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Meta-Analysis
. 2017 Feb 3;2(2):CD006066.
doi: 10.1002/14651858.CD006066.pub3.

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

Zarko Alfirevic  1 , Declan Devane  2 , Gillian Ml Gyte  3 , Anna Cuthbert  3
Affiliations
Meta-Analysis

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

Zarko Alfirevic et al. Cochrane Database Syst Rev. .

Abstract

Background: Cardiotocography (CTG) records changes in the fetal heart rate and their temporal relationship to uterine contractions. The aim is to identify babies who may be short of oxygen (hypoxic) to guide additional assessments of fetal wellbeing, or determine if the baby needs to be delivered by caesarean section or instrumental vaginal birth. This is an update of a review previously published in 2013, 2006 and 2001.

Objectives: To evaluate the effectiveness and safety of continuous cardiotocography when used as a method to monitor fetal wellbeing during labour.

Search methods: We searched the Cochrane Pregnancy and Childbirth Group Trials Register (30 November 2016) and reference lists of retrieved studies.

Selection criteria: Randomised and quasi-randomised controlled trials involving a comparison of continuous cardiotocography (with and without fetal blood sampling) with no fetal monitoring, intermittent auscultation intermittent cardiotocography.

Data collection and analysis: Two review authors independently assessed study eligibility, quality and extracted data from included studies. Data were checked for accuracy.

Main results: We included 13 trials involving over 37,000 women. No new studies were included in this update.One trial (4044 women) compared continuous CTG with intermittent CTG, all other trials compared continuous CTG with intermittent auscultation. No data were found comparing no fetal monitoring with continuous CTG. Overall, methodological quality was mixed. All included studies were at high risk of performance bias, unclear or high risk of detection bias, and unclear risk of reporting bias. Only two trials were assessed at high methodological quality.Compared with intermittent auscultation, continuous cardiotocography showed no significant improvement in overall perinatal death rate (risk ratio (RR) 0.86, 95% confidence interval (CI) 0.59 to 1.23, N = 33,513, 11 trials, low quality evidence), but was associated with halving neonatal seizure rates (RR 0.50, 95% CI 0.31 to 0.80, N = 32,386, 9 trials, moderate quality evidence). There was no difference in cerebral palsy rates (RR 1.75, 95% CI 0.84 to 3.63, N = 13,252, 2 trials, low quality evidence). There was an increase in caesarean sections associated with continuous CTG (RR 1.63, 95% CI 1.29 to 2.07, N = 18,861, 11 trials, low quality evidence). Women were also more likely to have instrumental vaginal births (RR 1.15, 95% CI 1.01 to 1.33, N = 18,615, 10 trials, low quality evidence). There was no difference in the incidence of cord blood acidosis (RR 0.92, 95% CI 0.27 to 3.11, N = 2494, 2 trials, very low quality evidence) or use of any pharmacological analgesia (RR 0.98, 95% CI 0.88 to 1.09, N = 1677, 3 trials, low quality evidence).Compared with intermittent CTG, continuous CTG made no difference to caesarean section rates (RR 1.29, 95% CI 0.84 to 1.97, N = 4044, 1 trial) or instrumental births (RR 1.16, 95% CI 0.92 to 1.46, N = 4044, 1 trial). Less cord blood acidosis was observed in women who had intermittent CTG, however, this result could have been due to chance (RR 1.43, 95% CI 0.95 to 2.14, N = 4044, 1 trial).Data for low risk, high risk, preterm pregnancy and high-quality trials subgroups were consistent with overall results. Access to fetal blood sampling did not appear to influence differences in neonatal seizures or other outcomes.Evidence was assessed using GRADE. Most outcomes were graded as low quality evidence (rates of perinatal death, cerebral palsy, caesarean section, instrumental vaginal births, and any pharmacological analgesia), and downgraded for limitations in design, inconsistency and imprecision of results. The remaining outcomes were downgraded to moderate quality (neonatal seizures) and very low quality (cord blood acidosis) due to similar concerns over limitations in design, inconsistency and imprecision.

Authors' conclusions: CTG during labour is associated with reduced rates of neonatal seizures, but no clear differences in cerebral palsy, infant mortality or other standard measures of neonatal wellbeing. However, continuous CTG was associated with an increase in caesarean sections and instrumental vaginal births. The challenge is how best to convey these results to women to enable them to make an informed decision without compromising the normality of labour.The question remains as to whether future randomised trials should measure efficacy (the intrinsic value of continuous CTG in trying to prevent adverse neonatal outcomes under optimal clinical conditions) or effectiveness (the effect of this technique in routine clinical practice).Along with the need for further investigations into long-term effects of operative births for women and babies, much remains to be learned about the causation and possible links between antenatal or intrapartum events, neonatal seizures and long-term neurodevelopmental outcomes, whilst considering changes in clinical practice over the intervening years (one-to-one-support during labour, caesarean section rates). The large number of babies randomised to the trials in this review have now reached adulthood and could potentially provide a unique opportunity to clarify if a reduction in neonatal seizures is something inconsequential that should not greatly influence women's and clinicians' choices, or if seizure reduction leads to long-term benefits for babies. Defining meaningful neurological and behavioural outcomes that could be measured in large cohorts of young adults poses huge challenges. However, it is important to collect data from these women and babies while medical records still exist, where possible describe women's mobility and positions during labour and birth, and clarify if these might impact on outcomes. Research should also address the possible contribution of the supine position to adverse outcomes for babies, and assess whether the use of mobility and positions can further reduce the low incidence of neonatal seizures and improve psychological outcomes for women.

