WHO recommendations:
Intrapartum care for a
positive childbirth experience
Web annex. Evidence base
WHO recommendations:
Intrapartum care for a
positive childbirth experience
Web annex. Evidence base
WHO/RHR/18.04
© World Health Organization 2018
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Contents
Abbreviations vi
3.1 Care throughout labour and birth 1
EB Table 3.1.1 Respectful maternity care (RMC) 1
Comparison: RMC intervention compared with usual practice (no RMC intervention) 1
EB Table 3.1.2 Effective communication 6
Comparison: Effective communication by health care staff compared with usual practice 6
EB Table 3.1.3 Companionship during labour and childbirth 9
Comparison: Companionship during labour and childbirth compared with usual practice 9
Companionship during labour and childbirth – subgroup analysis according to the type of support person 11
3.2 First stage of labour 14
EB Table 3.2.3 Progress of the first stage of labour 14
i. Cervical dilatation patterns in women with normal perinatal outcomes – nulliparous women 14
ii. Cervical dilatation patterns in women with normal perinatal outcomes – parous women 16
EB Table 3.2.4 Labour ward admission policy 17
Comparison: Delaying admission compared with direct admission to the labour ward 17
EB Table 3.2.5 Clinical pelvimetry on admission 18
Comparison: Routine clinical pelvimetry compared with no pelvimetry 18
EB Table 3.2.6 Routine assessment of fetal wellbeing on labour admission 19
Comparison: Cardiotocography (CTG) compared with auscultation on labour admission 19
EB Table 3.2.10 Continuous cardiotocography (CTG) during labour 21
Comparison: Continuous cardiotocography (CTG) compared with intermittent auscultation (IA) 21
EB Table 3.2.11 Intermittent fetal heart rate auscultation 22
Comparison 1: Intermittent monitoring with Doppler ultrasound device compared with routine Pinard fetal stethoscope 22
Comparison 2: Intermittent cardiotocography (CTG) compared with routine Pinard fetal stethoscope 24
Comparison 3: “Strict” (or intensive) monitoring compared with “routine” monitoring with Pinard fetal stethoscope 26
EB Table 3.2.12 Epidural analgesia for pain relief 28
Comparison 1: Any epidural analgesia compared with placebo or no epidural analgesia 28
Comparison 2: Epidural analgesia compared with parenteral opioid analgesia 31
EB Table 3.2.13 Opioid analgesia for pain relief 34
Comparison 1: Parenteral opioids compared with placebo or no opioids 34
Comparison 1.a. Pethidine intramuscular (IM) compared with placebo 34
Comparison 1.b. Pethidine (intravenous [IV]) compared with placebo 36
Comparison 1.c. Pentazocine intramuscular (IM) compared with placebo 37
Comparison 1.d. Tramadol intramuscular (IM) compared with no analgesia 38
Comparison 2: Parenteral opioids (various types) compared with pethidine 39
Comparison 2.a. Meptazinol intramuscular (IM) compared with pethidine (IM) 39
Comparison 2.b. Tramadol intramuscular (IM) compared with pethidine (IM) 42
Comparison 2.c. Tramadol intramuscular (IM) with triflupromazine compared with pethidine (IM) with triflupromazine 44 Comparison 2.d(i). Morphine or diamorphine intramuscular (IM) compared with pethidine (IM) 45 Comparison 2.d(ii). Diamorphine intramuscular (IM) plus prochlorperazine compared with pethidine plus prochlorperazine 47
Comparison 2.e. Dihydrocodeine intramuscular (IM) compared with pethidine (IM) 49
Comparison 2.f. Pentazocine intramuscular (IM) compared with pethidine (IM) 50
Comparison 2.g. Nalbuphine intramuscular (IM) compared with pethidine (IM) 52
Comparison 2.h. Phenazocine intramuscular (IM) compared with pethidine (IM) 54
Comparison 2.i. Butorphanol intramuscular (IM) compared with pethidine (IM) 55
Comparison 2.j. Fentanyl intravenous (IV) compared with pethidine (IV) 56
Comparison 2.k. Nalbuphine intravenous (IV) compared with pethidine (IV) 58
Comparison 2.l. Phenazocine intravenous (IV) compared with pethidine (IV) 59
Comparison 2.m. Butorphanol intravenous (IV) compared with pethidine (IV) 60
Comparison 2.n. Morphine intravenous (IV) compared with pethidine (IV) 62
Comparison 2.o. Alphaprodine intravenous (IV) compared with pethidine (IV) 63
Comparison 2.p. Patient-controlled analgesia (PCA) pentazocine compared with PCA pethidine 64
Comparison 2.q. Patient-controlled analgesia (PCA) remifentanil compared with PCA pethidine 66
Comparison 2.r. Patient-controlled analgesia (PCA) nalbuphine compared with PCA pethidine 68
Comparison 2.s. Patient-controlled analgesia (PCA) fentanyl compared with PCA pethidine 69 Comparison 2.t. Patient-controlled analgesia (PCA) (intramuscular [IM]) meptazinol compared with PCA (IM) pethidine 71
EB Table 3.2.14 Relaxation techniques for pain management 72
Comparison 1: General relaxation techniques compared with usual care (no relaxation techniques) 72
Comparison 2: Yoga techniques compared with control (no yoga techniques) 74
Comparison 3: Music compared with usual care (no music) 75
Comparison 4: Audio-analgesia compared with control 76
Comparison 5: Mindfulness training compared with control (no mindfulness training) 77
EB Table 3.2.15 Manual techniques for pain management 78
Comparison 1: Massage techniques compared with usual care (no massage) 78
Comparison 2: Warm pack compared with usual care (no warm packs) 80
3.3 Second stage of labour 81
EB Table 3.3.2 Birth position for women without epidural analgesia 81
Comparison: Upright position compared with recumbent position in the second stage of labour without epidural analgesia 81
EB Table 3.3.3 Birth position for women with epidural analgesia 84
Comparison: Upright position compared with recumbent position in the second stage of labour for women with epidural analgesia 84
EB Table 3.3.4 Method of pushing 86
Comparison: Spontaneous pushing compared with directed pushing 86
EB Table 3.3.5 Method of pushing for women with epidural analgesia 88
Comparison: Delaying pushing compared with immediate pushing in women with epidural analgesia 88
EB Table 3.3.6 Techniques for preventing perineal trauma 90
Comparison 1: Perineal massage compared with control (“hands off” or usual care) 90
Comparison 2: Warm perineal compress compared with control (“hands off” or usual care) 91
Comparison 3: “Hands-off” compared with “hands-on” perineum approach 92
Comparison 4: Ritgen’s manoeuvre compared with usual practice (“hands-on” approach) 93
EB Table 3.3.7 Episiotomy policy 94
Comparison: Policy of selective/restrictive compared with routine or liberal use of episiotomy 94
EB Table 3.3.8 Fundal pressure 96
Abbreviations
aOR adjusted odds ratio CI confidence interval
cRCT cluster-randomized controlled trial CTG cardiotocography
EB evidence base
GRADE Grading of Recommendations Assessment, Development and Evaluation IA intermittent auscultation
IM intramuscular IV intravenous MD mean difference
mMISS-21 modified 21-item Medical Interview Satisfaction Scale n/a not applicable
PCA patient-controlled analgesia PPH postpartum haemorrhage RCT randomized controlled trial RMC respectful maternity care RR risk ratio
SMD standardized mean difference
3.1 Care throughout labour and birth
EB Table 3.1.1: Respectful maternity care (RMC)
Comparison: RMC intervention compared with usual practice (no RMC intervention)
Source: Downe S, Lawrie TA, Finlayson K, Oladapo OT. Effectiveness of respectful care policies for women using intrapartum care services. Reprod Health. 2018 (in press).
