Fetal Monitoring: A Collection of Abstracts and References from PubMed
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J Midwifery Womens Health 2001 Nov-Dec;46(6):366-73 |
Books
Monitoring the fetus in labor: evidence to
support the methods.
Albers LL.
University of New Mexico College of Nursing, Albuquerque 87131-5688, USA.
Electronic fetal monitoring (EFM) was implemented across the United States in
the 1970s. By 1998, it was used in 84% of all U.S. births, regardless of
whether the primary caregiver was a physician or a midwife. Numerous randomized
trials have agreed that continuous EFM in labor increases the operative
delivery rate, without clear benefit to the baby. Intermittent auscultation
(IA) is safe and effective in low-risk pregnancies and may play a role in
helping birth remain normal. Clinicians and educators are encouraged to
reconsider the use of IA in the care of healthy childbearing women.
PMID: 11783684 [PubMed - in process]
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Obstet Gynecol Surv 2001 Nov;56(11):707-19 |
Historical controversy in health technology
assessment: the case of electronic fetal monitoring.
Banta DH, Thacker SB.
Netherlands organization for Applied Scientific Research, Leiden.
Electronic fetal monitoring (EFM) was introduced in the late 1950s as an
alternative to traditional auscultation by stethoscope or fetoscope in the
management of labor and delivery. The new technology was seen as a valuable
tool in the prevention of cerebral palsy and other adverse fetal outcomes and
diffused rapidly into clinical practice. In the late 1970s, some scepticism
began to be voiced about the evidence for the effectiveness of EFM. The authors
published a systematic review of the evidence in 1979 that concluded that there
was insufficient evidence for the effectiveness of the routine use of EFM and a
clear rise in the cesarean delivery rate associated with its use. The analysis
was based on a thorough review of approximately 600 books and articles, but
focused heavily on the evidence of four randomized clinical trials (RCTs) that
had been published. An economic analysis further underscored the importance of
this issue. The report was met with harsh ad hominem criticism from clinicians
both in public venues and in the medical literature. Subsequently, additional
RCTs were conducted and other analyzes were published, and in 1987 the American
College of Obstetricians and Gynecologists recommended that auscultation was an
acceptable alternative to EFM in routine labor and delivery. Yet, today EFM
continues to be the standard of practice, used in 80% of labors in this
country. The most important conclusion drawn from this experience is the need
to evaluate new technologies before their widespread diffusion into clinical
practice.
Publication Types:
· Review
· Review, Tutorial
PMID: 11711906 [PubMed - indexed for MEDLINE]
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BMJ 2001 Jun 16;322(7300):1457-60; discussion 1460-2 |
Comment in:
· BMJ. 2001 Jun 16;322(7300):1436-7.
Randomised controlled trial of
cardiotocography versus Doppler auscultation of fetal heart at admission in
labour in low risk obstetric population.
Mires G, Williams F, Howie P.
Department of Obstetrics and Gynaecology, Ninewells Hospital and Medical
School, Dundee, Tayside DD1 9SY. g.j.mires@dundee.ac.uk
OBJECTIVE: To compare the effect of admission cardiotocography and Doppler
auscultation of the fetal heart on neonatal outcome and levels of obstetric
intervention in a low risk obstetric population. DESIGN: Randomised controlled
trial. SETTING: Obstetric unit of teaching hospital PARTICIPANTS: Pregnant
women who had no obstetric complications that warranted continuous monitoring
of fetal heart rate in labour. INTERVENTION: Women were randomised to receive
either cardiotocography or Doppler auscultation of the fetal heart when they
were admitted in spontaneous uncomplicated labour. MAIN OUTCOME MEASURES: The
primary outcome measure was umbilical arterial metabolic acidosis. Secondary
outcome measures included other measures of condition at birth and obstetric
intervention. RESULTS: There were no significant differences in the incidence
of metabolic acidosis or any other measure of neonatal outcome among women who
remained at low risk when they were admitted in labour. However, compared with
women who received Doppler auscultation, women who had admission
cardiotocography were significantly more likely to have continuous fetal heart
rate monitoring in labour (odds ratio 1.49, 95% confidence interval 1.26 to
1.76), augmentation of labour (1.26, 1.02 to 1.56), epidural analgesia (1.33,
1.10 to 1.61), and operative delivery (1.36, 1.12 to 1.65). CONCLUSIONS:
Compared with Doppler auscultation of the fetal heart, admission
cardiotocography does not benefit neonatal outcome in low risk women. Its use
results in increased obstetric intervention, including operative delivery.
Publication Types:
· Clinical Trial
· Randomized Controlled Trial
PMID: 11408301 [PubMed - indexed for MEDLINE]
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Cochrane Database Syst Rev 2001;2:CD000063 |
Continuous electronic heart rate monitoring
for fetal assessment during labor (Cochrane Review).
Thacker SB, Stroup D, Chang M.
Epidemiology Program Office, Centers for Disease Control and Prevention (CDC),
1600 Clifton Road, NE, Atlanta, Georgia, USA, 30333. sbt1@cdc.gov
BACKGROUND: Electronic fetal monitoring (EFM) is used in the management of
labor and delivery in nearly three of four pregnancies in the United States.
The apparent contradiction between the widespread use of EFM and expert
recommendations to limit routine use indicates that a reassessment of this
practice is warranted. OBJECTIVES: To compare the efficacy and safety of
routine continuous EFM during labor with intermittent auscultation, using the
results of published randomized controlled trials (RCTs). SEARCH STRATEGY: We
identified RCTs by searching MEDLINE and the register maintained by the
Cochrane Pregnancy and Childbirth Group, and by contacting experts, and
reviewing published references. Date of last search: January 2001. SELECTION
CRITERIA: Randomized controlled trials. DATA COLLECTION AND ANALYSIS: Data were
abstracted by one of us, and their accuracy was confirmed independently by a
second person. A single reviewer assessed study quality based on criteria
developed by others for RCTs. Data reported from similar studies were used to
calculate a combined risk estimate for each of eight outcomes. MAIN RESULTS:
Our search identified 13 published RCTs addressing the efficacy and safety of
EFM; no unpublished studies were found. Four trials that did not fulfil our
selection criteria were excluded. The remaining nine trials included 18,561
pregnant women and their 18,695 infants in both high- and low-risk pregnancies
from seven clinical centers in the United States, Europe, and Australia.
Overall, a statistically significant decrease was associated with routine EFM
for neonatal seizures (relative risk (RR) 0.51, 95% confidence interval (CI)
0.32-0.82). The protective effect for neonatal seizures was only evident in
studies with high-quality scores. No significant differences were observed in
1-minute Apgar scores below four or seven, rate of admissions to neonatal intensive
care units, perinatal deaths or cerebral palsy. An increase associated with the
use of EFM was observed in the rate of cesarean delivery (RR 1.41, 95% CI
1.23-1.61) and operative vaginal delivery (RR 1.20, 95% CI 1.11-1.30).
REVIEWER'S CONCLUSIONS: The only clinically significant benefit from the use of
routine continuous EFM was in the reduction of neonatal seizures. In view of
the increase in cesarean and operative vaginal delivery, the long-term benefit
of this reduction must be evaluated in the decision reached jointly by the
pregnant woman and her clinician to use continuous EFM or intermittent
auscultation during labor.
PMID: 11405949 [PubMed - in process]