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Conflict of interest statement

Zarko Alfirevic (ZA) is Director of Harris Wellbeing Preterm Birth Centre which is grant funded by the charity Wellbeing of Women. This grant is administered by University of Liverpool and Zarko Alfirevic is not paid directly. He is the principal investigator or co‐investigator on several grants from public funders including National Institute of Health Research, British Medical Association, European Commission and WHO. He has received research support in the past from Perkin Elmer and Alere for research related to pre‐eclampsia and preterm birth prevention. These grants were administered by his employers and ZA did not benefit directly. ZA is also a Co‐coordinating Editor of Cochrane Pregnancy and Childbirth.

Declan Devane has conducted a trial, known as the ADCAR Trial, evaluating the effectiveness of the admission cardiotocograph (CTG) compared with intermittent auscultation. This study is funded by the Health Research Board (Ireland). If this trial is eligible for inclusion in the full review, or a subsequent review update, the investigators will not be involved in assessing the trial for inclusion, assessing risk of bias, or data extraction. These tasks will be carried out by two other members of the review team who are not directly involved with the ADCAR Trial.

Gillian ML Gyte has received royalties from John Wiley & Son in respect of ‘A Cochrane Pocket Handbook – Pregnancy and Childbirth’ Hofmeyr GJ et al. 2008.

Anna Cuthbert: I am a research associate working in the editorial base of Cochrane Pregnancy and Childbirth. I am employed by the University of Liverpool to work as a research assistant in Cochrane Pregnancy and Childbirth (who receives infrastructure funding from the NIHR, UK).