Outcome
Quality assessment1 No. of participants
Relative effect2 Certainty
(GRADE) Importance Design
(no. of studies) Risk of bias3 Inconsistency Indirectness Imprecision RMC policy Usual practice Birth experience
Respectful
care cluster-
randomized controlled trial (cRCT) (1) observational (2)
serious: cRCT had two arms only; other data were from observational studies
not serious not serious not serious 2983 (total no.
for RCT) 149 and 2469 (observational)
2983 (total no.
for RCT) 70 and 2000 (observational)
The effect estimate for the cRCT was aOR 3.44 (2.45–
4.84).
Both observational studies showed higher ratings of
”respect” in the RMC arms (22.8% vs 0% in one study and 94.7% vs 89.7% in the other study).
㊉㊉㊉㊀
MODERATE critical
Satisfaction (very satisfied with birth)
cRCT (1) observational (1)
serious: cRCT had two arms only; other data were from observational study
not serious not serious serious: wide range of effect across the two studies
2983 (total no.
for RCT) 149
(observational)
2983 (total no.
for RCT) 70
(observational)
The effect estimate for the cRCT was aOR 0.98 (0.91–
1.06). The observational study showed higher satisfaction with RMC (75.8%) than control (12.9%).
㊉㊉㊀㊀
LOW critical
Good quality of care (rated good or excellent)
cRCT (1) observational (1)
serious: cRCT had two arms only; other data were from an observational study
not serious not serious not serious 2983 (total no.
for RCT) 149
(observational)
2983 (total no.
for RCT) 70
(observational)
The effect estimate for the cRCT was aOR 6.19 (4.29–
8.94). The observational study also showed higher rating of quality of care with 63.1%
vs 2.9% in RMC and control reporting this outcome.
㊉㊉㊉㊀
MODERATE critical
1 Publication bias could not be assessed due to few included studies.
2 A single pooled estimate is not available and only a narrative synthesis of the evidence was provided in the review.
Outcome
Quality assessment1 No. of participants
Relative effect2 Certainty
(GRADE) Importance Design
(no. of studies) Risk of bias3 Inconsistency Indirectness Imprecision RMC policy Usual practice Experience of mistreatment
Any disrespectful or abusive care
cRCT (1) observational (2)
serious: cRCT had two arms only; other data were from observational studies
not serious not serious not serious 2983 (total no.
for RCT) 149 and 728 (observational)
2983 (total no.
for RCT) 64 and 641 (observational)
The effect estimate for the cRCT was aOR 0.34 (95% CI: 0.21–0.58) (3.2%
vs 15.8% in RMC and control, respectively). The observational studies showed similar substantial reductions – 1 study from 70% to 18%
and the other reporting an aOR of 0.6 (95% CI:
0.4–0.8) and rates of 13.2%
vs 20.1% for RMC and control, respectively).
㊀㊉㊉㊉
MODERATE critical
Non-consent observational
(2) serious: data
were from observational studies
serious:
direction of effect differed across the included studies
not serious serious:
size of effect very different between studies
523 and 359
(observational) 677 and 208
(observational) One study reported an increase [aOR 3.43 (95%
CI: 2.52–4.66)] with the intervention (80% vs 60.6%) and the other reported a reduction from 85.1% to 0%
(all observed events).
㊉㊀㊀㊀
VERY LOW critical
Lack of privacy/
confidential- ity
cRCT (1) observational (2)
serious: cRCT had two arms only; other data were from observational studies
serious:
direction of effect differed across the included studies and there were different measures within studies
not serious serious:
effect size very different between studies and different measures used
various numbers for the different studies and measures
various numbers for the different studies and measures
The effect estimate for the cRCT was aOR 0.25 (95% CI:
0.05–1.23). The observational studies reported various measures with estimates including a range of effects between and within studies.
㊉㊀㊀㊀
VERY LOW critical
1 Publication bias could not be assessed due to few included studies.
2 A single pooled estimate is not available and only a narrative synthesis of the evidence was provided in the review.
3 Assessment of risk of bias: All of the observational studies were assessed as having “serious risk” of bias, due to lack of allocation concealment and blinding, lack of randomization and use of self-reported measures for some or all outcomes. Both cluster-RCTs were also assessed as having “serious risk” of bias, due to lack of allocation concealment and blinding, and use of self-reported measures for some outcomes.
Outcome
Quality assessment1 No. of participants
Relative effect2 Certainty
(GRADE) Importance Design
(no. of studies) Risk of bias3 Inconsistency Indirectness Imprecision RMC policy Usual practice Physical
abuse cRCT (2)
observational (2)
serious: both cRCTs had methodological limitations and other data were observational
not serious not serious not serious 2983 (total no.
for one cRCT) and 1039 for the other cRCT Various numbers were reported in the observational studies for different measures (according to observed or self-reported events and different types of physical abuse).
2983 (total no.
for one cRCT) and 1051 for the other cRCT Various numbers were reported in the observational studies for different measures (according to observed or self-reported events and different types of physical abuse).
The effect estimate for one cRCT was aOR 0.22 (0.05–
0.97). The other cRCT did not report a summary effect but showed an average 50%
reduction in the RMC arm (from average 2% to 1%) and an increase in the control arm.
Reductions in physical abuse were consistently reported across the observational studies for various physical abuse measures.
㊉㊉㊉㊀
MODERATE critical
Verbal abuse cRCT (1) observational (2)
serious: risk cRCT had methodological limitations and other data were observational
not serious not serious serious:
estimates of effect include the possibility of harm
1039 for the cRCT Various numbers were reported in the observational studies for different measures (according to observed or self-reported).
