fetal blood sampling: primary outcomes, Outcome 2 Neonatal seizures.
5.1
5.1. Analysis
Comparison 5 Primary outcomes: FPO + CTG versus fetal ECG + CTG, Outcome 1 Caesarean section.
6.1
6.1. Analysis
Comparison 6 Secondary outcomes: maternal: FPO + CTG versus fetal ECG + CTG, Outcome 1 Caesarean section for nonreassuring fetal status.
6.2
6.2. Analysis
Comparison 6 Secondary outcomes: maternal: FPO + CTG versus fetal ECG + CTG, Outcome 2 Caesarean section for dystocia.
6.3
6.3. Analysis
Comparison 6 Secondary outcomes: maternal: FPO + CTG versus fetal ECG + CTG, Outcome 3 Operative birth (caesarean section, forceps, vacuum).
6.4
6.4. Analysis
Comparison 6 Secondary outcomes: maternal: FPO + CTG versus fetal ECG + CTG, Outcome 4 Operative birth (caesarean section, forceps, vacuum) for nonreassuring fetal status.
7.1
7.1. Analysis
Comparison 7 Secondary outcomes: fetal/neonatal: FPO + CTG versus fetal ECG + CTG, Outcome 1 Admission to neonatal intensive care unit.
See this image and copyright information in PMC

Update of

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