Figures

1
1
Methodological quality summary: review authors' judgements about each methodological quality item for each included study
2
2
Funnel plot of comparison: 1 Continuous CTG versus intermittent auscultation, outcome: 1.1 Perinatal mortality (main outcome)
3
3
Funnel plot of comparison: 1 Continuous CTG versus intermittent auscultation, outcome: 1.2 Neonatal seizures (main outcome)
4
4
Funnel plot of comparison: 1 Continuous CTG versus intermittent auscultation, outcome: 1.4 Caesarean section (main outcome)
5
5
Funnel plot of comparison: 1 Continuous CTG versus intermittent auscultation, outcome: 1.5 Instrumental vaginal birth (main outcome)
1.1
1.1. Analysis
Comparison 1 Continuous CTG versus intermittent auscultation, Outcome 1 Perinatal mortality (main outcome).
1.2
1.2. Analysis
Comparison 1 Continuous CTG versus intermittent auscultation, Outcome 2 Neonatal seizures (main outcome).
1.3
1.3. Analysis
Comparison 1 Continuous CTG versus intermittent auscultation, Outcome 3 Cerebral palsy (main outcome).
1.4
1.4. Analysis
Comparison 1 Continuous CTG versus intermittent auscultation, Outcome 4 Caesarean section (main outcome).
1.5
1.5. Analysis
Comparison 1 Continuous CTG versus intermittent auscultation, Outcome 5 Instrumental vaginal birth (main outcome).
1.6
1.6. Analysis
Comparison 1 Continuous CTG versus intermittent auscultation, Outcome 6 Cord blood acidosis (main outcome).
1.7
1.7. Analysis
Comparison 1 Continuous CTG versus intermittent auscultation, Outcome 7 Any pharmacological analgesia (main outcome).
1.8
1.8. Analysis
Comparison 1 Continuous CTG versus intermittent auscultation, Outcome 8 Hypoxic ischaemic encephalopathy.
1.9
1.9. Analysis
Comparison 1 Continuous CTG versus intermittent auscultation, Outcome 9 Neurodevelopmental disability at at least 12 months of age.
1.10
1.10. Analysis
Comparison 1 Continuous CTG versus intermittent auscultation, Outcome 10 Apgar score < 7 at 5 minutes.
1.11
1.11. Analysis
Comparison 1 Continuous CTG versus intermittent auscultation, Outcome 11 Apgar score < 4 at 5 minutes.
1.12
1.12. Analysis
Comparison 1 Continuous CTG versus intermittent auscultation, Outcome 12 Neonatal ICU admissions.
1.13
1.13. Analysis
Comparison 1 Continuous CTG versus intermittent auscultation, Outcome 13 Fetal blood sampling.
1.14
1.14. Analysis
Comparison 1 Continuous CTG versus intermittent auscultation, Outcome 14 Damage/infection from scalp electrode or scalp sampling.
1.15
1.15. Analysis
Comparison 1 Continuous CTG versus intermittent auscultation, Outcome 15 Caesarean section for abnormal FHR pattern and/or acidosis.
1.16
1.16. Analysis
Comparison 1 Continuous CTG versus intermittent auscultation, Outcome 16 Instrumental vaginal birth for abnormal CTG or fetal acidosis.
1.17
1.17. Analysis
Comparison 1 Continuous CTG versus intermittent auscultation, Outcome 17 Spontaneous vaginal birth.
1.18
1.18. Analysis
Comparison 1 Continuous CTG versus intermittent auscultation, Outcome 18 Epidural analgesia.
1.19
1.19. Analysis
Comparison 1 Continuous CTG versus intermittent auscultation, Outcome 19 Oxytocin during 1st and/or 2nd stage of labour.
1.20
1.20. Analysis
Comparison 1 Continuous CTG versus intermittent auscultation, Outcome 20 Length of stay on NICU.
2.1
2.1. Analysis
Comparison 2 Continuous CTG versus IA (pregnancy risk status ‐ high/low), Outcome 1 Perinatal mortality.
2.2
2.2. Analysis
Comparison 2 Continuous CTG versus IA (pregnancy risk status ‐ high/low), Outcome 2 Neonatal seizures.
2.3
2.3. Analysis
Comparison 2 Continuous CTG versus IA (pregnancy risk status ‐ high/low), Outcome 3 Cerebral palsy.
2.4
2.4. Analysis
Comparison 2 Continuous CTG versus IA (pregnancy risk status ‐ high/low), Outcome 4 Caesarean section.
2.5
2.5. Analysis
Comparison 2 Continuous CTG versus IA (pregnancy risk status ‐ high/low), Outcome 5 Instrumental vaginal birth.
2.6
2.6. Analysis
Comparison 2 Continuous CTG versus IA (pregnancy risk status ‐ high/low), Outcome 6 Cord blood acidosis.
2.7
2.7. Analysis
Comparison 2 Continuous CTG versus IA (pregnancy risk status ‐ high/low), Outcome 7 Any pharmacological analgesia.
3.1
3.1. Analysis
Comparison 3 Continuous CTG versus IA (onset of labour ‐ spontaneous/induced), Outcome 1 Perinatal mortality.
3.2
3.2. Analysis
Comparison 3 Continuous CTG versus IA (onset of labour ‐ spontaneous/induced), Outcome 2 Neonatal seizures.
3.3
3.3. Analysis
Comparison 3 Continuous CTG versus IA (onset of labour ‐ spontaneous/induced), Outcome 3 Cerebral palsy.
3.4
3.4. Analysis
Comparison 3 Continuous CTG versus IA (onset of labour ‐ spontaneous/induced), Outcome 4 Caesarean section.
3.5
3.5. Analysis
Comparison 3 Continuous CTG versus IA (onset of labour ‐ spontaneous/induced), Outcome 5 Instrumental vaginal birth.
3.6
3.6. Analysis
Comparison 3 Continuous CTG versus IA (onset of labour ‐ spontaneous/induced), Outcome 6 Cord blood acidosis.
3.7
3.7. Analysis
Comparison 3 Continuous CTG versus IA (onset of labour ‐ spontaneous/induced), Outcome 7 Any pharmacological analgesia.
4.1
4.1. Analysis
Comparison 4 Continuous CTG versus IA (preterm/term labour), Outcome 1 Perinatal mortality.
4.2
4.2. Analysis
