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

With the exception of reduction in the incidence of neonatal seizures, there were no short- or long-term benefits of routine continuous electronic fetal monitoring. The use of electronic fetal monitoring was associated with significant increases in the rates of caesarean section and assisted vaginal delivery. RHL Commentary by ardin !M

"# E$%&E CE '(MM)R*

This Cochrane systematic review ( ! evaluated the effectiveness and safety of continuous cardiotocography (CT"! (defined as an attempt to produce a continuous and simultaneous hard-copy recording of the fetal heart rate and uterine contractions in real-time throughout the woman#s labour for monitoring fetal well being! by comparing continuous CT" with$ (i! no fetal monitoring% (ii! intermittent auscultation (&'! of the fetal heart rate with (inard stethoscope or hand-held )oppler ultrasound device% and (iii! intermittent CT". 'n extensive and appropriate literature search, based on the strategy used by the (regnancy and Childbirth "roup of the Cochrane Collaboration was performed. The outcome measures proposed by the authors are those considered to be of ma*or importance in evaluating electronic monitoring for fetal assessment. The methodology used for data extraction, analysis and presentation is sound. ' total of + studies involving ,- . / women were included in the review. 0leven of these studies compared continuous CT" with intermittent auscultation% six used complementary fetal blood sampling. 1ne trial compared continuous CT" with intermittent CT", in which fetal blood sampling was made available for both groups. The authors included both randomized and 2uasi-randomized trials in the review, which caused methodological diversity or heterogeneity in the data available for the review. Three of the trials included only low-ris3 women, five recruited only high-ris3 women, while the other four evaluated women with mixed ris3. 4our of the included trials had inade2uate allocation concealment, accounting for a total of - +,/ women, e2uivalent to half of the total sample size, which may have influenced the overall results. 5owever, to deal with this problem, the authors performed a subgroup analysis based on methodological 2uality. Two methodological issues regarding the current update of the review need to be mentioned. 4irst, the main difference to the previous version(+! is the inclusion of an alternate allocation trial that contributes 6 . 7 low-ris3 women to the continuous CT" versus &' comparison (,!% and second, the data from the ,-arm trial comparing

continuous CT" with or without fetal scalp sample (6! were handled using an arbitrary division of the number of controls to avoid double-counting when comparing women in this group with both experimental groups. These data should also be interpreted cautiously since controls were divided into two non-randomized groups, which could wea3en the statistical power and 2uality of the original trial. . Continuous versus intermittent CT" 8ased on one trial which included 6966 women at low to moderate ris3 for complications, no significant differences were found between continuous CT" and intermittent CT" (/!.. 5owever, a trend favourable to intermittent CT" could be observed for most of the outcomes evaluated in the review (comparison 9/!, including caesarean section :relative ris3 (;;! .+<, </= confidence interval (C&! 9.76- .<->, instrumental vaginal birth (;; . ., </= C& 9.<+- .6.!, 'pgar score less than seven at five minutes (;; +../, </= C& 9.-9-<.<-! and admission to ?eonatal &ntensive Care @nit (?&C@! (;; .,6, </= C& 9.< - .<7!. .+ Continuous CT" versus intermittent auscultation 1f the eleven trials in this comparison only two had ade2uate allocation concealment ( , , 6 women!, five were unclear (,9,+ women!, and four had inade2uate allocation concealment ( - +,/ women!. There were no differences in perinatal death, hypoxic encephalopathy and neurodevelopmental disability at + months of age. The meta-analysis of nine trials showed a decrease of /9= in neonatal seizures (;; 9./9, </= C& 9., -9.79!. There was a trend towards increased cerebral palsy with continuous CT" (;; .-6, </= C& 9.<--,. !. This result is, however, strongly influenced by one small trial, with ,/= of the cases excluded after randomization (birth weight A -/9 g!, analysing data from the remaining cohort of neonates with birth weight between -99- -/9 g (. -!. 'n overall statistically significant increase in caesarean sections (;; ..., </= C& .,9+. ,! and instrumental vaginal deliveries (;; . ., </= C& .9 - .,+! in the continuous CT" group, are also presented by the authors of the review.

+# RELE$) CE T, ( &ER-RE',(RCE& 'ETT% G' +#"# Magnitude of the problem

1xygenation of the fetus re2uires an ade2uate supply of maternal blood to the placenta, a properly functioning placenta, and a patent umbilical vein in the umbilical cord. @terine contractions during labour may decrease or stop altogether maternal blood flow to the fetus, compromising fetal well being. Bost fetuses have sufficient oxygen reserve to deal with the reduced oxygen supply, but in a limited number of cases fetuses suffer distress from lac3 of oxygen. Compression of the umbilical cord during labour may also be a cause of fetal distress (7!. Ceveral antenatal and intrapartum ris3 factors have been associated with the development of neonatal encephalopathy, cerebral palsy or even perinatal death (<!. 5owever, monitoring of fetal well being has not improved much over the last decades and interventions currently in use in developing countries do not differ significantly from those used

many years ago. Boreover, while continuous CT" is widely used in developed countries, its use in many under-resourced settings is infre2uent.

+#+# )pplicability of the results

1nly one of the included trials was conducted in a developing country. This trial included +99 high-ris3 women (all of whom had meconium stained li2uor!. 1nly unpublished data from this trial were available for the authors of the review and the authors considered the trial to have an inade2uate concealment of allocation ( 9!. The other eleven trials were conducted in developed countries, and most of them under strictly controlled research protocols. Thus, the results of this review would not be easily applicable to under-resourced settings, where only a few or no cardiotocographs are available, personnel is limited in number and training, and resources for maintenance and consumables are scarce, in which it would be difficult to replicate the ideal conditions for continuous CT".

+#.# %mplementation of the inter/ention

The use of continuous CT" in under-resourced settings is not recommended on the basis of the data reviewed here. (olicy-ma3ers and health administrators who consider implementing such a policy should ta3e into account the fact that continuous CT" has not been shown to have an overall advantage over the other methods assessed and its introduction would considerably increase the costs of maternal health care. &f introduced, a careful evaluation or audit after its implementation should be performed.

.# RE'E)RCH
'lthough neonatal seizures were significantly decreased by the use of continuous CT" compared with intermittent auscultation, the factors behind this reduction are not 3nown. To investigate such factors and their potencial long-term conse2uences, trials with long-term infant follow up are needed. Boreover, the use of continuous CT" in many hospitals in developing countries, is not a standard procedure and sometimes is never performed. &nstead, a combination of intermittent CT", with intermittent auscultation using handheld devices or (inard stethoscope between recording periods is in many cases seen and accepted as standard practice. This combination allows to maximise the use of the often scarce number of cardiotocographs and consumables. Comparisons of continuous versus intermittent CT" did not have sufficient power to detect differences between groups. 4uture ade2uately powered ;CTs should explore the possibility of comparing the two abovementioned variations of the method in moderate to high ris3 patients. This comparison should include total health costs evaluation ta3ing into consideration machines, consumables and maintenance of the e2uipment, as well as the need of proper training on the interpretation of results. ;CTs evaluating the performance of continuous CT" compared to &' in low to highris3 pregnancies with regard to long-term outcomes, cerebral palsy and

neurodevelopmental disability should be encouraged. Baternal and health providersD views and satisfaction should also be considered.

References

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This document should be cited as$ ?ardin HB. Continuous cardiotocography (CT"! as a form of electronic monitoring (04B! for fetal assessment during labour$ ;5F commentary (last revised$ < Hanuary +99-!. The &' Re(roductive 'ealth #ibrary% "eneva$ World 5ealth 1rganization.