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

Research output: Contribution to journalArticlepeer-review


  • Bassel H Al Wattar
  • Emma Honess
  • Sarah Bunnewell
  • Nicky J Welton
  • Siobhan Quenby
  • Khalid S Khan

External organisations

  • University College London Hospitals NHS Foundation Trust
  • University of Bristol
  • Birmingham Women's and Children's Hospital NHS Foundation Trust
  • University of Warwick
  • University Hospitals of Coventry and Warwickshire NHS Trust
  • University of Granada


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.

Bibliographic note

Funding Information: Content licence: This is an Open Access article distributed in accordance with the terms of the Creative Commons Attribution (CC BYNCND 4.0) licence, which permits use, distribution and reproduction in any medium, provided that the original publication is properly cited, the use is noncommercial (i.e., research or educational use), and no modifications or adaptations are made. See: https://creativecommons. org/licenses/byncnd/4.0/ Funding: Bassel Al Wattar holds a personal Academic Clinical Lectureship from the UK National Health Institute of Research. Khalid Khan is a Distinguished Investigator funded by the Beatriz Galindo (senior modality) Program Grant given to the University of Granada by the Ministry of Science, Innovation, and Universities of the Spanish Government. Publisher Copyright: © 2021 Canadian Medical Association. All rights reserved.


Original languageEnglish
Pages (from-to)E468-E477
Number of pages10
JournalCanadian Medical Association Journal
Issue number14
Publication statusPublished - 6 Apr 2021

ASJC Scopus subject areas