Comparison 4 Continuous CTG versus IA (preterm/term labour), Outcome 2 Neonatal seizures.
4.3
4.3. Analysis
Comparison 4 Continuous CTG versus IA (preterm/term labour), Outcome 3 Cerebral palsy.
4.4
4.4. Analysis
Comparison 4 Continuous CTG versus IA (preterm/term labour), Outcome 4 Caesarean section.
4.5
4.5. Analysis
Comparison 4 Continuous CTG versus IA (preterm/term labour), Outcome 5 Instrumental vaginal birth.
4.6
4.6. Analysis
Comparison 4 Continuous CTG versus IA (preterm/term labour), Outcome 6 Cord blood acidosis.
4.7
4.7. Analysis
Comparison 4 Continuous CTG versus IA (preterm/term labour), Outcome 7 Any pharmacological analgesia.
5.1
5.1. Analysis
Comparison 5 Continuous CTG versus IA (singleton/twin pregnancy), Outcome 1 Perinatal mortality.
5.2
5.2. Analysis
Comparison 5 Continuous CTG versus IA (singleton/twin pregnancy), Outcome 2 Neonatal seizures.
5.3
5.3. Analysis
Comparison 5 Continuous CTG versus IA (singleton/twin pregnancy), Outcome 3 Cerebral palsy.
5.4
5.4. Analysis
Comparison 5 Continuous CTG versus IA (singleton/twin pregnancy), Outcome 4 Caesarean section.
5.5
5.5. Analysis
Comparison 5 Continuous CTG versus IA (singleton/twin pregnancy), Outcome 5 Instrumental vaginal birth.
5.6
5.6. Analysis
Comparison 5 Continuous CTG versus IA (singleton/twin pregnancy), Outcome 6 Cord blood acidosis.
5.7
5.7. Analysis
Comparison 5 Continuous CTG versus IA (singleton/twin pregnancy), Outcome 7 Any pharmacological analgesia.
6.1
6.1. Analysis
Comparison 6 Continuous CTG versus IA (access to FBS during labour ‐ yes/no), Outcome 1 Perinatal mortality.
6.2
6.2. Analysis
Comparison 6 Continuous CTG versus IA (access to FBS during labour ‐ yes/no), Outcome 2 Neonatal seizures.
6.3
6.3. Analysis
Comparison 6 Continuous CTG versus IA (access to FBS during labour ‐ yes/no), Outcome 3 Cerebral palsy.
6.4
6.4. Analysis
Comparison 6 Continuous CTG versus IA (access to FBS during labour ‐ yes/no), Outcome 4 Caesarean section.
6.5
6.5. Analysis
Comparison 6 Continuous CTG versus IA (access to FBS during labour ‐ yes/no), Outcome 5 Instrumental vaginal birth.
6.6
6.6. Analysis
Comparison 6 Continuous CTG versus IA (access to FBS during labour ‐ yes/no), Outcome 6 Cord blood acidosis.
6.7
6.7. Analysis
Comparison 6 Continuous CTG versus IA (access to FBS during labour ‐ yes/no), Outcome 7 Any pharmacological analgesia.
7.1
7.1. Analysis
Comparison 7 Continuous CTG versus IA (primiparous/multiparous women), Outcome 1 Perinatal mortality.
7.2
7.2. Analysis
Comparison 7 Continuous CTG versus IA (primiparous/multiparous women), Outcome 2 Neonatal seizures.
7.3
7.3. Analysis
Comparison 7 Continuous CTG versus IA (primiparous/multiparous women), Outcome 3 Cerebral palsy.
7.4
7.4. Analysis
Comparison 7 Continuous CTG versus IA (primiparous/multiparous women), Outcome 4 Caesarean section.
7.5
7.5. Analysis
Comparison 7 Continuous CTG versus IA (primiparous/multiparous women), Outcome 5 Instrumental vaginal birth.
7.6
7.6. Analysis
Comparison 7 Continuous CTG versus IA (primiparous/multiparous women), Outcome 6 Cord blood acidosis.
7.7
7.7. Analysis
Comparison 7 Continuous CTG versus IA (primiparous/multiparous women), Outcome 7 Any pharmacological analgesia.
8.1
8.1. Analysis
Comparison 8 Continuous CTG versus IA (sensitivity analysis: high and low quality studies), Outcome 1 Perinatal mortality.
8.2
8.2. Analysis
Comparison 8 Continuous CTG versus IA (sensitivity analysis: high and low quality studies), Outcome 2 Neonatal seizures.
8.3
8.3. Analysis
Comparison 8 Continuous CTG versus IA (sensitivity analysis: high and low quality studies), Outcome 3 Cerebral palsy.
8.4
8.4. Analysis
Comparison 8 Continuous CTG versus IA (sensitivity analysis: high and low quality studies), Outcome 4 Caesarean section.
8.5
8.5. Analysis
Comparison 8 Continuous CTG versus IA (sensitivity analysis: high and low quality studies), Outcome 5 Instrumental vaginal birth.
8.6
8.6. Analysis
Comparison 8 Continuous CTG versus IA (sensitivity analysis: high and low quality studies), Outcome 6 Cord blood acidosis.
8.7
8.7. Analysis
Comparison 8 Continuous CTG versus IA (sensitivity analysis: high and low quality studies), Outcome 7 Any pharmacological analgesia.
9.1
9.1. Analysis
Comparison 9 Continuous CTG versus intermittent CTG, Outcome 1 Caesarean section (main outcome).
9.2
9.2. Analysis
Comparison 9 Continuous CTG versus intermittent CTG, Outcome 2 Instrumental vaginal birth (main outcome).
9.3
9.3. Analysis
Comparison 9 Continuous CTG versus intermittent CTG, Outcome 3 Cord blood acidosis (main outcome).
9.4
9.4. Analysis
Comparison 9 Continuous CTG versus intermittent CTG, Outcome 4 Apgar score < 7 at 5 minutes.
9.5
9.5. Analysis
Comparison 9 Continuous CTG versus intermittent CTG, Outcome 5 Neonatal ICU admissions.
9.6
9.6. Analysis
Comparison 9 Continuous CTG versus intermittent CTG, Outcome 6 Caesarean section for abnormal FHR pattern and/or acidosis.
9.7
9.7. Analysis
Comparison 9 Continuous CTG versus intermittent CTG, Outcome 7 Spontaneous vaginal birth.
9.8
9.8. Analysis
Comparison 9 Continuous CTG versus intermittent CTG, Outcome 8 Epidural analgesia.
See this image and copyright information in PMC

