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Is continuous electronic fetal monitoring useful for all women in labour?

BMJ 2017; 359 doi: https://doi.org/10.1136/bmj.j5423 (Published 05 December 2017) Cite this as: BMJ 2017;359:j5423
  1. Edward Mullins, NIHR academic clinical lecturer, obstetrics and gynaecology1,
  2. Christoph Lees, reader in obstetrics and fetal medicine1 2,
  3. Peter Brocklehurst, professor of women’s health3
  1. 1Imperial College London, London, UK
  2. 2Department of Development and Regeneration, KU Leuven, Belgium
  3. 3Birmingham Clinical Trials Unit, Institute of Applied Health Research, University of Birmingham, Birmingham, UK
  1. Correspondence to: C Lees c.lees{at}imperial.ac.uk, P Brocklehurst p.brocklehurst{at}bham.ac.uk

Routine monitoring of all women would prevent much neonatal morbidity, argue Edward Mullins and Christoph Lees, but Peter Brocklehurst believes that it will increase the risk of harm from unnecessary caesarean sections

Yes— Edward Mullins, Christoph Lees

Electronic fetal monitoring is commonly used during labour to detect fetuses at risk of hypoxia and acidaemia, Interpretation is based on subjective assessment and informed by guidance from the International Federation of Gynaecology and Obstetrics and, in the UK, National Institute for Health and Care Excellence.

A Cochrane review provides clear evidence that neonatal seizures are less common when labour is monitored continuously rather than with intermittent auscultation.1 Such seizures, which most commonly result from a lack of blood flow and oxygen to the brain (neonatal or hypoxic ischaemic encephalopathy),23 occur in around 1.8-3.5/1000 live births and are associated with a range of long term motor and cognitive sequelae. These affect not only the function and educational attainment of the child but also their carers and those funding services to support them.4

Wrong prioritisation

However, in the UK continuous monitoring is used only for women in high risk labour. This is because 13 trials including more than 37 000 women have not provided evidence that that it confers benefit for uncommon outcomes such as perinatal death and cerebral palsy (roughly 3/1000 live births and 1/1000, respectively).1 As less than 20% of cases of cerebral palsy occur in children with acute intrapartum hypoxic events5 and death is uncommon, no randomised controlled trials have examined the effectiveness of intrapartum electronic fetal monitoring in reducing these outcomes. Furthermore, intrapartum monitoring would not be expected to reduce the incidence of cerebral palsy because, contrary to widespread belief, it is rarely linked to intrapartum events.6

We should be focusing on …

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