1051 for the cRCT Various numbers were reported in the observational studies for different measures (according to observed or self-reported).
cRCT did not report a summary effect but showed little difference at follow-up in RMC and control arms.
One observational study reported no clear difference (on self-reported and observed measures) and the other showed an absolute reduction of 49%.
㊉㊉㊀㊀
LOW critical
1 Publication bias could not be assessed due to few included studies.
2 A single pooled estimate is not available and only a narrative synthesis of the evidence was provided in the review.
Outcome
Quality assessment1 No. of participants
Relative effect2 Certainty
(GRADE) Importance Design
(no. of studies) Risk of bias3 Inconsistency Indirectness Imprecision RMC policy Usual practice Neglect/
abandonment cRCTs (2) observational (2)
serious: both cRCTs had methodological limitations and other data were observational
not serious not serious serious:
estimates of effect include the possibility of harm
2983 (total no.
for one cRCT) and 1039 for the other cRCT 149 and 728 for observational studies
2983 (total no.
for one cRCT) and 1051 for the other cRCT 64 and 641 for observational studies
Effects differed across studies with one cRCT showing a reduction with RMC [aOR 0.36 (95% CI: 0.19–0.71)]. The other cRCT did not report a summary effect but showed an average 33% increase in the RMC arm (from average 12%
to 16%). One observational study showed a 38% absolute decrease and the other showed no clear difference.
㊉㊉㊀㊀
LOW critical
Non- dignified
care cRCT (1)
observational (1)
serious: cRCT had two arms only; other data were from an observational study
not serious not serious serious:
estimates of effect include the possibility of harm
2983 (total no.) for the cRCT) and
149 for the observational study
2983 (total no.) for the cRCT and 64 for the observational study
The cRCT showed no difference but direction of effect favoured reduction [aOR 0.58 (95% CI 0.30–1.12)]. The observational study showed an overall reduction in non- dignified care (self-reported) from 54% to 5% and also reductions from baseline in 8/9 submeasures of non- dignified care with RMC arm (observed events); those reductions ranged from 13.5%
(mother not told where to go in antenatal ward) to 81.3%
(provider did not introduce themselves).
㊉㊉㊀㊀
LOW critical
Detention observational
(2) serious: data
were from observational studies
serious:
the direction of effect across these two studies differed
not serious serious:
estimates of effect include the possibility of harm
149 and 728 64 and 641 One study showed an absolute decrease of 1% and the other study showed an increase [aOR 1.28 (95% CI: 0.93–
1.76)].
㊉㊀㊀㊀
VERY LOW critical
1 Publication bias could not be assessed due to few included studies.
2 A single pooled estimate is not available and only a narrative synthesis of the evidence was provided in the review.
3 Assessment of risk of bias: All of the observational studies were assessed as having “serious risk” of bias, due to lack of allocation concealment and blinding, lack of randomization and use of self-reported measures for some or all outcomes. Both cluster-RCTs were also assessed as having “serious risk” of bias, due to lack of allocation concealment and blinding, and use of self-reported measures for some outcomes.
Outcome
Quality assessment1 No. of participants
Relative effect2 Certainty
(GRADE) Importance Design
(no. of studies) Risk of bias3 Inconsistency Indirectness Imprecision RMC policy Usual practice Clinical outcomes
Perineal/
vaginal trauma
cRCT (1) serious:
data from observational study
not serious not serious serious:
only one study 1039 1051 This study showed a reduction in episiotomy at follow up (mean rate of 21% at RMC sites vs 39% at control sites;
P = 0.02).
㊉㊉㊀㊀
LOW critical
aOR: adjusted odds ratio; CI: confidence interval; cRCT: cluster-randomized controlled trial
1 Publication bias could not be assessed due to few included studies.
2 A single pooled estimate is not available and only a narrative synthesis of the evidence was provided in the review.
EB Table 3.1.2: Effective communication
Comparison: Effective communication by health care staff compared with usual practice
Source: Chang YS, Coxon K, Portela AG, Furuta M, Bick D. Interventions to support effective communication between maternity care staff and women in labour: a mixed methods systematic review. Midwifery. 2017;59:4–16.
Quality assessment No. of participants
Effect Certainty
(GRADE) Importance Outcome Study design
(no. of
studies) Risk of bias Inconsistency Indirectness Imprecision Other
considerations Intervention Control Training doctors in communication skills compared with no training
Birth experience – satisfaction
stepped- wedge cluster- randomized controlled trial (cRCT) (1)
very seriousa not applicable
(n/a)b not serious seriousc none 1000 1000 The mean modified 21-
item Medical Interview Satisfaction Scale (MISS-21) average score in the intervention groups was 0.22 lower (95% CI:
-0.28–0.16)
㊉㊀㊀㊀
VERY LOW critical
Any obstetric emergency training: before intervention compared with after intervention Birth
experience – perception of respect
RCT (1) seriousd n/ab very seriouse seriousc none post-training:
• 24 for postpartum haemor- rhage (PPH)/
eclampsia
• 132 for shoulder dystocia
pre-training:
• 23 for PPH/
eclampsia
• 139 for shoulder dystocia
The mean patient-actor perception scores in post- training were 0.5 higher for both the postpartum haemorrhage (PPH) scenario (P = 0.007) and the eclampsia scenario (P = 0.005), and 0.6 higher for shoulder dystocia (P < 0.001) (95% CI: not reported)
㊉㊀㊀㊀
VERY LOW critical
Birth experience – perception of safety
RCT (1) seriousd n/ab very seriouse seriousc none post-training:
• 24 for PPH/
eclampsia
• 132 for shoulder dystocia
pre-training:
• 23 for PPH/
eclampsia
• 139 for shoulder dystocia
The mean patient-actor perceptions scores in post- training was 0.8 higher for both PPH and shoulder dystocia scenarios (P < 0.001) and 1.0 higher for eclampsia (P < 0.001) (95% CI: not reported)
㊉㊀㊀㊀
VERY LOW critical
Quality assessment No. of participants
Effect Certainty
(GRADE) Importance Outcome Study design
(no. of
studies) Risk of bias Inconsistency Indirectness Imprecision Other
considerations Intervention Control Perception of
communica- tion
RCT (1) seriousd n/ab very seriouse seriousc none post-training:
• 24 for PPH/
eclampsia
• 132 for shoulder dystocia
pre-training:
• 23 for PPH/
eclampsia
• 139 for shoulder dystocia
The mean patient-actor perceptions scores in post- training was 0.7 higher for both PPH and eclampsia scenarios (P = 0.005), and 0.5 higher for shoulder dystocia (P < 0.001) (95% CI: not reported)
㊉㊀㊀㊀
VERY LOW critical
Obstetric emergency training at the local hospital compared with obstetric emergency training at central simulation centre Birth
