Randomised controlled trial of cardiotocography versus Doppler auscultation of fetal heart at admission in labour in low risk obstetric population Commentary: changes between protocol and manuscript should be declared at submission Commentary: research governance must focus on research training Commentary: Approach to power calculations has to be realistic

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Abstract
Objective: To compare the effect of admission cardiotocography and Doppler auscultation of the fetal heart on neonatal outcome and levels of obstetric intervention in a low risk obstetric population. Design: Randomised controlled trial. Setting: Obstetric unit of teaching hospital Participants: Pregnant women who had no obstetric complications that warranted continuous monitoring of fetal heart rate in labour. Intervention: Women were randomised to receive either cardiotocography or Doppler auscultation of the fetal heart when they were admitted in spontaneous uncomplicated labour. Main outcome measures: The primary outcome measure was umbilical arterial metabolic acidosis. Secondary outcome measures included other measures of condition at birth and obstetric intervention. Results: There were no significant differences in the incidence of metabolic acidosis or any other measure of neonatal outcome among women who remained at low risk when they were admitted in labour. However, compared with women who received Doppler auscultation, women who had admission cardiotocography were significantly more likely to have continuous fetal heart rate monitoring in labour (odds ratio 1.49, 95% confidence interval 1.26 to 1.76), augmentation of labour (1.26, 1.02 to 1.56), epidural analgesia (1.33, 1.10 to 1.61), and operative delivery (1.36, 1.12 to 1.65). Conclusions: Compared with Doppler auscultation of the fetal heart, admission cardiotocography does not benefit neonatal outcome in low risk women. Its use results in increased obstetric intervention, including operative delivery. What is already known on this topic The admission cardiotocogram is a short recording of the fetal heart rate immediately after admission to the labour ward Opinion varies about its value in identifying a potentially compromised fetus In low risk women, the incidence of intrapartum fetal compromise is low What this study adds Compared with Doppler auscultation of the fetal heart, admission cardiotocography has no benefit on neonatal outcome in low risk women Admission cardiotocography results in increased obstetric intervention, including operative delivery Objective: To compare the effect of admission cardiotocography and Doppler auscultation of the fetal heart on neonatal outcome and levels of obstetric intervention in a low risk obstetric population. Design: Randomised controlled trial. Setting: Obstetric unit of teaching hospital Participants: Pregnant women who had no obstetric complications that warranted continuous monitoring of fetal heart rate in labour. Intervention: Women were randomised to receive either cardiotocography or Doppler auscultation of the fetal heart when they were admitted in spontaneous uncomplicated labour. Main outcome measures: The primary outcome measure was umbilical arterial metabolic acidosis. Secondary outcome measures included other measures of condition at birth and obstetric intervention. Results: There were no significant differences in the incidence of metabolic acidosis or any other measure of neonatal outcome among women who remained at low risk when they were admitted in labour. However, compared with women who received Doppler auscultation, women who had admission cardiotocography were significantly more likely to have continuous fetal heart rate monitoring in labour (odds ratio 1.49, 95% confidence interval 1.26 to 1.76), augmentation of labour (1.26, 1.02 to 1.56), epidural analgesia (1.33, 1.10 to 1.61), and operative delivery (1.36, 1.12 to 1.65). Conclusions: Compared with Doppler auscultation of the fetal heart, admission cardiotocography does not benefit neonatal outcome in low risk women. Its use results in increased obstetric intervention, including operative delivery. What is already known on this topic The admission cardiotocogram is a short recording of the fetal heart rate immediately after admission to the labour ward Opinion varies about its value in identifying a potentially compromised fetus In low risk women, the incidence of intrapartum fetal compromise is low What this study adds Compared with Doppler auscultation of the fetal heart, admission cardiotocography has no benefit on neonatal outcome in low risk women Admission cardiotocography results in increased obstetric intervention, including operative delivery

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