• Bassel H Al Wattar, Emma Honess, Sarah Bunnewell, Nicky J Welton, Siobhan Quenby, Khalid S Khan, Javier Zamora, and Shakila Thangaratinam.
• Warwick Medical School (Al Wattar, Honess, Bunnewell, Quenby), University of Warwick, Coventry, UK; Reproductive Medicine Unit (Al Wattar), University College London Hospitals, London, UK; Population Health Sciences (Welton), Bristol Medical School, University of Bristol, Bristol, UK; University Hospital of Coventry and Warwickshire (Quenby), Coventry, UK; Department of Preventive Medicine and Public Health (Khan), University of Granada, Granada, Spain; Clinical Biostatistics Unit, Ramon y Cajal Hospital (IRYCIS) and CIBER Epidemiology and Public Health (Khan, Zamora), Madrid, Spain; CIBER of Epidemiology and Public Health (CIBERESP) (Zamora), Madrid, Spain; WHO Collaborating Centre for Global Women's Health, Institute of Metabolism and Systems Research (Thangaratinam), University of Birmingham; Birmingham Women's and Children's NHS Foundation Trust (Thangaratinam), Birmingham, UK dr.basselwa@gmail.com.
• CMAJ. 2021 Apr 6; 193 (14): E468-E477.

BackgroundCesarean 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.MethodsWe 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).ResultsWe 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.InterpretationCompared with other types of fetal surveillance, intermittent auscultation seems to reduce emergency cesarean deliveries in labour without increasing adverse neonatal and maternal outcomes.© 2021 Joule Inc. or its licensors.

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