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Cardiotocography for antepartum fetal assessment (Review)
Pattison N, McCowan L
ThisisareprintofaCochranereview,preparedandmaintained byTheCochraneCollaborationandpublishedinTheCochraneLibrary
2007, Issue 2
http://www.thecochranelibrary.com
Cardiotocographyfor antepartum fetal assessment (Review) 1
Copyright©2007 The CochraneCollaboration.Published byJohn Wiley & Sons, Ltd
TABLE OF CONTENTS
ABSTRACT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
BACKGROUND . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
OBJECTIVES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
CRITERIAFORCONSIDERINGSTUDIESFORTHISREVIEW . . . . . . . . . . . . . . . . . . 2
SEARCHMETHODSFORIDENTIFICATIONOFSTUDIES . . . . . . . . . . . . . . . . . . . 2
METHODSOFTHEREVIEW . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
DESCRIPTIONOFSTUDIES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
METHODOLOGICALQUALITY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
RESULTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
DISCUSSION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
AUTHORS’CONCLUSIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
NOTES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
POTENTIALCONFLICTOFINTEREST . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
ACKNOWLEDGEMENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
SOURCESOFSUPPORT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
TABLES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
Characteristics of included studies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
ANALYSES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Comparison 01. Antenatal care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Comparison 02. Onset of labour . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Comparison 03. Method of delivery . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Comparison 04. Perinatal outcomes . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
INDEXTERMS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
COVERSHEET . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
GRAPHSANDOTHERTABLES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Analysis 01.01. Comparison 01 Antenatal care, Outcome 01 Outpatients who required admission . . . . . . . 9
Analysis 01.02. Comparison 01 Antenatal care, Outcome 02 Inpatients who were required to remain in hospital . . 9
Analysis 01.03. Comparison 01 Antenatal care, Outcome 03 Number of inpatient days (mean) . . . . . . . . 10
Analysis 02.01. Comparison 02 Onset of labour, Outcome 01 Spontaneous onset . . . . . . . . . . . . 10
Analysis 02.02. Comparison 02 Onset of labour, Outcome 02 Elective Caesarean section . . . . . . . . . . 11
Analysis 02.03. Comparison 02 Onset of labour, Outcome 03 Induced labour . . . . . . . . . . . . . . 11
Analysis 03.01. Comparison 03 Method of delivery, Outcome 01 Normal vaginal delivery . . . . . . . . . 12
Analysis 03.02. Comparison 03 Method of delivery, Outcome 02 Operative vaginal delivery . . . . . . . . . 12
Analysis 03.03. Comparison 03 Method of delivery, Outcome 03 All Caesarean sections . . . . . . . . . . 13
Analysis 03.04. Comparison 03 Method of delivery, Outcome 04 Emergency Caesarean sections . . . . . . . 13
Analysis 04.01. Comparison 04 Perinatal outcomes, Outcome 01 ’Fetal distress’ . . . . . . . . . . . . . 14
Analysis 04.02. Comparison 04 Perinatal outcomes, Outcome 02 Abnormal neurological signs . . . . . . . . 14
Analysis 04.03. Comparison 04 Perinatal outcomes, Outcome 03 Neonatal admission . . . . . . . . . . . 15
Analysis 04.04. Comparison 04 Perinatal outcomes, Outcome 04 Perinatal mortality (non lethal) . . . . . . . 15
Analysis 04.05. Comparison 04 Perinatal outcomes, Outcome 05 Abnormal Apgar score . . . . . . . . . . 16
Cardiotocographyfor antepartum fetal assessment (Review) i
Copyright©2007 The CochraneCollaboration.Published byJohn Wiley & Sons, Ltd
Cardiotocography for antepartum fetal assessment (Review)
Pattison N, McCowan L
This record should be cited as:
Pattison N, McCowan L. Cardiotocography for antepartum fetal assessment. Cochrane Database of Systematic Reviews 1999, Issue 1.
Art. No.: CD001068. DOI: 10.1002/14651858.CD001068.
This version first published online: 25 January 1999 in Issue 1, 1999.
Date of most recent substantive amendment: 19 November 1998
ABSTRACT
Background
Cardiotocography is a form of fetal assessment which simultaneously records fetal heart rate, fetal movements and uterine contractions
to investigate hypoxia.
Objectives
Theobjective was to assess the effects of antenatal cardiotocography on perinatal morbidity and mortality and maternal morbidity.
Search strategy
WesearchedtheCochranePregnancyandChildbirthGrouptrialsregisterandtheCochraneControlledTrialsRegister(to1November
1998).
Selection criteria
Randomised trials comparing antenatal cardiotocography with a control group for fetal assessment.
Data collection and analysis
Trial quality was assessed.
Main results
Four studies involving 1,588 pregnancies were included. All trials were conducted on high or intermediate risk pregnancies. Antenatal
cardiotocography appearedtohavenosignificant effectonperinatalmortalityormorbidity.Therewasatrendtoanincreaseinperinatal
deaths in the cardiotocography group (odds ratio 2.85, 95% confidence interval 0.99 to 7.12). There was no increase in the incidence
of interventions such as elective caesarean section or induction of labour. The one trial which examined an effect on antenatal patient
management showed a significant reduction in hospital admissions and a reduction in inpatient stay in the cardiotocography group.
