Intrapartum cardiotocography: an exploratory analysis of interpretational variation.

Our aim was to evaluate the intra- and inter-operator agreement in cardiotocography (CTG) traces analysis using the 2015 FIGO classification guidelines, and whether the educational background and the knowledge of anamnestic data can influence the interpretation of CTG traces. A retrospective interpretation of 73 intrapartum CTGs at time 0 (T0) for a first blind interpretation and at time 1 (T1) two months later with additional anamnestic pregnancy information was made by eight different operators (four obstetricians and four midwives with different years of work experience). The intra-observer agreement demonstrates that midwifes are more concordant than obstetricians with a mean of 77.05% versus a mean of 65.75%. There is moderate inter-observer agreement in classifying a CTG trace as 'normal'; on the contrary, there is no consensus on the 'suspect' and 'pathological' classification category.IMPACT STATEMENTWhat is already known on this subject? Interpretation of intrapartum CTG is affected by significant subjective variables with relevant intra- and inter-observer lack of optimal agreement, especially in case of abnormal o pathologic findings.What do the results of this study add? Clinical data seem to play a role in interpretation of suspicious and pathological traces while they do not affect the rate of agreement for normal traces. Midwives tend to be less influenced by anamnestic data in visual CTG interpretation. Instead, obstetricians tend to be more focussed on clinical data and clinical setting that, as a consequence, tend to have great impact on CTG trace interpretation.What are the implications of these findings for clinical practice and/or further research? Cooperation among obstetricians and between obstetricians and midwives should be encouraged in order to optimise CTG reading and improve maternal and neonatal outcomes. Regarding the influence of clinical parameters in classification of intrapartum CTG traces, especially in case of abnormal CTG traces, it should be conceivable to improve medical skills in CTG blind interpretation and further investigate which clinical parameters are mainly related with an augmented risk of foetal asphyxia and adverse neonatal outcomes.

Practice, skills and experience with the Pinard stethoscope for intrapartum Foetal monitoring: Focus group interviews with Norwegian midwives.

OBJECTIVE: In most high-income countries, the cardiotocography and handheld Doppler device have replaced the Pinard stethoscope for intrapartum foetal monitoring. As a result, the skills required to use the Pinard are rapidly disappearing from midwifery. The aim of this study was thus to illuminate the knowledge before it is lost, by exploring the practice, skills and experience of Norwegian midwives familiar with the Pinard for intrapartum foetal monitoring. We included midwives who still regularly use the Pinard in their current practice in a variety of birth settings, and those who used the Pinard in the era prior to the introduction of the CTG. DESIGN: This study followed a qualitative descriptive design based on mainly focus group interviews, but also including one individual interview. The interviews explored the participants` perspective on their practice, skills and experience regarding the use of the Pinard for intrapartum foetal monitoring. Reflexive thematic analysis captured common patterns across the data, and contextualism was used as research paradigm. SETTING AND PARTICIPANTS: In total, 21 midwives with experience using the Pinard for intrapartum foetal monitoring were interviewed. The midwives were either retired and had experience using the Pinard from before the CTG became widespread; worked in an alongside midwifery unit that only oversees low-risk births; or worked in an obstetric unit in a university hospital with an active policy of using the Pinard for intrapartum foetal monitoring. FINDINGS: The analysis resulted in four main themes: "Practice and experience with the Pinard are related to context", "Skills with the Pinard come with work experience", "The Pinard reveals certain characteristics of foetal sound" and "Midwives` experience with the benefits of using the Pinard". The midwives considered the context for using the Pinard for intrapartum foetal monitoring relevant. The e availability of technology and applicable situations for using the Pinard influenced how and when they use the Pinard. They further underpinned training and work experience as important for feeling secure when using the Pinard, and this experience made them recognize normal and abnormal foetal sounds. Defining and characterizing these sounds appeared difficult for the midwives, however, and they hesitated and imitated the sound. The midwives felt that the Pinard is beneficial for both the labouring woman and the midwife, as the Pinard's features bring them closer to the labouring woman and help calm the birth suite. They also felt that the Pinard adds further information about the birth and birth process, such as foetal lie, rotation and descent. KEYCONCLUSIONS: Norwegian midwives' practice, and experiences in using the Pinard for intrapartum foetal monitoring are connected to context as technological development and applicable situations. The midwives explained that knowledge obtained through experience gives them skills to differentiate between normal and abnormal foetal sound characteristics, though they found it difficult to define the characteristics themselves. Using the Pinard stethoscope during birth calms the birth suite and brings the midwife closer to the labouring woman.

The overuse of intrapartum cardiotocography (CTG) for low-risk women: An actor-network theory analysis of data from focus groups.