experience – perception of respect
RCT (1) not serious n/ab very seriouse seriousc none • 12 for PPH/
eclampsia
• 64 for shoulder dystocia
• 12 for PPH/
eclampsia
• 68 for shoulder dystocia
PPH: P = 0.077 eclampsia: P = 0.14 shoulder dystocia:
P = 0.719
(mean difference, 95% CI:
not reported)
㊉㊀㊀㊀
VERY LOW critical
Birth experience – perception of safety
RCT (1) not serious n/ab very seriouse seriousc none • 12 for PPH/
eclampsia
• 64 for shoulder dystocia
• 12 for PPH/
eclampsia
• 68 for shoulder dystocia
PPH: P = 0.048 eclampsia: P = 0.214 shoulder dystocia:
P = 0.532
(mean difference, 95% CI:
not reported)
㊉㊀㊀㊀
VERY LOW critical
Birth experience – perception of communica- tion
RCT (1) not serious n/ab very seriouse seriousc none • 12 for PPH/
eclampsia
• 64 for shoulder dystocia
• 12 for PPH/
eclampsia
• 68 for shoulder dystocia
PPH: P = 0.035 eclampsia: P = 0.071 shoulder dystocia:
P = 0.502
(mean difference, 95% CI:
not reported)
㊉㊀㊀㊀
VERY LOW critical
Clinical training plus teamwork training compared with clinical training only Birth
experience – perception of respect
RCT (1) not serious n/ab very seriouse seriousc none • 12 for PPH/
eclampsia
• 66 for shoulder dystocia
• 12 for PPH/
eclampsia
• 66 for shoulder dystocia
PPH: P = 0.899 eclampsia: P = 0.521 shoulder dystocia:
P = 0.82
(mean difference, 95% CI:
not reported)
㊉㊀㊀㊀
VERY LOW critical
Birth experience – perception of safety
RCT (1) not serious n/ab very seriouse seriousc none • 12 for PPH/
eclampsia
• 66 for shoulder dystocia
• 12 for PPH/
eclampsia
• 66 for shoulder dystocia
PPH: P = 0.147 eclampsia: P = 0.849 shoulder dystocia: P = 0.68
(mean difference, 95% CI:
㊉㊀㊀㊀
VERY LOW critical
Quality assessment No. of participants
Effect Certainty
(GRADE) Importance Outcome Study design
(no. of
studies) Risk of bias Inconsistency Indirectness Imprecision Other
considerations Intervention Control Birth
experience – perception of communica- tion
RCT (1) not serious n/ab very seriouse seriousC none • 12 for PPH/
eclampsia
• 66 for shoulder dystocia
• 12 for PPH/
eclampsia
• 66 for shoulder dystocia
PPH: P = 0.686 eclampsia: P = 0.626 shoulder dystocia:
P = 0.82
(mean difference, 95% CI:
not reported)
㊉㊀㊀㊀
VERY LOW critical
CI: confidence interval; cRCT: cluster-randomized controlled trial; PPH: postpartum haemorrhage.
a Downgraded by two levels to serious because information was from a single study with a high risk of bias.
b Not applicable because only one study contributed to this outcome.
c Downgraded by one level to “serious” – only one study contributed to this outcome.
d Downgraded by one level to “serious” – although the study design was RCT, for this outcome, the study did a before-and-after comparison within a group.
e Downgraded by two levels to “very serious” – measured using acted patients (an experienced midwife), which may not reflect real women’s perspectives. Also, outcomes were measured using one statement:
“I felt well informed due to good communication”, which is not a validated measure, and differences in scores before and after the intervention may not accurately reflect clinically significant change.
EB Table 3.1.3: Companionship during labour and childbirth
Comparison: Companionship during labour and childbirth compared with usual practice
Source: Bohren MA, Hofmeyr G, Sakala C, Fukuzawa RK, Cuthbert A. Continuous support for women during childbirth. Cochrane Database Syst Rev. 2017;(7):CD003766.
Quality assessment No. of participants Effect
Certainty
(GRADE) Importance No. of
studies Study design Risk of bias Inconsistency Indirectness Imprecision Other considerations
Companionship during labour and childbirth
Usual
practice Relative
(95% CI) Absolute (95% CI) Spontaneous vaginal birth
21 RCTs seriousa not serious not serious not serious publication bias strongly
suspectedb
5092/7153
(71.2%) 4898/7216
(67.9%) RR 1.08
(1.04–1.12) 54 more per 1000 (from 27 more to 81
more)
㊉㊉◯◯
LOW critical
Caesarean birth
24 RCTs not serious not serious seriousa not serious publication bias strongly
suspectedb
948/7663
(12.4%) 1120/7684
(14.6%) RR 0.75
(0.64–0.88) 36 fewer per 1000 (from 17 fewer to 52
fewer)
㊉㊉◯◯
LOW critical
Instrumental vaginal birth
19 RCTs not serious not serious seriousa not serious publication bias strongly
suspectedb
1283/7028
(18.3%) 1420/7090
(20.0%) RR 0.90
(0.85–0.96) 20 fewer per 1000 (from 8 fewer
to 30 fewer)
㊉㊉◯◯
LOW
critical
Perineal trauma
4 RCTs not serious not serious seriousc not serious none 2339/4057
(57.7%) 2396/4063
(59.0%) RR 0.97
(0.92–1.01) 18 fewer per 1000 (from 6 more
to 47 fewer)
㊉㊉㊉◯
MODERATE critical
Labour length
13 RCTs not serious not serious not serious not serious publication bias strongly
suspectedb
2732 2697 – MD 0.69
lower (1.04 lower to
0.34 lower)
㊉㊉㊉◯
MODERATE critical
Any analgesia/anaesthesia
15 RCTs not serious not serious seriousa not serious publication bias strongly
suspectedb
4455/6173
(72.2%) 4699/6260
(75.1%) RR 0.90
(0.84–0.96) 75 fewer per 1000 (from 30 fewer to 120
㊉㊉◯◯
LOW critical
Quality assessment No. of participants Effect
Certainty
(GRADE) Importance No. of
studies Study design Risk of bias Inconsistency Indirectness Imprecision Other considerations
Companionship during labour and childbirth
Usual
practice Relative
(95% CI) Absolute (95% CI) Regional analgesia/anaesthesia
9 RCTs not serious seriousc seriousa not serious none 3760/5727
(65.7%) 3959/5717
(69.2%) RR 0.93
(0.88–0.99) 48 fewer per 1000 (from 7 fewer
to 83 fewer)
㊉㊉◯◯
LOW critical
Synthetic oxytocin during labour
17 RCTs not serious not serious seriousa not serious publication bias strongly
suspectedb
2375/6383
(37.2%) 2343/6450
(36.3%) RR 0.97
(0.91–1.03) 11 fewer per 1000 (from 11 more
to 33 fewer)
㊉㊉◯◯
LOW critical
Negative rating of/negative feelings about birth experience
11 RCTs not serious not serious not serious not serious publication bias strongly
suspectedb
653/5583
(11.7%) 982/5550
(17.7%) RR 0.69 (0.59–0.79)
55 fewer per 1000 (from 37 fewer
to 73 fewer)
㊉㊉㊉◯
MODERATE critical
Postpartum report of severe labour pain
4 RCTs not serious seriousc not serious not serious none 532/1223
(43.5%) 516/1233
(41.8%) RR 1.00 (0.83–1.21)
0 fewer per 1000 (from 71 fewer
to 88 more)
㊉㊉㊉◯
MODERATE critical
Low 5-minute Apgar score
14 RCTs seriousd not serious not serious not serious none 62/6327 (1.0%) 99/6288
(1.6%) RR 0.62
(0.46–0.85) 6 fewer per 1000 (from 2 fewer
to 9 fewer)
㊉㊉㊉◯
MODERATE critical
Exclusive or any breastfeeding at any time point, as defined by trial authors
4 RCTs not serious seriousc seriousa not serious none 1707/2855
(59.8%) 1639/2729
(60.1%) RR 1.05 (0.96–1.16)
30 more per 1000 (from 24 fewer to 96
more)
㊉㊉◯◯
LOW critical
CI: confidence interval; MD: mean difference; RCT: randomized controlled trial; RR: risk ratio. RR: relative risk.