Update of

References

References to studies included in this review

Athens 1993 {published and unpublished data}
    1. Vintzileos A, Nochimson D, Guzman E, Knuppel R. Comparison of intrapartum electronic fetal heart rate monitoring versus intermittent auscultation in detecting fetal acidemia at birth. American Journal of Obstetrics and Gynecology 1995;172:367. - PubMed
    1. Vintzileos AM, Antsaklis A, Varvarigos I, Papas C, Sofatzis I, Montgomery JT. A randomized trial of intrapartum electronic fetal heart rate monitoring versus intermittent auscultation. Obstetrics and Gynecology 1993;81(6):899‐907. - PubMed
    1. Vintzileos AM, Antsaklis AJ, Varvarigos I, Karaiskakis P, Gazis I, Pappas C, et al. A prospective randomized trial of intrapartum electronic fetal heart rate monitoring vs intermittent auscultation. American Journal of Obstetrics and Gynecology 1993;168(6):343. - PubMed
    1. Vintzileos AM, Nochimson DJ, Antsaklis A, Varvarigos I, Guzman ER, Knuppel RA. Comparison of intrapartum electronic fetal heart rate monitoring vs intermittent auscultation in detecting fetal acidemia at birth. American Journal of Obstetrics and Gynecology 1995;173:1021‐4. - PubMed
Copenhagen 1985 {published data only}
    1. Hansen PK, Smith SF, Nim J, Neldam S, Osler M. Maternal attitudes to fetal monitoring. European Journal of Obstetrics, Gynecology, and Reproductive Biology 1985;20(1):43‐51. - PubMed
    1. Neldam S, Osler M, Hansen PK, Nim J, Smith SF, Hertel J. Intrapartum fetal heart rate monitoring in a combined low‐ and high‐risk population: a controlled clinical trial. European Journal of Obstetrics, Gynecology, and Reproductive Biology 1986;23(1‐2):1‐11. - PubMed
    1. Neldam S, Osler M, Hansen PK, Nim J, Smith SF, Hertel J. Monitoring of labour with cardiotocography and stethoscopic examination in normal and at risk deliveries. A controlled clinical investigation. Ugeskrift for Laeger 1985;147:2901‐7. - PubMed
Dallas 1986 {published and unpublished data}
    1. Leveno KJ, Cunningham FG, Nelson S, Roark ML, Williams ML, Guzick DS, et al. A prospective comparison of selective and universal electronic fetal monitoring in 34,995 pregnancies. New England Journal of Medicine 1986;315(10):615‐9. - PubMed
    1. Leveno KJ, Cunningham FG, Nelson S, Roark ML, Williams ML, Guzick DS, et al. Selected versus universal electronic fetal monitoring: a randomized study of 31,352 women. Proceedings of 6th Annual Meeting of the Society of Perinatal Obstetricians; 1986 January 30‐February 1. San Antonio, Texas, USA, 1986:208.
Denver 1976 {published and unpublished data}
    1. Haverkamp AD, Thompson HE, McFee JG, Cetrulo C. The evaluation of continuous fetal heart rate monitoring in high‐risk pregnancy. American Journal of Obstetrics and Gynecology 1976;125(3):310‐7. - PubMed
Denver 1979 {published and unpublished data}
    1. Haverkamp AD, Orleans M, Langendoerfer S, McFee J, Murphy J, Thompson HE. A controlled trial of the differential effects of intrapartum fetal monitoring. American Journal of Obstetrics and Gynecology 1979;134(4):399‐412. - PubMed
    1. Koszalka MF Jr, Haverkamp AD, Orleans M, Murphy J. The effects of internal electronic fetal heart rate monitoring on maternal and infant infections in high‐risk pregnancies. Journal of Reproductive Medicine 1982;27(10):661‐5. - PubMed
    1. Langendoerfer S, Haverkamp AD, Murphy J, Nowick KD, Orleans M, Pacosa F, et al. Pediatric follow‐up of a randomized controlled trial of intrapartum fetal monitoring techniques. Journal of Pediatrics 1980;97(1):103‐7. - PubMed
Dublin 1985 {published and unpublished data}
    1. Boylan P, MacDonald D, Grant AM, Pereira M, Chalmers I. The Dublin randomised controlled trial of intrapartum fetal heart rate monitoring. In: Kunzel W editor(s). Fetal Heart Rate Monitoring. Berlin: Springer Verlag, 1985:231‐3. - PubMed
    1. Ellison PH, Foster M, Sheridan‐Pereira M, MacDonald D. Electronic fetal heart monitoring, auscultation, and neonatal outcome. American Journal of Obstetrics and Gynecology 1991;164(5 Pt 1):1281‐9. - PubMed
    1. Garcia J, Corry M, MacDonald D, Elbourne DR, Grant AM. Mothers' views of continuous electronic fetal heart monitoring and intermittent auscultation in a randomized controlled trial. Birth 1985;12(2):79‐86. - PubMed
    1. Grant A, O'Brien N, Joy MT, Hennessy E, MacDonald D. Cerebral palsy among children born during the Dublin randomised trial of intrapartum monitoring. Lancet 1989;334(8674):1233‐6. - PubMed
    1. Macdonald D, Grant A, Sheridan‐Pereira M, Boylan P, Chalmers I. The Dublin randomized controlled trial of intrapartum fetal heart rate monitoring. American Journal of Obstetrics and Gynecology 1985;152(5):524‐39. - PubMed
Lund 1994 {published and unpublished data}
    1. Herbst A, Ingemarsson I. Intermittent versus continuous electronic fetal monitoring in labour: a randomized study. British Journal of Obstetrics and Gynaecology 1994;101(8):663‐8. - PubMed
    1. Herbst A, Ingemarsson I. Intermittent vs continuous monitoring in labour. Proceedings of 14th European Congress of Perinatal Medicine; 1994 June 5‐8; Helsinki, Finland. 1994:474.
Melbourne 1976 {published and unpublished data}
    1. Renou P, Chang A, Anderson I, Wood C. Controlled trial of fetal intensive care. American Journal of Obstetrics and Gynecology 1976;126(4):470‐6. - PubMed
    1. Wood C, Renou P. Fetal heart rate monitoring, Chapter 23. In: Beard RW, Nathanielsz PW editor(s). Fetal Physiology and Medicine. London: Saunders, 1976:471‐3.
Melbourne 1981 {published data only}
    1. Wood C, Renou P, Oats J, Farrell E, Beischer N, Anderson I. A controlled trial of fetal heart rate monitoring in a low‐risk obstetric population. American Journal of Obstetrics and Gynecology 1981;141(5):527‐34. - PubMed
New Delhi 2006 {published data only}
    1. Madaan M, Trivedi SS. Intrapartum electronic fetal monitoring vs. intermittent auscultation in postcesarean pregnancies. International Journal of Gynecology & Obstetrics 2006;94(2):123‐5. - PubMed
Pakistan 1989 {unpublished data only}
    1. Azhar NA, Neilson JP. Randomised trial of electronic intrapartum fetal heart rate monitoring with fetal blood sampling versus intermittent auscultation in a developing country. Personal communication 2001.
Seattle 1987 {published and unpublished data}
    1. Killien MG, Shy K. A randomized trial of electronic fetal monitoring in preterm labor: mothers' views. Birth 1989;16(1):7‐12. - PubMed
    1. Larson EB, Belle G, Shy KK, Luthy DA, Strickland D, Hughes JP. Fetal monitoring and predictions by clinicians: observations during a randomized clinical trial in very low birth weight infants. Obstetrics and Gynecology 1989;74(4):584‐9. - PubMed
    1. Luthy DA, Shy KK, Belle G, Larson EB, Hughes J, Benedetti TJ, et al. A randomized trial of electronic fetal heart rate monitoring in infants of low birth weight. Proceedings of 6th Annual Meeting of the Society of Perinatal Obstetricians; 1986 January 30‐February 1. San Antonio, Texas, USA, 1986:207.
    1. Luthy DA, Shy KK, Belle G, Larson EB, Hughes JP, Benedetti TJ, et al. A randomized trial of electronic fetal monitoring in preterm labor. Obstetrics and Gynecology 1987;69(5):687‐95. - PubMed
    1. Shy KK, Luthy DA, Bennett FC, Whitfield M, Larson EB, Belle G, et al. Effects of electronic fetal heart rate monitoring, as compared with periodic auscultation, on the neurologic development of premature infants. New England Journal of Medicine 1990;322(9):588‐93. - PubMed
Sheffield 1978 {published and unpublished data}
    1. Kelso IM, Parsons RJ, Lawrence GF, Arora SS, Edmonds DK, Cooke CD. An assessment of continuous fetal heart rate monitoring in labor: a randomized trial. American Journal of Obstetrics and Gynecology 1978;131(5):526‐31. - PubMed

