mary have u changed your address? jan
daer mary i sent a lovely couple to you she was
tall and french and he dark and hand some they were all keen on home birth have
they had their yet lots of love jan
----- Original Message -----
Sent: Thursday, September 04, 2003 9:54
AM
Subject: [ozmidwifery] fetal
monitoring
References from
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20030826-33# Revisiting the use of the
electronic fetal monitor - Lancet , vol 361, no 9356, February 2003,
pp 445-446 Thacker SB; Stroud DF - (February
2003) |
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Concerns
about the efficacy and safety of routine electronic fetal
monitoring in labour have led expert panels in the USA and
Canada(1,2) to recommend that such monitoring be limited to
high-risk pregnancies. The latest systematic review supports
that concern;(3) yet, the use of electronic fetal monitoring
in low-risk pregnancies continues to expand globally. The
identification of high-risk pregnancies that would benefit
from the use of electronic fetal monitoring during labour
remains an important research issue. In this issue of The
Lancet, Lawrence Impey and colleagues report the results of
a randomised controlled trial that assessed the efficacy of
admission cardiotocography for 8580 low-risk women in labour
as measured by reductions in the rate of neonatal and
maternal morbidity and mortality. Like the 1985 trial from
the same institution that assessed the efficacy of
intrapartum fetal monitoring,(4) this study is carefully
designed and well conducted. Taken together with similar
findings from the only other reported trial of this
intervention,(5) the conclusion that routine use of
cardiotocography for 20 minutes on admission to the delivery
ward does not improve neonatal outcome is reasonable.
Several aspects of the Impey report deserve comment. The
investigators were very careful in the implementation of
their trial. Randomisation of women to the treatment or
control group was blinded and statistically based. The
authors used an appropriate intention-to-treat analysis and
prespecified any subgroup analyses. Non-parametric methods
were used appropriately when data failed to satisfy Gaussian
assumptions. The analysis examined the effect of changing
the method of randomisation during the trial. One concern
about the study design is that the power calculation assumed
a 50% reduction in risk, whereas practitioners might find a
25% reduction clinically meaningful. This issue, along with
difficulties in generalising to other populations from two
trials (the Impey study and Mires et al(5)) done in
populations at similar risk, may mean that further trials
are still warranted. The finding that there was no increase
in caesarean delivery rate, for example, could relate to a
low rate of caesarean delivery at this hospital compared
with other institutions. The study by Impey and colleagues
provides no evidence that the routine use of
cardiotocography for 20 minutes on admission is effective
for identifying pregnancies that will benefit from
electronic fetal monitoring in labour, but additional
trials, particularly among high-risk populations, might
allow a meta-analysis so that as much could be known about
the value of admission cardiotocography as about EFM during
labour.(3) It is important to explore new and better uses of
technologies in medicine. However, technology must not be
allowed to diffuse unchecked. The use of electronic fetal
monitoring in low-risk pregnancies is of limited
effectiveness and carries an increased risk of interventions
including instrumental delivery, caesarean delivery,
augmentation of labour, and epidural anaesthesia.(3) The
lessons learnt too slowly from the experience with
electronic fetal monitoring are relevant for admission
cardiotocography.(6) Increased information on admission will
not necessarily lead to better clinical outcomes. New
technologies must be evaluated before their widespread
implementation and randomised trials are critical to a valid
assessment of a screening technology such as admission
cardiotocography. Even the best trials have limitations, if
only in generalisability. Sometimes the best studies are
done in settings that are not readily transferable to other
places because of differences in resources or
characteristics of the study population. Systematic reviews
and cumulative meta-analyses can help to address the
limitations of single trials. The extent of use of admission
cardiotocography is not well documented, but widespread use
of admission cardiotocography should be discouraged until
better evidence from randomised trials that examine efficacy
and safety in populations that are likely to benefit, is
available. (6 references) (Author)
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