a Hodnett 2002 included high-risk pregnancies.
b Evident asymmetry in funnel plot with at least 10 studies.
c Severe, unexplained heterogeneity (I2 ≥ 60% or Chi2 < 0.05).
d Most of the pooled effect derived from studies with moderate or high risk of bias but without a substantial proportion (i.e. < 50%) from studies with high risk of bias.
e Most of the pooled effect derived from studies with moderate or high risk of bias but with a substantial proportion (i.e. > 50%) from studies with high risk of bias.
f The CI is imprecise.
Companionship during labour and childbirth – subgroup analysis according to the type of support person
Quality assessment No. of participants Effect
Certainty
(GRADE) Importance No. of
studies Study
design Risk of bias Inconsistency Indirectness Imprecision Other
considerations Companionship
during labour Usual
practice Relative
(95% CI) Absolute (95% CI) Spontaneous vaginal birth – support people were hospital staff
9 RCTs seriousa not serious seriousb not serious none 3818/5418
(70.5%) 3678/5395
(68.2%) RR 1.05
(1.01–1.09) 34 more per 1000 (from 7 more to
61 more)
㊉㊉◯◯
LOW critical
Spontaneous vaginal birth – support people were not hospital staff and were chosen by woman
6 RCTs not serious not serious not serious not serious none 528/808
(65.3%) 504/812
(62.1%) RR 1.04
(0.97–1.11) 25 more per 1000 (from 19 fewer to
68 more)
㊉㊉㊉㊉
HIGH critical
Spontaneous vaginal birth – support people were not hospital staff and not chosen by woman
6 RCTs seriousa seriousc not serious not serious none 783/973
(80.5%) 764/1062
(71.9%) RR 1.15
(1.05–1.26) 108 more per 1000 (from 36 more to
187 more)
㊉㊉◯◯
LOW critical
Caesarean birth – support people were hospital staff
9 RCTs seriousa not serious seriousb not serious none 613/5403
(11.3%) 648/5383
(12.0%) RR 0.94
(0.84–1.05) 7 fewer per 1000 (from 6 more to
19 fewer)
㊉㊉◯◯
LOW critical
Caesarean birth – support people were not hospital staff and were chosen by woman
6 RCTs not serious seriousc not serious seriousf none 160/1029
(15.5%) 200/1030
(19.4%) RR 0.76
(0.50–1.17) 47 fewer per 1000 (from 33 more to
97 fewer)
㊉㊉◯◯
LOW critical
Caesarean birth – support people were not hospital staff and not chosen by woman
9 RCTs seriousa not serious not serious not serious none 175/1231
(14.2%) 272/1271
(21.4%) RR 0.61
(0.45–0.83) 83 fewer per 1000 (from 36 fewer to
118 fewer)
㊉㊉㊉◯
MODERATE critical
Any analgesia/anaesthesia – support people were hospital staff
6 RCTs not serious not serious seriousb not serious none 3624/4574
(79.2%) 3757/4578
(82.1%) RR 0.97
(0.96–0.99) 25 fewer per 1000 (from 8 fewer to
33 fewer)
㊉㊉㊉◯
MODERATE critical
Quality assessment No. of participants Effect
Certainty
(GRADE) Importance No. of
studies Study
design Risk of bias Inconsistency Indirectness Imprecision Other
considerations Companionship
during labour Usual
practice Relative
(95% CI) Absolute (95% CI) Any analgesia/anaesthesia – support people were not hospital staff and were chosen by woman
4 RCTs not serious not serious not serious not serious none 372/704
(52.8%) 405/704
(57.5%) RR 0.93
(0.86–1.01) 40 fewer per 1000 (from 6 more to
81 fewer)
㊉㊉㊉㊉
HIGH critical
Any analgesia/anaesthesia – support people were not hospital staff and not chosen by woman
4 RCTs not serious seriousc not serious seriousf none 401/851 (47.1%) 477/939
(50.8%) RR 0.72
(0.47–1.10) 142 fewer per 1000 (from 51 more to
269 fewer)
㊉㊉◯◯
LOW critical
Synthetic oxytocin during labour – support people were hospital staff
6 RCTs seriousa not serious seriousb not serious none 1795/4786
(37.5%) 1685/4775
(35.3%) RR 1.01
(0.93–1.11) 4 more per 1000 (from 25 fewer to
39 more)
㊉㊉◯◯
LOW critical
Synthetic oxytocin during labour – support people were not hospital staff and were chosen by woman
7 RCTs very seriouse not serious not serious not serious none 501/1092
(45.9%) 533/1099
(48.5%) RR 0.99
(0.96–1.01) 5 fewer per 1000 (from 5 more to
19 fewer)
㊉㊉◯◯
LOW critical
Synthetic oxytocin during labour – support people were not hospital staff and not chosen by woman
4 RCTs seriousc not serious not serious not serious none 79/505 (15.6%) 125/576
(21.7%) RR 0.67
(0.43–1.06) 72 fewer per 1000 (from 13 more to
124 fewer)
㊉㊉㊉◯
MODERATE critical
Negative rating of/negative feelings about birth experience – support people were hospital staff
4 RCTs seriousa not serious seriousb not serious none 225/4106
(5.5%) 256/4039
(6.3%) RR 0.87
(0.73–1.03) 8 fewer per 1000 (from 2 more to
17 fewer)
㊉㊉◯◯
LOW critical
Negative rating of/negative feelings about birth experience – support people were not hospital staff and were chosen by woman
4 RCTs not serious not serious not serious not serious none 245/833
(29.4%) 453/875
(51.8%) RR 0.58
(0.50–0.67) 217 fewer per 1000 (from 171 fewer
to 259 fewer)
㊉㊉㊉㊉
HIGH critical
Quality assessment No. of participants Effect
Certainty
(GRADE) Importance No. of
studies Study
design Risk of bias Inconsistency Indirectness Imprecision Other
considerations Companionship
during labour Usual
practice Relative
