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Continuous cardiotocography (CTG) as a form of electronic fetal monitoring (EFM) for fetal assessment during labour
Alfirevic Z, Devane D, Gyte GML
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Comparing continuous electronic monitoring of the baby""s heartbeat in labour using cardiotocography (CTG, sometimes known as EFM) with intermittent monitoring (intermittent auscultation, IA)
Monitoring the baby""s heartbeat is one way of checking babies"" well-being in labour. By listening to, or recording the baby""s heartbeat, it is hoped to identify babies who are becoming short of oxygen (hypoxic) and who may benefit from caesarean section or instrumental vaginal birth. A baby""s heartbeat can be monitored intermittently by using a fetal stethoscope, Pinard (special trumpet shaped device), or by a handheld Doppler device. The heartbeat can also be checked continuously by using a CTG machine. This method is sometimes known as electronic fetal monitoring (EFM) and produces a paper recording of the baby""s heart rate and their mother""s labour contractions. Whilst a continuous CTG gives a written record, it prevents women from moving during labour. This means that women may be unable to change positions or use a bath to help with comfort and control during labour. It also means that some resources tend to be focused on the needs of the CTG rather than the woman in labour. This review compared continuous CTG monitoring with intermittent auscultation (listening). It found 12 trials involving over 37,000 women. Most studies were not of high quality and the review is dominated by one large, well-conducted trial of almost 13,000 women who received care from one person throughout labour in a hospital where the membranes have either ruptured spontaneously or were artificial ruptured as early as possible and oxytocin stimulation of contractions was used in about a quarter of the women. There was no difference in the number of babies who died during or shortly after labour (about 1 in 300). Fits (neonatal seizures) in babies were rare (about 1 in 500 births), but they occurred significantly less often when continuous CTG was used to monitor fetal heart rate. There was no difference in the incidence of cerebral palsy, although other possible long-term effects have not been fully assessed and need further study. Continuous monitoring was associated with a significant increase in caesarean section and instrumental vaginal births. Both procedures are known to carry the risks associated with a surgical procedure although the specific adverse outcomes have not been assessed in the included studies.

This is a Cochrane review abstract and plain language summary, prepared and maintained by The Cochrane Collaboration, currently published in The Cochrane Database of Systematic Reviews 2008 Issue 2, Copyright © 2008 The Cochrane Collaboration. Published by John Wiley and Sons, Ltd.. The full text of the review is available in The Cochrane Library (ISSN 1464-780X).
This record should be cited as: 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. Art. No.: CD006066. DOI: 10.1002/14651858.CD006066

This version first published online: July 19. 2006
Date of last subtantive update: April 24. 2006

Abstract
Background
Cardiotocography (sometimes known as electronic fetal monitoring), 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), so additional assessments of fetal well-being may be used, or the baby delivered by caesarean section or instrumental vaginal birth.

Objectives
To evaluate the effectiveness of continuous cardiotocography during labour.

Search strategy
We searched the Cochrane Pregnancy and Childbirth Group Trials Register (March 2006), CENTRAL (The Cochrane Library 2005, Issue 4), MEDLINE (1966 to December 2005), EMBASE (1974 to December 2005), Dissertation Abstracts (1980 to December 2005) and the National Research Register (December 2005).

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

Data collection and analysis
Two authors independently assessed eligibility, quality and extracted data.

Main results
Twelve trials were included (over 37,000 women); only two were high quality. Compared to intermittent auscultation, continuous cardiotocography showed no significant difference in overall perinatal death rate (relative risk (RR) 0.85, 95% confidence interval (CI) 0.59 to 1.23, n = 33,513, 11 trials), but was associated with a halving of neonatal seizures (RR 0.50, 95% CI 0.31 to 0.80, n = 32,386, nine trials) although no significant difference was detected in cerebral palsy (RR 1.74, 95% CI 0.97 to 3.11, n = 13,252, two trials). There was a significant increase in caesarean sections associated with continuous cardiotocography (RR 1.66, 95% CI 1.30 to 2.13, n =18,761, 10 trials). Women were also more likely to have an instrumental vaginal birth (RR 1.16, 95% CI 1.01 to 1.32, n = 18,151, nine trials). Data for subgroups of low-risk, high-risk, preterm pregnancies and high quality trials were consistent with overall results. Access to fetal blood sampling did not appear to influence the difference in neonatal seizures nor any other prespecified outcome.

Authors"" conclusions
Continuous cardiotocography during labour is associated with a reduction in neonatal seizures, but no significant differences in cerebral palsy, infant mortality or other standard measures of neonatal well-being. However, continuous cardiotocography was associated with an increase in caesarean sections and instrumental vaginal births. The real challenge is how best to convey this uncertainty to women to enable them to make an informed choice without compromising the normality of labour.

Jak vidis, to neni vycuc na odstavecek, pod Main results jsou cisla. Pokud nevis co to je Cochrane library, over si to v encyklopedii, ja jen ti kratce naznacim, ze je to lekarska databaze evidence based mediciny, velice seriozni zdroj. Reviews pro nej delaji renomovani vyzkumniky, a dela se to pro vyzkumniky, lekare praktiky a laiky, aby si overily, jestli postup jejich lecby byl legitimni a opreny na dukazech.

Ja jsem cetla tvuj pribeh, jsi naopak necetla muj odkaz. Nevim proc. Je tam jasne receno, ze zaver: kontinualni monitorovani nezlepsuje cisla perinatalni umrtnosti ani stavu novorozencu, jedine vyrazne zvetsuje pravdepodobnost operativneho porodu, a to je kompatibilni pro veskere skupiny: rizikovych a nerizikovych rodicek. Takze jako reprezentant seriozni instituce, Cochrane recenzent porovnaval srovnatelne: rizikove monitorovane rodicky s rizikovymi auskultovanymi, a nizkorizikove s nizkorizikovymi.

Nevime jak by dopadl tvuj porod bez sondy, nemuzeme vedet. Nemuzeme nikdy vedet, jak individualni telo zareaguje na nejaky postup. Proto se delaji empiricke vyzkumy, aby medicina byla vedou. Jedine co je znamo v tvem pripade je, ze pro postup tve doktorky nebyl zadny vedecky dukaz. Klidne si ji ver, jen je dulezite, aby vira se nestala neurozou, ktera nuti zavirat oci pred fakty. Plny text citovaneho odkazu, pokud ti to citovane jeste nestaci, je pristupny v Cochrane Library, vstup je placeny.