Authors’ conclusions
There is not enough evidence to evaluate the use of antenatal cardiotocography for fetal assessment. All of the trials included in this
review date from the introduction of antenatal cardiotocography and may be difficult to relate to current practice.
BACKGROUND where fetal wellbeing is questioned, including post term preg-
nancy, reduced fetal movements, hypertensive disease, growth re-
striction and bleeding in pregnancy (Phelan 1981).
Antenatalcardiotocography(CTG),thenonstresstest(NST),has
become widely accepted as the primary method of antenatal fe- The antenatal CTG is a continuous record of the fetal heart rate
tal monitoring (Freeman 1982). In conjunction with ultrasound obtained via an ultrasound transducer placed on the maternal ab-
imaging and Doppler measurements, the CTG has replaced lab- domen. The fetal heart rate, including variability, accelerations
oratory based methods. It is applied to pregnancy complications, and decelerations, if any occur, is recorded electronically on a pa-
Cardiotocographyfor antepartum fetal assessment (Review) 1
Copyright©2007 The CochraneCollaboration.Published byJohn Wiley & Sons, Ltd
per trace. Interpretation of the fetal heart rate pattern can be dif- performing a CTG and withholding the result from the caregiver
ficult. A reactive (normal) CTG is defined by two accelerations or a non monitored group. Additional tests of fetal wellbeing in-
exceeding 15bpm, sustained for at least 15 seconds in a 20 minute cluded biochemical tests and ultrasound.
period (Devoe 1990). Reduced variability and the presence of de- Types of outcome measures
celerations are abnormal. Various scoring systems have been de-
vised to classify the CTG. Studies of intra and interobserver vari- The main focus was on obstetric interventions including rates of
ation performed in the late 1970s have shown very good agree- induction of labour and Caesarean section. Perinatal outcomes
ment for the classification of CTGs as either reactive or non re- suchasmortality,short termneurological sequelae including con-
active (98% intraobserver agreement, 93% interobserver agree- vulsions and abnormal neurological signs, rate of neonatal admis-
ment).However,variabilitywasgreaterwhenscoringsystemswere sion, low Apgar scores, intrapartum fetal heart rate abnormalities,
used (Flynn 1982). presence of meconium and mode of delivery were also compared.
Initial observational studies showed a strong correlation between Measures of reduced intervention such as reduced antenatal hos-
the abnormal CTG and poor fetal outcome (Freeman 1982; Phe- pital stay and reduced rates of antenatal admission were reported.
lan 1981). Introduction of this test followed rapidly without sup-
portive evidence of benefit from randomised trials. SEARCH METHODS FOR
I D E N T I F I C A T I O N O F S T U D I E S
OBJECTIVES
See: Cochrane Pregnancy and Childbirth Group methods used
The objectives of this review are to determine whether antenatal in reviews.
cardiotocography has a role in either identifying pregnancies at This review used the search strategy developed for the Pregnancy
high risk where induction of labour or immediate delivery are re- and Childbirth Group as a whole. Relevant trials were identified
quired, or in reassuring the mother, obstetrician and midwife that in the Group’s Specialised Register of Controlled Trials. See
the pregnancy can continue. We tested the following hypotheses: Review Group’s details for more information.
that the use of antenatal cardiotocography The Cochrane Controlled Trials Register (CENTRAL/CCTR)
1) will lead to a reduction in fetal mortality and mordibity due to was searched on 1 November 1998.
asphyxial complications,
2) can be used to reassure the mother, obstetrician and midwife
that the pregnancy can continue at present without intervention, METHODS OF THE REVIEW
3) will lead to an increase in obstetric interventions, Tworeviewers,NeilPattisonandLesleyMcCowan,independently
4)willleadtoaworseningofoutcomeseitherbymisinterpretation assessed the trials to be included in this review and reasons
of the cardiotocograph, by increasing the rates of intervention or for exclusion of any apparently eligible trial were clearly stated.
by falsely reassuring the caregiver of fetal welbeing. The methological quality of the trials was assessed by the above
reviewerswithdetailsofrandomisation,blinding,andapplicability
explored. All possible data were sought to allow analysis by
CRITERIA FOR CONSIDERING intention to treat.
STUDIES FOR THIS REVIEW Statistical analysis used the Review Manager (RevMan) software
Types of studies for calculation of thetreatment effectas representedbyodds ratios
and proportional and absolute risk reductions. Heterogeneity
Anyrandomisedcontrolledtrialcomparingantenatalcardiotocog- between trial results was investigated and sensitivity analysis used
raphy with alternative methods of assessing fetal health was con- where appropriate.
sidered.
Types of participants
All women, both primigravid and multigravid in the antenatal DESCRIPTION OF STUDIES
period. Trials for both low and high obstetric risk groups were Four trials were identified which met the inclusion criteria de-
sought. scribed above. All trials studied high/intermediate risk pregnan-
Types of intervention cies. There were 300 to 550 women in each trial, 1,588 pregnan-
Electronicfetalmonitoring withanantenatal CTGwascompared cies in total. The gestation of all pregnancies were more than 26
to a control group. Methods used for the control group included weeks of pregnancy. Women studied were either admitted to the
Cardiotocographyfor antepartum fetal assessment (Review) 2
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