Author Reply

We welcome the letter from Garabedian et al. [1] and their interest in our updated systematic review, comparing admission cardiotocography (CTG) and intermittent auscultation (IA) in low-risk term pregnancies [2]. Considering that classic two-arm RCTs are challenging to conduct for rare heterogeneous pregnancy outcomes (e.g., hypoxic-ischaemic enteropathy or perinatal mortality), routinely collected large datasets and/or innovative trial designs may play an important role in generating reliable evidence. We also agree that the particular question ‘Is this fetus fit to undertake the journey of labour?’ [3] is fundamental and future research could evaluate the utility of admission CTG and IA specifically for this. Moreover, the absence of accelerations and cyclicity may play a major role at admission, while current intrapartum CTG and IA protocols are typically focused on baseline and decelerations. This discrepancy drives the need for different interpretation criteria for admission CTG. In prior work, we analysed the data of 27 000 births [4] and showed that the CTGs recorded within the first hour of admission were more likely to have baseline fetal heart rate ≥ 150 bpm; non-reactive trace; reduced variability and decelerative capacity; and no accelerations [4] in babies later born with severe complications (perinatal death, seizures, neonatal encephalopathy or need for intensive resuscitation). Given the complexity of labour and the nature of acute intrapartum events, a CTG at labour onset cannot foretell all causes of severe compromise at birth. However, identifying those with abnormal admission CTG is of particular interest because it provides an opportunity to prevent further deterioration, rather than discover compromise many hours later after the additional hypoxic stress of labour. Finally, the appropriate clinical response to an abnormal admission CTG findings, amongst other things, is determined by labour progression, parity, maternal and pregnancy-specific risk factors, patient preferences, and the clinical resources available within the unit. The meta-analysis indicated that concerns about increased caesarean deliveries are likely overstated [2] and we believe that objective, evidence-based criteria to define abnormal admission CTG and clinical protocols could minimise false-positive findings and safely reduce unnecessary interventions. Given the inherent uncertainty and imprecision of current assessment tools, it is crucial to conceptualise risk as a continuum and to engage patients in informed, shared decision-making that carefully balances potential risks and benefits in light of the best available evidence. A.G. wrote the first draft of this article. All authors reviewed, contributed to and approved the final version. The authors have nothing to report. The authors declare no conflicts of interest. This article is linked to Garabedian et al. papers. To view this article, visit https://doi.org/10.1111/1471-0528.70085. The authors have nothing to report.