(95% CI) Absolute (95% CI) Negative rating of/negative feelings about birth experience – support people were not hospital staff and not chosen by woman
3 RCTs not serious not serious not serious not serious none 183/665
(27.5%) 273/660
(41.4%) RR 0.65
(0.53–0.80) 145 fewer per 1000 (from 83 fewer to
194 fewer)
㊉㊉㊉㊉
HIGH critical
Postpartum depression – support people were hospital staff
1 RCT not serious not serious seriousb not serious none 245/2816
(8.7%) 277/2751
(10.1%) RR 0.86
(0.73–1.02) 14 fewer per 1000 (from 2 more to
27 fewer)
㊉㊉㊉◯
MODERATE critical
Postpartum depression – support people were not hospital staff and not chosen by woman
1 RCT seriousa not serious not serious seriousd none 8/74 (10.8%) 48/75
(64.0%) RR 0.17
(0.09–0.33) 531 fewer per 1000 (from 429 fewer
to 582 fewer)
㊉㊉◯◯
LOW critical
Postpartum depression – support people were not hospital staff and were chosen by woman
0 not
applicable (n/a)
n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a critical
Exclusive or any breastfeeding at any time point, as defined by trial authors – support people were hospital staff
1 RCT not serious not serious seriousb not serious none 1312/2339
(56.1%) 1283/2220
(57.8%) RR 0.97
(0.92–1.02) 17 fewer per 1000 (from 12 more to
46 fewer)
㊉㊉㊉◯
MODERATE critical
Exclusive or any breastfeeding at any time point, as defined by trial authors – support people were not hospital staff and were chosen by woman
0 n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a
Exclusive or any breastfeeding at any time point, as defined by trial authors – support people were not hospital staff and not chosen by woman
3 RCTs not serious not serious not serious seriousf none 395/516
(76.6%) 356/509
(69.9%) RR 1.11
(0.98–1.26) 77 more per 1000 (from 14 fewer to
182 more)
㊉㊉㊉◯
MODERATE critical
CI: confidence interval; n/a: not applicable; RCT: randomized controlled trial; RR: risk ratio.
a Most of the pooled effect derived from studies with moderate or high risk of bias but without a substantial proportion (i.e. < 50%) from studies with high risk of bias.
b Hodnett 2002 included high-risk pregnancies.
c Severe, unexplained, heterogeneity (I2 ≥ 60% or Chi2 < 0.05).
3.2 First stage of labour
EB Table 3.2.3: Progress of the first stage of labour
i. Cervical dilatation patterns in women with normal perinatal outcomes – nulliparous women
Source: Oladapo OT, Diaz V, Bonet M, Abalos E, Thwin SS, Souza H, et al. Cervical dilatation patterns of “low-risk” women with spontaneous labour and normal perinatal outcomes: a systematic review. BJOG. 2017. doi:10.1111/1471-0528.14930.
Quality assessment
No. of participants
Pooled estimate
Certainty
(GRADE) Importance
No. of
studies Study design Risk of bias Inconsistency Indirectness Imprecision Other
considerations Median
(95% CI) Time (in hours) to progress from 2–3 cm
3 observational
studiesa seriousb seriousc not seriousd not seriouse nonef 4622 median 5.28
(5.07–5.46) ㊉㊉◯◯
LOW critical
Time (in hours) to progress from 3–4 cm 6 observational
studiesa not seriousg not serioush not seriousd not seriousi nonef 42 648 median 2.00
(1.89–2.11) ㊉㊉㊉㊉
HIGH critical
Time (in hours) to progress from 4–5 cm 6 observational
studiesa not seriousg not serioush not seriousd not seriousi nonef 42 648 median 1.46
(1.39–1.52)
㊉㊉㊉㊉
HIGH critical
Time (in hours) to progress from 5–6 cm 6 observational
studiesa not seriousg not serioush not seriousd not seriousi nonef 42 648 median 0.92
(0.89 to 0.96) ㊉㊉㊉㊉
HIGH critical
Time (in hours) to progress from 6–7 cm 6 observational
studiesa not seriousg not serioush not seriousd not seriousi nonef 42 648 median 0.70
(0.68–0.73) ㊉㊉㊉㊉
HIGH critical
Time (in hours) to progress from 7–8 cm 6 observational
studiesa not seriousg not serioush not seriousd not seriousi nonef 42 648 median 0.55
(0.53–0.57) ㊉㊉㊉㊉
HIGH critical
Time (in hours) to progress from 8–9 cm 5 observational
studiesa not seriousj not seriousk not seriousd not seriousi nonef 40 482 median 0.52
(0.50–0.53) ㊉㊉㊉㊉
HIGH critical
Quality assessment
No. of participants
Pooled estimate
Certainty
(GRADE) Importance
No. of
studies Study design Risk of bias Inconsistency Indirectness Imprecision Other
considerations Median
(95% CI) Time (in hours) to progress from 9–10 cm
5 observational
studiesa not seriousj not seriousk not seriousd not seriousi nonef 40 482 median 0.49
(0.48–0.51) ㊉㊉㊉㊉
HIGH critical
a Observational studies reporting on labour assessments of cervical dilatation patterns over time are considered as being of high quality.
b Two studies providing data for 76% of the participants in the three studies included were at moderate risk of bias. Risk of bias was assessed using the following domains specifically developed for the systematic review: primary intent of the study research question; representativeness of the study population; ascertainment and temporality of observations; adequacy of data points for valid assessment of cervical dilatation patterns for each study participant; use of a valid and robust approach for analysis of labour progression and construction of labour curve.