References to studies excluded from this review

Greece 2012 {published data only}
    1. Siristatidis C, Kassanos D, Salamalekis G, Creatsa M, Chrelias C, Creatsas G. Cardiotocography alone versus cardiotocography plus Doppler evaluation of the fetal middle cerebral and umbilical artery for intrapartum fetal monitoring: A Greek prospective controlled trial. Journal of Maternal‐Fetal and Neonatal Medicine 2012;25(7):1183‐7. - PubMed
Harare 1994 {published and unpublished data}
    1. Mahomed K, Nyoni R, Mlambo T, Jacobus E, Kasule J. Intrapartum foetal heart rate monitoring ‐ continuous electronic vs intermittent doppler ‐ a randomised controlled trial. Central African Journal of Medicine 1992;38(12):458‐62. - PubMed
    1. Mahomed K, Nyoni R, Mulambo T, Kasule J, Jacobus E. Randomised controlled trial of intrapartum fetal heart rate monitoring. BMJ 1994;308(6927):497‐500. - PMC - PubMed
Ioannina 2001 {published data only}
    1. Stefos T, Sotiriadis A, Tsirkas P, Korkontzelos I, Papadimitriou D, Lolis D. Evaluation of fetal heart monitoring in the first stage of labor. Journal of Maternal‐Fetal Medicine 2001;10(1):48‐51. - PubMed
Manchester 1982 {published data only}
    1. D'Souza SW, Black P, MacFarlane T. Fetal scalp damage and neonatal jaundice: a risk of routine fetal scalp electrode monitoring. Journal of Obstetrics and Gynaecology 1982;2(3):161‐4.
North America 2000 {published data only}
    1. Garite TJ, Dildy GA, McNamara H, Nageotte MP, Boehm FH, Dellinger EH, et al. A multicenter controlled trial of fetal pulse oximetry in the intrapartum management of nonreassuring fetal heart rate patterns. American Journal of Obstetrics and Gynecology 2000;183(5):1049‐58. - PubMed

