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. 2021 Apr 6;193(14):E468-E477.
doi: 10.1503/cmaj.202538.

Effectiveness of intrapartum fetal surveillance to improve maternal and neonatal outcomes: a systematic review and network meta-analysis

Bassel H Al Wattar  1 , Emma Honess  2 , Sarah Bunnewell  2 , Nicky J Welton  2 , Siobhan Quenby  2 , Khalid S Khan  2 , Javier Zamora  2 , Shakila Thangaratinam  2
Affiliations

Effectiveness of intrapartum fetal surveillance to improve maternal and neonatal outcomes: a systematic review and network meta-analysis

Bassel H Al Wattar et al. CMAJ. .

Abstract

Background: Cesarean delivery is the most common surgical procedure worldwide. Intrapartum fetal surveillance is routinely offered to improve neonatal outcomes, but the effects of different methods on the risk of emergency cesarean deliveries remains uncertain. We conducted a systematic review and network meta-analysis to evaluate the effectiveness of different types of fetal surveillance.

Methods: We searched MEDLINE, Embase and CENTRAL until June 1, 2020, for randomized trials evaluating any intrapartum fetal surveillance method. We performed a network meta-analysis within a frequentist framework. We assessed the quality and network inconsistency of trials. We reported primarily on intrapartum emergency cesarean deliveries and other secondary maternal and neonatal outcomes using risk ratios (RRs) and 95% confidence intervals (CIs).

Results: We included 33 trials (118 863 patients) evaluating intermittent auscultation with Pinard stethoscope/handheld Doppler (IA), cardiotocography (CTG), computerized cardiotocography (cCTG), CTG with fetal scalp lactate (CTG-lactate), CTG with fetal scalp pH analysis (CTG-FBS), CTG with fetal pulse oximetry (FPO-CTG), CTG with fetal heart electrocardiogram (CTG-STAN) and their combinations. Intermittent auscultation reduced the risk of emergency cesarean deliveries compared with other types of surveillance (IA v. CTG: RR 0.83, 95% CI 0.72-0.97; IA v. CTG-FBS: RR 0.71, 95% CI 0.63-0.80; IA v.CTG-lactate: RR 0.77, 95% CI 0.64-0.92; IA v. FPO-CTG: RR 0.75, 95% CI 0.65-0.87; IA v.FPO-CTG-FBS: RR 0.81, 95% CI 0.67-0.99; cCTG-FBS v. IA: RR 1.21, 95% CI 1.04-1.42), except STAN-CTG-FBS (RR 1.17, 95% CI 0.98-1.40). There was a similar reduction observed for emergency cesarean deliveries for fetal distress. None of the evaluated methods was associated with a reduced risk of neonatal acidemia, neonatal unit admissions, Apgar scores or perinatal death.

Interpretation: Compared with other types of fetal surveillance, intermittent auscultation seems to reduce emergency cesarean deliveries in labour without increasing adverse neonatal and maternal outcomes.

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Conflict of interest statement

Competing interests: None declared.

Figures

Figure 1:
Figure 1:
Flow chart of the study selection and inclusion process for network meta-analysis on intrapartum fetal surveillance.
Figure 2:
Figure 2:
Network comparing the effectiveness of types of intrapartum fetal surveillance to reduce all emergency cesarean sections in labour. The dot size represents the number of participants in each comparison arm and the thickness of the lines represent the number of randomized trials directly comparing the pair of methods. Note: cCTG-FBS = computer-aided cardiotocography with fetal scalp blood pH sampling, CTG = cardiotocography, CTG-FBS = cardiotocography with fetal scalp blood pH sampling, CTG-lactate = cardiotocography with fetal scalp blood lactate, FPO-CTG = cardiotocography with fetal pulse oximetry, FPO-CTG-FBS = cardiotocography with fetal pulse oximetry and fetal blood pH sampling, IA = intermittent auscultation, STAN-CTG-FBS = cardiotocography with fetal heart electrocardiogram and fetal scalp blood pH sampling.
Figure 3:
Figure 3:
Network meta-analysis comparing the effectiveness of intermittent auscultation (IA) to reduce (A) all emergency cesarean deliveries in labour and (B) emergency cesarean deliveries for suspected fetal distress. The forest plots depict the effectiveness of IA compared with other types of fetal surveillance using both mixed evidence network meta-analysis (M) and direct evidence pairwise meta-analysis (D). Note: cCTG-FBS = computer-aided cardiotocography with fetal scalp blood pH sampling, CTG = cardiotocography, CTG-FBS = cardiotocography with fetal scalp blood pH sampling, CTG-lactate = cardiotocography with fetal scalp blood lactate, FPO-CTG = cardiotocography with fetal pulse oximetry, FPO-CTG-FBS = cardiotocography with fetal pulse oximetry and fetal blood pH sampling, LCL = lower confidence limit, RR = risk ratio, STAN-CTG-FBS = cardiotocography with fetal heart electrocardiogram and fetal scalp blood pH sampling, UCL = upper confidence limit.
Figure 4:
Figure 4:
The ranking probability of types of intrapartum fetal surveillance to reduce all emergency cesarean deliveries when used in labour. The graph depicts the probability of each type to be ranked the highest in reducing the incidence of all emergency cesarean deliveries in labour. IA was consistently ranked first, followed by STAN-CTG-FBS and CTG-FBS. Note: cCTG = computer-aided cardiotocography, cCTG-FBS = computer-aided cardiotocography with fetal scalp blood pH sampling, CTG = cardiotocography, CTG-FBS = cardiotocography with fetal scalp blood pH sampling, CTG-lactate = cardiotocography with fetal scalp blood lactate, FPO-CTG = cardiotocography with fetal pulse oximetry, FPO-CTG-FBS = cardiotocography with fetal pulse oximetry and fetal blood pH sampling, IA = intermittent auscultation, STAN-CTG = cardiotocography with fetal heart electrocardiogram, STAN-CTG-FBS = cardiotocography with fetal heart electrocardiogram and fetal scalp blood pH sampling.
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