c The magnitude of the medians was consistent in two studies. However, the third study with inconsistent median had over 50% of the participants contributing data to the pooled estimate.
d The women, the method of cervical dilatation assessment and the statistical analytical approach for labour progression in the three studies all provide direct evidence against the question at hand.
e The lower and upper confidence bounds are both within 0.2 hours of the pooled median time. The total number of women in each study was more than 1000.
f We did not strongly suspect publication bias because the search for the studies was comprehensive.
g Four out of the six studies with over 90% of study participants contributing data to the pooled median were at low risk of bias.
h The magnitude of the medians was consistent in five out of the six studies. The outlier presents 5.6% of the total number of participants contributing to the pooled median.
i The lower and upper confidence bounds are both within 0.1 hour of the pooled median time. The total number of women in each study was more than 1000.
j Three out of five studies with 86% of the total number of participants contributing to the pooled median were at low risk of bias.
k The magnitude of the median was consistent in all five studies contributing to the pooled estimate.
ii. Cervical dilatation patterns in women with normal perinatal outcomes – parous women
Source: Oladapo OT, Diaz V, Bonet M, Abalos E, Thwin SS, Souza H, et al. Cervical dilatation patterns of “low-risk” women with spontaneous labour and normal perinatal outcomes: a systematic review. BJOG. 2017. doi:10.1111/1471-0528.14930.
Quality assessment
No. of particpants
Pooled estimate
Certainty
(GRADE) Importance No. of
studies Study design Median
(5th to 95th centile) Inconsistency Indirectness Imprecision Other
considerations Median
(95% CI) Time (in hours) to progress from 3–4 cm
1 observational
studya seriousb not seriousc not seriousd seriouse nonef 3440 median 2.38
(1.41–2.99) ㊉㊉◯◯
LOW critical
Time (in hours) to progress from 4–5 cm 3 observational
studiesa not seriousg not serioush not seriousd not seriousi nonef 56 823 median 1.17
(1.15–1.18) ㊉㊉㊉㊉
HIGH critical Time (in hours) to progress from 5–6 cm
3 observational
studiesa not seriousg not serioush not seriousd not seriousi nonef 56 823 median 0.67
(0.66–0.67) ㊉㊉㊉㊉
HIGH critical
Time (in hours) to progress from 6–7 cm 3 observational
studiesa not seriousg not seriousj not seriousd not seriousi nonef 56 823 median 0.44
(0.43–0.44)
㊉㊉㊉㊉
HIGH critical
Time (in hours) to progress from 7–8 cm 3 observational
studiesa not seriousg not seriousk not seriousd not seriousi nonef 56 823 median 0.35
(0.34–0.35) ㊉㊉㊉㊉
HIGH critical Time (in hours) to progress from 8–9 cm
2 observational
studiesa not serious not seriousj not seriousd not seriousi nonef 53 383 median 0.28
(0.27–0.28) ㊉㊉㊉㊉
HIGH critical
Time (in hours) to progress from 9–10 cm 2 observational
studiesa not serious not seriousj not seriousd not seriousi nonef 53 383 median 0.27
(0.26–0.27) ㊉㊉㊉㊉
HIGH critical
a Observational studies reporting on labour assessments of cervical dilatation patterns over time are considered as being of high quality.
b The study providing data was at moderate risk of bias. Risk of bias was assessed using the following domains specifically developed for the systematic review: primary intent of the study research question;
representativeness of the study population; ascertainment and temporality of observations; adequacy of data points for valid assessment of cervical dilatation patterns for each study participants; use of a valid and robust approach for analysis of labour progression and construction of labour curve.
c The magnitude of the medians was consistent in women with parity = 1 and parity > 1 in the only study providing data.
d The women, the method for cervical dilatation assessment and the statistical analytical approach for labour progression in the included studies all provide direct evidence against the question at hand.
e The lower and upper confidence bounds are both within 0.5 hours of the pooled median time.
f We did not strongly suspect publication bias because the search for the studies was comprehensive.
g Two out of three studies with 94% of the total number of participants contributing to the pooled median were at low risk of bias.
h The magnitude of the medians was consistent in two studies. The outlier represents 32% of the total number of participants contributing to the pooled median.
i The lower and upper confidence bounds are both within 0.1 hour of the pooled median time. The total number of women in each study was more than 1000.
EB Table 3.2.4: Labour ward admission policy
Comparison: delaying admission compared with direct admission to the labour ward
Source: Kobayashi S, Hanada N, Matsuzaki M, Takehara K, Ota E, Sasaki H, Nagata C, Mori R. Assessment and support during early labour for improving birth outcomes. Cochrane Database Syst Rev. 2017;(4):CD011516.
Quality assessment No. of participants Effect
Certainty
(GRADE) Importance No. of
studies Study
design Risk of
bias Inconsistency Indirectness Imprecision Other considerations
Delaying admission for women in
early labour following initial
assessment
Direct admission for women in
early labour following initial
assessment
Relative
(95% CI) Absolute (95% CI)
Rate of caesarean section
1 RCT seriousa not serious not serious very seriousb,c none 8/105 (7.6%) 11/104 (10.6%) RR 0.72
(0.30–1.72) 30 fewer per 1000 (from 74 fewer to 76
more)
㊉◯◯◯
VERY LOW critical
Rate of instrumental vaginal birth
1 RCT seriousa not serious not serious very seriousb,c none 32/105
(30.5%) 37/104 (35.6%) RR 0.86
(0.58–1.26) 50 fewer per 1000 (from 93 more to 149
fewer)
㊉◯◯◯
VERY LOW critical
Length of labour (hours)
1 RCT seriousa not serious not serious seriousb none 105 104 – MD 5.2 lower
(7.06 lower to 3.34 lower)
㊉㊉◯◯
LOW critical
Use of epidural or any regional anaesthesia
1 RCT seriousa not serious not serious seriousb none 83/105
(79.0%) 94/104
(90.4%) RR 0.87
(0.78–0.98) 118 fewer per 1000 (from 18 fewer to 199
fewer)
㊉㊉◯◯
LOW critical
Maternal satisfaction (score)
1 RCT seriousa not serious not serious seriousb none 99 102 – MD 16 higher
(7.53 higher to 24.47 higher)
㊉㊉◯◯
LOW critical
Apgar score < 7 at 5 minutes
1 RCT seriousa not serious not serious very seriousb,c none 1/105 (1.0%) 0/104 (0.0%) RR 2.97
(0.12–72.12) 0 fewer per 1000 (from 0 fewer to
0 fewer)
㊉◯◯◯
VERY LOW critical
CI: confidence interval; MD: mean difference. RCT: randomized controlled trial; RR: risk ratio.
a Most of the pooled effect derived from studies with moderate or high risk of bias but without a substantial proportion (i.e. with < 50%) from studies with high risk of bias.
b Small sample size and/or few events.