Additional references

ACOG 2009
    1. American College of Obstetricians and Gynecologists. ACOG Practice Bulletin. Clinical management guidelines for obstetrician–gynecologists. Number 106. July 2009 (replaces Number 70, December 2005). Intrapartum Fetal Heart Rate Monitoring: Nomenclature, Interpretation, and General Management Principles. Obstetrics and Gynecology 2009;114(1):192‐202. - PubMed
Bayley 1993
    1. Bayley N. Bayley Scales of Infant Development. 2nd Edition. San Diego: USA: Harcourt Brace & Company, 1993.
Carbonne 1997
    1. Carbonne B, Langer B, Goffinet F, Audibert F, Tardif D, Goueff F, et al. Multicenter study on the clinical value of fetal pulse oximetry and fetal blood analysis. American Journal of Obstetrics and Gynecology 1997;177(3):593‐8. - PubMed
Chen 2011
    1. Chen H‐Y, Chauhan SP, Ananth CV, Vintzileos AM, Abuhamad AZ. Electronic fetal heart rate monitoring and its relationship to neonatal and infant mortality in the United States. American Journal of Obstetrics and Gynecology 2011;204(6):491.e1‐10. - PubMed
Dennis 1978
    1. Dennis J. Neonatal convulsions: aetiology, late neonatal status and long‐term outcome. Developmental Medicine and Child Neurology 1978;20(2):143‐8. - PubMed
Derham 1985
    1. Derham RJ, Matthews TG, Clarke TA. Early seizures indicate quality of perinatal care. Archives of Disease in Childhood 1985;60(9):809‐13. - PMC - PubMed
Devane 2005
    1. Devane D, Lalor J. Midwives' visual interpretation of intrapartum cardiotocographs: intra‐ and inter‐ observer agreement. Journal of Advanced Nursing 2005;52(2):133‐41. - PubMed
Devane 2017
    1. Devane D, Lalor JG, Daly S, McGuire W, Cuthbert A, Smith V. Cardiotocography versus intermittent auscultation of fetal heart on admission to labour ward for assessment of fetal wellbeing. Cochrane Database of Systematic Reviews 2017, Issue 1. [DOI: 10.1002/14651858.CD005122.pub5] - DOI - PMC - PubMed
East 2007
    1. East CE, Begg L, Colditz PB. Fetal pulse oximetry for fetal assessment in labour. Cochrane Database of Systematic Reviews 2007, Issue 2. [DOI: 10.1002/14651858.CD004075.pub3] - DOI - PubMed
East 2013
    1. East CE, Smyth RMD, Leader LR, Henshall NE, Colditz PB, Lau R, et al. Vibroacoustic stimulation for fetal assessment in labour in the presence of a nonreassuring fetal heart rate trace. Cochrane Database of Systematic Reviews 2013, Issue 1. [DOI: 10.1002/14651858.CD004664.pub3] - DOI
Enkin 2000
    1. Enkin M, Keirse MJNC, Neilson J, Crowther C, Duley L, Hodnett E, et al. A Guide to Effective Care in Pregnancy and Childbirth. 3rd Edition. Oxford: Oxford University Press, 2000.
Estan 1997
    1. Estan J, Hope P. Unilateral neonatal cerebral infarction in full term infants. Archives of Disease in Childhood. Fetal and Neonatal Edition 1997;76(2):F88‐F93. - PMC - PubMed
Gamble 2007
    1. Gamble J, Creedy DK, McCourt C, Weaver J, Beake S. A critique of the literature on women’s request for cesarean section. Birth 2007;34(4):331‐40. - PubMed
Garcia 1985
    1. Garcia J, Corry M, MacDonald D, Elbourne DR, Grant AM. Mothers' views of continuous electronic fetal heart monitoring and intermittent auscultation in a randomized controlled trial. Birth 1985;12(2):79‐86. - PubMed
Gibb 1992
    1. Gibb D, Arulkumaran S. Fetal Monitoring in Practice. Oxford: Butterworth‐Heinemann Ltd, 1992.
Grant 1989a
    1. Grant A. Monitoring the fetus during labour. In: Chalmers I, Enkin M, Keirse MJNC editor(s). Effective Care in Pregnancy and Childbirth. Oxford: Oxford University Press, 1989:846‐82.
Higgins 2011
    1. Higgins JPT, Green S, editors. Cochrane Handbook for Systematic Reviews of Interventions Version 5.1.0 [updated March 2011]. The Cochrane Collaboration, 2011. Available from www.cochrane‐handbook.org.
Keegan 1985
    1. Keegan KA Jr, Waffarn F, Quilligan EJ. Obstetric characteristics and fetal heart rate patterns of infants who convulse during the newborn period. American Journal of Obstetrics and Gynecology 1985;153(7):732‐7. - PubMed
Killien 1989
    1. Killien MG, Shy K. A randomized trial of electronic fetal monitoring in preterm labor: mothers' views. Birth 1989;16(1):7‐12. - PubMed
Lawn 2005
    1. Lawn JE, Cousens S, Zupan J. 4 million neonatal deaths: when? where? why?. Lancet 2005;365(9462):891‐900. - PubMed
Lie 2010
    1. Lie KK, Grøholt EK, Eskild A. Association of cerebral palsy with Apgar score in low and normal birthweight infants: population based cohort study. BMJ 2010;341:c4990. [DOI: 10.1136/bmj.c4990] - DOI - PMC - PubMed
Lien 1995
    1. Lien JM, Towers CV, Quilligan EJ, Veciana M, Toohey JS, Morgan MA. Term early‐onset neonatal seizures: obstetric characteristics, etiologic classifications, and perinatal care. Obstetrics and Gynecology 1995;85(2):163‐9. - PubMed
Lindström 2006
    1. Lindström K, Lagerroos P, Gillberg C, Fernell E. Teenage outcome after being born at term with moderate neonatal encephalopathy. Pediatric Neurology 2006;35(4):268‐74. - PubMed
Liston 2007
    1. Liston R, Sawchuck D, Young D. Fetal Health Surveillance: Antepartum and Intrapartum Consensus Guideline. Journal of Obstetrics and Gynaecology Canada 2007;29(9):25‐44. - PubMed
Lutomski 2015
    1. Lutomski JE, Meaney S, Greene RA, Ryan AC, Devane D. Expert systems for fetal assessment in labour. Cochrane Database of Systematic Reviews 2015, Issue 4. [DOI: 10.1002/14651858.CD010708.pub2] - DOI
Luttkus 2004
