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Could routine cardiotocography reduce long term cognitive impairment?

BMJ 2011; 342 doi: (Published 31 May 2011) Cite this as: BMJ 2011;342:d3120
  1. Charlotte Dyson, specialist trainee 3 in obstetrics 1,
  2. Topun Austin, consultant in neonatology2,
  3. Christoph Lees, consultant in obstetrics and fetomaternal medicine1
  1. 1Divisions of Fetal-Maternal Medicine, Addenbrooke’s Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge CB2 2QQ, UK
  2. 2Division of Neonatology,Addenbrooke’s Hospital
  1. Correspondence to: Christoph Lees christoph.lees{at}
  • Accepted 18 April 2011

NICE recommends that continuous monitoring of the fetal heart with cardiotocography should be restricted to high risk deliveries. But Charlotte Dyson, Topun Austin, and Christoph Lees disagree

Cardiotocographic monitoring of the fetal heart in labour is standard care in most developed and many developing countries. However, in the UK guidance from the National Institute for Health and Clinical Excellence (NICE) in 2007 recommended replacing it with regular auscultation of the fetal heart in low risk deliveries.1 Cardiotocography is used to detect fetal hypoxia, and although continuous monitoring does not reduce rates of intrapartum death or cerebral palsy, it has been shown to reduce the rate of neonatal seizures.2 These cause considerable long term developmental and cognitive problems. In this paper we argue the case for a randomised controlled trial of intrapartum cardiotocographic monitoring versus regular auscultation to see if the former results in better neurodevelopment outcomes in the infants of low risk women.

Neonatal seizures and hypoxia

Neonatal seizures are common—around 1.8–3.5/1000 live births—although they are poorly classified, often underdiagnosed, and difficult to treat.3 In term infants, neonatal seizures are usually the result of neonatal encephalopathy. This is most commonly caused by lack of blood flow and oxygen to the brain.4 Other causes of neonatal encephalopathy include fetal metabolic disease, infections, drug exposure, and neonatal stroke. About two thirds of neonatal seizures are associated with hypoxic-ischaemic encephalopathy or cerebrovascular disorders.5 6 7

Neonatal seizures are not only closely associated with hypoxic-ischaemic encephalopathy, but are independently associated with worse neurodevelopmental outcome. Children who had had neonatal seizures had worse motor and cognitive outcomes at age 4 years compared with children with hypoxic-ischaemic encephalopathy who did not have seizures after …

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