EB Table 3.2.5: Clinical pelvimetry on admission
Comparison: Routine clinical pelvimetry compared with no pelvimetry
Source: Pattinson RC, Cuthbert A, Vannevel V. Pelvimetry for fetal cephalic presentations at or near term for deciding on mode of delivery. Cochrane Database Syst Rev. 2017;(3):CD000161.
Quality assessment No. of participants Effect
Certainty
(GRADE) Importance No. of
studies Study
design Risk of bias Inconsistency Indirectness Imprecision Other
considerations Pelvimetry No
pelvimetry Relative
(95% CI) Absolute (95% CI) Caesarean section
3 RCTs seriousa not serious seriousb not serious none 145/386
(37.6%) 116/383
(30.3%) RR 1.24
(1.02–1.52) 73 more per 1000 (from 6 more to
157 more)
㊉㊉◯◯
LOW critical
Perinatal mortality
3 RCTs seriousa not serious seriousb very seriousc,d none 5/386 (1.3%) 8/383 (2.1%) RR 0.64
(0.21–1.90) 8 fewer per 1000 (from 17 fewer
to 19 more)
㊉◯◯◯
VERY LOW critical
Perinatal asphyxia
1 RCT seriousa not serious seriousb seriousc none 20/151
(13.2%) 31/154
(20.1%) RR 0.66
(0.39–1.10) 68 fewer per 1000 (from 20 more
to 123 fewer)
㊉◯◯◯
VERY LOW critical
CI: confidence interval; RCT: randomized controlled trial; RR: risk ratio.
a Most of the pooled effect derived from studies with moderate or high risk of bias without a substantial proportion (i.e. with < 50%) from studies with high risk of bias.
b Studies evaluated X-ray pelvimetry and not clinical pelvimetry.
c Wide confidence interval crossing the line of no effect.
d Few events.
EB Table 3.2.6: Routine assessment of fetal wellbeing on labour admission
Comparison: Cardiotocography (CTG) compared with auscultation on labour admission
Source: Devane D, Lalor JG, Daly S, McGuire W, Smith V. Cardiotocography versus intermittent auscultation of fetal heart on admission to labour ward for assessment of fetal wellbeing.
Cochrane Database Syst Rev. 2012;(2):CD005122.
Quality assessment No. of participants Effect
Certainty
(GRADE) Importance No. of
studies Study
design Risk of bias Inconsistency Indirectness Imprecision Other
considerations CTG on
admission Auscultation on
admission Relative
(95% CI) Absolute (95% CI) Caesarean section
4 RCTs not serious not serious not serious seriousa none 248/5657
(4.4%) 207/5681 (3.6%) RR 1.20
(1.00–1.44) 7 more per 1000 (from 0 fewer to
16 more)
㊉㊉㊉◯
MODERATE critical
Instrumental vaginal birth
4 RCTs not serious not serious not serious seriousa none 782/5657
(13.8%) 716/5681 (12.6%) RR 1.10
(0.95–1.27) 13 more per 1000 (from 6 fewer to
34 more)
㊉㊉㊉◯
MODERATE critical
Amniotomy
2 RCTs not serious not serious not serious not serious none 708/1342
(52.8%) 679/1352
(50.2%) RR 1.04
(0.97–1.12) 20 more per 1000 (from 15 fewer to
60 more)
㊉㊉㊉㊉
HIGH critical
Oxytocin for augmentation of labour
4 RCTs not serious not serious not serious not serious none 1920/5653
(34.0%) 1874/5671
(33.0%) RR 1.05
(0.95–1.17) 17 more per 1000 (from 17 fewer to
56 more)
㊉㊉㊉㊉
HIGH critical
Epidural
3 RCTs not serious seriousb not serious seriousa none 2623/5360
(48.9%) 2688/5397
(49.8%) RR 1.11
(0.87–1.41) 55 more per 1000 (from 65 fewer to
204 more)
㊉㊉◯◯
LOW critical
Continuous electronic fetal monitoring during labour
3 RCTs not serious seriousb not serious not serious none 3023/5359
(56.4%) 2247/5394
(41.7%) RR 1.30
(1.14–1.48) 125 more per 1000 (from 58 more to
200 more)
㊉㊉㊉◯
MODERATE critical
Admission to neonatal intensive care
4 RCTs not serious not serious not serious not serious none 219/5656
(3.9%) 213/5675 (3.8%) RR 1.03
(0.86–1.24) 1 more per 1000 (from 5 fewer to
9 more)
㊉㊉㊉㊉
HIGH critical
Quality assessment No. of participants Effect
Certainty
(GRADE) Importance No. of
studies Study
design Risk of bias Inconsistency Indirectness Imprecision Other
considerations CTG on
admission Auscultation on
admission Relative
(95% CI) Absolute (95% CI) Apgar score < 7 at or after 5 minutes
4 RCTs not serious not serious not serious seriousa none 39/5653
(0.7%) 38/5671 (0.7%) RR 1.00
(0.54–1.85) 0 fewer per 1000 (from 3 fewer to
6 more)
㊉㊉㊉◯
MODERATE critical
Neonatal seizures
1 RCT not serious not serious not serious seriousa,c none 10/4017
(0.2%) 14/4039 (0.3%) RR 0.72
(0.32–1.61) 1 fewer per 1000 (from 2 fewer to
2 more)
㊉㊉㊉◯
MODERATE critical
Hypoxic ischaemic encephalopathy
1 RCT not serious not serious not serious very seriousa,d none 6/1186
(0.5%) 5/1181 (0.4%) RR 1.19
(0.37–3.90) 1 more per 1000 (from 3 fewer to
12 more)
㊉㊉◯◯
LOW critical
Fetal and neonatal deaths
4 RCTs not serious not serious not serious seriousa,c none 5/5658
(0.1%) 5/5681 (0.1%) RR 1.01
(0.30–3.47) 0 fewer per 1000 (from 1 fewer to
2 more)
㊉㊉㊉◯
MODERATE critical
Fetal blood sampling
3 RCTs not serious not serious not serious not serious none 522/5360
(9.7%) 410/5397 (7.6%) RR 1.28
(1.13–1.45) 21 more per 1000 (from 10 more to
34 more)
㊉㊉㊉㊉
HIGH critical
CI: confidence interval; MD: mean difference; RCT: randomized controlled trial; RR: Risk ratio.
a Wide confidence interval crossing the line of no effect.
b Severe unexplained heterogeneity.
c Few events but more than 3000 women.
d Small sample size and/or few events.
