Guidelines highlight gaps in research evidence

EDITOR—The clinical effectiveness support unit of the Royal College of Obstetricians and Gynaecologists has recently developed the guideline of the National Institute for Clinical Excellence (NICE) on the use of electronic fetal monitoring.1 One of the potential benefits of guidelines is to highlight gaps in research evidence. As part of the guideline development process we conducted a survey of maternity units in England and Wales to evaluate the current use of electronic fetal monitoring in intrapartum care.2

The guideline recommends that in women who are healthy and have an uncomplicated pregnancy, intermittent auscultation is a suitable method of monitoring during labour. This recommendation was based on the evidence from nine randomised controlled trials that have enrolled 18 000 and are included in three systematic reviews.1 This conclusion was reached because screening with continuous electronic fetal monitoring should not be conducted in the absence of evidence of benefit. This recommendation will perhaps have a minimal impact in practice as the survey found that only 2.5% of units report using continuous electronic fetal monitoring for all women in labour.

Most maternity units (79%), however, reported using admission cardiotocography in the initial assessment of women who are healthy and have had an otherwise uncomplicated pregnancy. When evaluating the research that exists to support the use of admission tests in populations at low risk we were surprised to find only a single cohort study that addressed this issue; this cohort study included only 1041 women and related admission tests to fetal distress.3 The trial by Mires et al is the first published randomised controlled trial to address this clinically important question. The study is also nearly four times the sample size of previous studies. As such it would have been important to publish this trial irrespective of whether the results …