Evaluating Fetal Well‐Being at Labor Onset: Is Intermittent Auscultation Enough?

We read with great interest the updated systematic review by Tome et al. on admission cardiotocography (CTG) in low-risk term pregnancies [1]. While their conclusions align with current guidelines discouraging routine admission CTG, we believe several methodological and contextual considerations warrant further discussion. First, the context of the five RCTs included and the generalizability of these findings merit careful consideration. All five RCTs were conducted in high-income Anglo-Saxon countries (Scotland, Ireland, England), where neuraxial analgesia is less frequently used than in other countries such as France. This difference is clinically relevant: neuraxial use influences fetal heart rate patterns and may increase the incidence of non-reassuring CTG traces [2], making pre-analgesia assessment with continuous CTG potentially valuable in settings with higher epidural rates. Second, substantial methodological heterogeneity limits the comparability of these trials. Studies varied in their definitions of admission CTG, criteria for abnormal traces, and intermittent auscultation (IA) protocols. Furthermore, four of the five trials predate contemporary understanding of CTG pathophysiology, potentially affecting interpretation standards. Moreover, while the authors report moderate-certainty evidence for most outcomes, none of the trials were blinded, and several lacked pre-specified analysis plans, introducing potential bias in outcome assessment and reporting. Third, despite including 14 372 participants, this meta-analysis remains underpowered for rare but critical outcomes—specifically, chronic hypoxia detectable at labor onset [3]. Indeed, admission CTG aims to evaluate the ability of the fetus to support the labor, an aspect that IA may not adequately capture. Indeed, Jia et al. proposed a chronic hypoxia checklist addressing this fundamental question at labor onset: “Is this fetus fit to undertake the journey of labor?” [4]. In their checklist, five points need to be evaluated: (1) Is the baseline FHR “stable,” and “appropriate” for the gestational age? (2) Is there normal variability and cycling? (3) Are there accelerations? (4) Are shallow or late decelerations (i.e., uteroplacental insufficiency) “absent”? (5) No evidence of risk factors which may increase fetal compromise. Only continuous CTG could evaluate those points and detect chronic hypoxia which is associated with a higher occurrence of adverse neonatal outcomes. In conclusion, this review contributes valuable insights to the ongoing debate on intrapartum fetal monitoring. The authors should emphasise their reassuring finding: admission CTG does not increase caesarean rates—a persistent concern that may have been overstated. However, the role of admission CTG in detecting chronic hypoxia and in settings with high neuraxial analgesia rates remains incompletely evaluated. Future research should address these specific clinical contexts before definitively excluding potential benefits in targeted populations. C.G., P.G. an P.B. wrote and validated the letter. The authors declare no conflicts of interest.