    1. Luttkus AK, Norén H, Stupin JH, Blad S, Arulkumaran S, Erkkola R, et al. Fetal scalp pH and ST analysis of the fetal ECG as an adjunct to CTG. A multicenter, observational study. Journal of Perinatal Medicine 2004;32(6):486‐94. - PubMed
MCHRC 1997
    1. Maternal and Child Health Research Consortium. Confidential enquiry into stillbirths and deaths in infancy (CESDI): 4th Annual Report. London: Maternal and Child Health Research Consortium, 1997.
MCHRC 1998
    1. Maternal and Child Health Research Consortium. Confidential enquiry into stillbirths and deaths in infancy (CESDI): 5th Annual Report. London: Maternal and Child Health Research Consortium, 1998.
MCHRC 1999
    1. Maternal and Child Health Research Consortium. Confidential enquiry into stillbirths and deaths in infancy (CESDI): 6th Annual Report. London: Maternal and Child Health Research Consortium, 1999.
Mozurkewich 2000
    1. Mozurkewich E, Wolf FM. Near‐infrared spectroscopy for fetal assessment during labour. Cochrane Database of Systematic Reviews 2000, Issue 3. [DOI: 10.1002/14651858.CD002254] - DOI - PMC - PubMed
Munro 2004
    1. Munro J, Soltani H, Layhe N, Watts K, Hughes A. Can women relate to the midwifery behind the machines? An exploration of women's experience of electronic fetal monitoring: cross‐sectional survey in three hospitals. Normal Labour and Birth: 2nd Research Conference; 2004 June 9‐11; University of Central Lancashire. 2004.
Neilson 2015
    1. Neilson JP. Fetal electrocardiogram (ECG) for fetal monitoring during labour. Cochrane Database of Systematic Reviews 2015, Issue 12. [DOI: 10.1002/14651858.CD000116.pub5] - DOI - PMC - PubMed
Nelson 1996
    1. Nelson KB, Dambrosia JM, Ting TY, Grether JK. Uncertain value of electronic fetal monitoring in predicting cerebral palsy. New England Journal of Medicine 1996;334(10):613‐8. - PubMed
NICE 2008
    1. National Institute for Health and Care Excellence. Inducing labour. Clinical guideline [CG70]. London: National Institute for Health and Care Excellence, 2008.
NICE 2011
    1. National Institute for Health and Care Excellence. Multiple pregnancy: antenatal care for twin and triplet pregnancies. Clinical guideline [CG129]. London: National Institute for Health and Care Excellence, 2011.
NICE 2014
    1. National Institute for Health and Care Excellence. Intrapartum care for healthy women and babies. Clinical guideline [CG190]. London: National Institute for Health and Care Excellence, 2014.
Palmer 1995
    1. Palmer L, Blair E, Petterson B, Burton P. Antenatal antecedents of moderate and severe cerebral palsy. Paediatric and Perinatal Epidemiology 1995;9(2):171‐84. - PubMed
RANZCOG 2014
    1. Royal Australian and New Zealand College of Obstetricians and Gynaecologists. Intrapartum Fetal Surveillance. Third Edition. East Melbourne: The Royal Australian and New Zealand College of Obstetricians and Gynaecologists, 2014.
RevMan 2014 [Computer program]
    1. The Nordic Cochrane Centre, The Cochrane Collaboration. Review Manager (RevMan). Version 5.3. Copenhagen: The Nordic Cochrane Centre, The Cochrane Collaboration, 2014.
Rothwell 2005
    1. Rothwell PM. Subgroup analysis in randomised controlled trials: importance, indications, and interpretation. Lancet 2005;365(9454):176‐86. - PubMed
Skupski 2002
    1. Skupski DW, Rosenberg CR, Eglinton GS. Intrapartum stimulation tests: meta‐analysis. Obstetrics and Gynecology 2002;99(1):129‐34. - PubMed
Smith 2012
    1. Smith V, Begley CM, Clarke M, Devane D. Professionals’ views of fetal monitoring during labour: a systematic review and thematic analysis. BMC Pregnancy and Childbirth 2012;12:166. [DOI: 10.1186/1471-2393-12-166] - DOI - PMC - PubMed
Spellacy 1985
    1. Spellacy WN, Peterson PQ, Winegar A, Quilligan EJ. Neonatal seizures after cesarean delivery: higher risk with labor. American Journal of Obstetrics and Gynecology 1987;157(2):377‐9. - PubMed
Stein 2006
    1. Stein W, Hellmeyer L, Misselwitz B, Schmidt S. Impact of fetal blood sampling on vaginal delivery and neonatal outcome in deliveries complicated by pathologic fetal heart rate: a population based cohort study. Journal of Perinatal Medicine 2006;34(6):479‐83. - PubMed
Temple 1995
    1. Temple CM, Dennis J, Carney R, Sharich J. Neonatal seizures: long‐term outcome and cognitive development among 'normal' survivors. Developmental Medicine and Child Neurology 1995;37(2):109‐18. - PubMed
Thacker 1995
    1. Thacker SB, Stroup DF, Peterson HB. Efficacy and safety of intrapartum electronic fetal monitoring: an update. Obstetrics & Gynecology 1995;86(4 Pt 1):613‐20. - PubMed

References to other published versions of this review

Alfirevic 2013
    1. Alfirevic Z, Devane D, Gyte GML. Continuous cardiotocography (CTG) as a form of electronic fetal monitoring (EFM) for fetal assessment during labour. Cochrane Database of Systematic Reviews 2013, Issue 5. [DOI: 10.1002/14651858.CD006066.pub2] - DOI - PubMed
Alfirevic 2006
    1. Alfirevic Z, Devane D, Gyte GML. Continuous cardiotocography (CTG) as a form of electronic fetal monitoring (EFM) for fetal assessment during labour. Cochrane Database of Systematic Reviews 2006, Issue 3. [DOI: 10.1002/14651858.CD006066] - DOI - PubMed
Thacker 2001
    1. Thacker SB, Stroup D, Chang M. Continuous electronic heart rate monitoring for fetal assessment during labor. Cochrane Database of Systematic Reviews 2001, Issue 2. [DOI: 10.1002/14651858.CD000063.pub2] - DOI - PubMed