Summaries & Abstracts

This second part of the appraisal of RCTs comparing CTG+ST to CTG focus on the five meta-analyses (MAs) published in 2012 and 2013. As discussed in the first part, there are considerable differences in several variables in the five RCTs that make a comparison between the trials, and hence performing adequate meta-analyses, challenging. The type of meta-analyses to use, fixed- or random-effect MA, depends on the heterogeneity of the trials. A random-effect MA as a rule gives a more conservative 95% confidence interval. Both types have been used adequately in the five MAs.

This first article in a series of two, addresses the quality of the five randomized controlled trials(RCTs) comparing CTG+ST vs. CTG (Plymouth trial 1993, Swedish trial 2001, Finnish trial 2006, French trial 2007 and Dutch trial 2010). The following issues are reviewed: power calculation, pre-study training, inclusion criteria, randomization and recruitment pace, intrapartum management protocols, intrapartum interventions, cord blood and early neonatal metabolic acidosis, and neonatal outcomes.

 It is time to introduce ST analysis for fetal monitoring in the labor ward?
After a thorough evaluation of the published data, the authors of this commentary take a definite position in favor of ST analysis in clinical practice. The basis for their standpoint is the solid fundament of experimental data revealing the importance of changes in the ST waveform of the fetal ECG for identification of intrauterine hypoxia.

The ability to identify fetuses at risk of hypoxia with ST Analysis in a high risk population.
The use of ST Analysis as an adjunct to CTG has during the recent years reduced the frequency of vaginal operative deliveries, the necessity of fetal blood sampling and the number of neonates transferred to NICU.

A nationwide descriptive study of obstetric claims for compensation in Norway.
“Increased training in fetal monitoring and obstetric emergency situations are recommended to decrease the obstetric compensation claims”
In this article reasons for substandard care in obstetric compensation claims are discussed.

Understanding cardiotocographic patterns associated with intrapartum fetal hypoxia and neurological injury
“If there are more focus on pattern recognition and pathophysiology it all becomes more evident.”

Poster at ECIC: Assessement of an e-Learning program of FHR monitoring. A randomised study
A French study shows that training in EFM interpretation using an e-learning program improves the performance of obstetrical staff.

Renewed meta-analysis: Further support for ST Analysis
The objective of this meta-analysis was to investigate the additional effect of ST Analysis as an adjunct to electronic fetal monitoring. In order to overcome the shortcomings of conventional meta-analysis that uses aggregated data, the present analysis used individual participant data to allow for a more thorough investigation by taking all information into account, including accounting for missing data.

Fetal ECG waveform – helps differentiating maternal from fetal heart rate
The objective of this retrospective study was to investigate the incidence of heart rate accelerations coinciding with contractions during the second stage of labour when monitored either with abdominal ultrasound (external) or scalp electrode (internal).

Five years of ST Analysis usage in Bergen – a quality improvement study
Data from five years of clinical usage of ST Analysis and Stan at the Labour and Delivery ward at Haukeland University Hospital in Bergen, Norway is reported in this prospective observational study. The study was defined as a project of quality improvement, and included a total of 22,475women selected for vaginal delivery.

Strict adherence to Stan Guidelines leads to improved outcome
In this sub-analysis of the Dutch randomised trial it is shown that cases with adverse outcome in the index group (CTG+ST analysis) could have been avoided by stricter adherence to Stan guidelines. Improved CTG interpretation and timing of fetal blood sampling could have led to better outcomes in the control group.

Poster at SMFM: Significantly improved outcomes over 10 years of STAN usage in Turku
Dr. Timonen from Turku University Hospital, Finland presented a poster with their experience of ST Analysis at the 2012 Society for Maternal Fetal Medicine (SMFM) congress in Dallas, TX USA.

No risk associated with high baseline T/QRS ratio
In the European Stan Expert meeting in 2009, the interpretation of a high baseline T/QRS ratio at the start of a registration was discussed since some cases with high baseline T/QRS followed by metabolic acidosis had been encountered.

Meta-Analysis concludes benefits of ST Analysis
The objective of this meta-analysis, which includes five randomised trials (RCT) and 15,352 patients, was to compare the effects of adding ST Analysis to conventional intrapartum EFM.

Effectiveness of pulse oximetry vs ST Analysis
The aim of this prospective randomized study was to compare the effectiveness of pulse oximetry and ST Analysis of the fetal ECG, and to determine which method was better at identifying the labour which could continue to deliver a healthy newborn.

Revised ITT analysis of Swedish RCT shows unchanged significant effect
The objective of this revision was to compare the results of the current standard intention-to-treat (ITT) analysis with the results of the previously published Swedish randomised controlled trial (RCT), and to perform a retrospective quality control and reanalysis of the data.

Dutch RCT Published
The Dutch Randomized Controlled Trial on ST Analysis is published in the June issue of Obstetrics & Gynecology – The Green Journal. The trial is one of the largest ever within obstetrics, and it confirms the results from the previous RCTs with the conclusion that ST Analysis as an adjunct to CTG “…substantially decreases the incidence of (metabolic) acidosis.”

Cost-effectiveness of ST Analysis
The long-term cost-effectiveness of fetal monitoring during labour: a comparison of cardiotocography complemented with ST analysis versus cardiotocography alone

High usage of CTG+ST Analysis results in a reduced rate of metabolic acidosis
This prospective clinical study investigated the improvements in quality-of-care after the introduction of ST Analysis in a Swedish district hospital. Data was collected during seven years and almost 13,000 deliveries were included in a detailed analysis. The number of deliveries increased by 47% during the time period, and during the same period the usage of CTG + ST Analysis increased from 26 to 69%. The rate of cord gas sampling also increased and was 96.3% in 2007.

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