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20030826-33# Revisiting the use of the
electronic fetal monitor - Lancet , vol 361, no 9356, February 2003, pp
445-446 Thacker SB; Stroud DF - (February
2003) |
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Concerns about the efficacy and safety of routine
electronic fetal monitoring in labour have led expert panels
in the USA and Canada(1,2) to recommend that such monitoring
be limited to high-risk pregnancies. The latest systematic
review supports that concern;(3) yet, the use of electronic
fetal monitoring in low-risk pregnancies continues to expand
globally. The identification of high-risk pregnancies that
would benefit from the use of electronic fetal monitoring
during labour remains an important research issue. In this
issue of The Lancet, Lawrence Impey and colleagues report the
results of a randomised controlled trial that assessed the
efficacy of admission cardiotocography for 8580 low-risk women
in labour as measured by reductions in the rate of neonatal
and maternal morbidity and mortality. Like the 1985 trial from
the same institution that assessed the efficacy of intrapartum
fetal monitoring,(4) this study is carefully designed and well
conducted. Taken together with similar findings from the only
other reported trial of this intervention,(5) the conclusion
that routine use of cardiotocography for 20 minutes on
admission to the delivery ward does not improve neonatal
outcome is reasonable. Several aspects of the Impey report
deserve comment. The investigators were very careful in the
implementation of their trial. Randomisation of women to the
treatment or control group was blinded and statistically
based. The authors used an appropriate intention-to-treat
analysis and prespecified any subgroup analyses.
Non-parametric methods were used appropriately when data
failed to satisfy Gaussian assumptions. The analysis examined
the effect of changing the method of randomisation during the
trial. One concern about the study design is that the power
calculation assumed a 50% reduction in risk, whereas
practitioners might find a 25% reduction clinically
meaningful. This issue, along with difficulties in
generalising to other populations from two trials (the Impey
study and Mires et al(5)) done in populations at similar risk,
may mean that further trials are still warranted. The finding
that there was no increase in caesarean delivery rate, for
example, could relate to a low rate of caesarean delivery at
this hospital compared with other institutions. The study by
Impey and colleagues provides no evidence that the routine use
of cardiotocography for 20 minutes on admission is effective
for identifying pregnancies that will benefit from electronic
fetal monitoring in labour, but additional trials,
particularly among high-risk populations, might allow a
meta-analysis so that as much could be known about the value
of admission cardiotocography as about EFM during labour.(3)
It is important to explore new and better uses of technologies
in medicine. However, technology must not be allowed to
diffuse unchecked. The use of electronic fetal monitoring in
low-risk pregnancies is of limited effectiveness and carries
an increased risk of interventions including instrumental
delivery, caesarean delivery, augmentation of labour, and
epidural anaesthesia.(3) The lessons learnt too slowly from
the experience with electronic fetal monitoring are relevant
for admission cardiotocography.(6) Increased information on
admission will not necessarily lead to better clinical
outcomes. New technologies must be evaluated before their
widespread implementation and randomised trials are critical
to a valid assessment of a screening technology such as
admission cardiotocography. Even the best trials have
limitations, if only in generalisability. Sometimes the best
studies are done in settings that are not readily transferable
to other places because of differences in resources or
characteristics of the study population. Systematic reviews
and cumulative meta-analyses can help to address the
limitations of single trials. The extent of use of admission
cardiotocography is not well documented, but widespread use of
admission cardiotocography should be discouraged until better
evidence from randomised trials that examine efficacy and
safety in populations that are likely to benefit, is
available. (6 references) (Author)
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