BACKGROUND: There is an overuse of cardiotocography for intrapartum fetal monitoring for low-risk women in high-income countries, despite recommendations from evidence-based guidelines. AIM: To understand why midwives use cardiotocography for low-risk women despite evidence-based recommendations and to understand the roles of the cardiotocograph machine. METHOD: This qualitative study used focus groups for data collection. Thirty-one midwives and three student midwives participated from four different countries: New Zealand, Australia, Denmark, and Norway. Constant comparative analysis, informed by an actor-network theory framework, was the method of data analysis. FINDINGS: Cardiotocography was multifaceted and influenced all attendants in the birth environment. The cardiotocograph itself is assigned different roles within the complex networks surrounding childbirth. The cardiotocograph's roles were as a babysitter, the midwives' partner, an agent of shared responsibility, a protector that 'covers your back', a disturber of normal birth, and a requested guest. DISCUSSION: The application of the actor-network theory enabled us to understand how midwives perceive cardiotocography. The assigned roles of the cardiotocograph shape its everyday use more than evidence-based guidelines. Discussion of these inconsistencies must inform the use of cardiotocography in the care of women with low-risk pregnancies. CONCLUSION: We found that the cardiotocograph is a multifaceted actant that influences practice by performing different roles. Drawing on this study, we suggest that actor-network theory could be a helpful theoretical perspective to critically reflect upon the increasing use of technologies within maternity care.

Acquiring Knowledge about the Use of a Newly Developed Electronic Fetal Heart Rate Monitor: A Qualitative Study Among Birth Attendants in Tanzania.

In an effort to reduce newborn mortality, a newly developed strap-on electronic fetal heart rate monitor was introduced at several health facilities in Tanzania in 2015. Training sessions were organized to teach staff how to use the device in clinical settings. This study explores skilled birth attendants' perceptions and experiences acquiring and transferring knowledge about the use of the monitor, also called Moyo. Knowledge about this learning process is crucial to further improve training programs and ensure correct, long-term use. Five Focus group discussions (FGDs) were carried out with doctors and nurse-midwives, who were using the monitor in the labor ward at two health facilities in Tanzania. The FGDs were analyzed using qualitative content analysis. The study revealed that the participants experienced the training about the device as useful but inadequate. Due to high turnover, a frequently mentioned challenge was that many of the birth attendants who were responsible for training others, were no longer working in the labor ward. Many participants expressed a need for refresher trainings, more practical exercises and more theory on labor management. The study highlights the need for frequent trainings sessions over time with focus on increasing overall knowledge in labor management to ensure correct use of the monitor over time.

Midwives' perceptions on using a fetoscope and Doppler for fetal heart rate assessments during labor: a qualitative study in rural Tanzania.

BACKGROUND: The Doppler is thought to be more comfortable and effective compared to the fetoscope for assessing the fetal heart rate (FHR) during labor. However, in a rural Tanzanian hospital, midwives who had easy access to both devices mostly used fetoscope. This study explored midwives' perception of factors influencing their preference for using either a Pinard fetoscope or a FreePlay wind-up Doppler for intermittent FHR monitoring. METHODS: Midwives who had worked for at least 6 months in the labor ward were recruited. Focus group discussion (FGD) was used to collect data. Five FGDs were conducted between December 2015 and February 2016. Qualitative content analysis was employed using NVivo 11.0. RESULTS: Three main themes emerged as factors perceived by midwives as influencing their preference; 1) Sufficient training and experience with using a device; Midwives had been using fetoscopes since their midwifery training, and they had vast experience using it. The Doppler was recently introduced in the maternity ward, and midwives had insufficient training in how to use it. 2) Ability of the device to produce reliable measurements; Using a fetoscope, one must listen for the heartbeat, count using a watch, and calculate, the Doppler provides both a display and sound of the FHR. Fetoscope measurements are prone to human errors, and Doppler measurements are prone to instrumental errors. 3) Convenience of use and comfort of a device; Fetoscopes do not need charging, and while it is possible to "personalize/hide" the measurements, and may be painful for mothers. Dopplers need charging and do not cause pain, but provide limited privacy. CONCLUSION: Midwives' preferences of FHR monitoring devices are influenced by the level of device training, experience with using a device, reliable measurements, and convenience and comfort during use. Fetoscopes and Dopplers should be equally available during midwifery training and in clinical practice.

Estimation of neonatal outcome artery pH value according to CTG interpretation of the last 60 min before delivery: a retrospective study. Can the outcome pH value be predicted?

PURPOSE: The aim of this study was to analyze whether the umbilical artery pH value can be estimated throughout CTG assessment 60 min prior to delivery and if the estimated umbilical artery pH value correlates with the actual one. This includes analysis of correlation between CTG trace classification and actual umbilical artery pH value. Intra-and interobserver agreement and the impact of professional experience on visual analysis of fetal heart rate tracing were evaluated. METHODS: This was a retrospective study. 300 CTG records of the last 60 min before delivery were picked randomly from the computer database with the following inclusion criteria; singleton pregnancy >37 weeks, no fetal anomalies, vaginal delivery either spontaneous or instrumental-assisted. Five obstetricians and two midwives of different professional experience classified 300 CTG traces according to the FIGO criteria and estimated the postnatal umbilical artery pH. RESULTS: The results showed a significant difference (p < 0.05) in estimated and actual pH value, independent of professional experience. Analysis and correlation of CTG assessment and actual umbilical artery pH value showed significantly (p < 0.05) diverging results. Intra- and interobserver variability was high. Intraobserver variability was significantly higher for the resident (p = 0.001). No significant differences were detected regarding interobserver variability. CONCLUSION: An estimation of the pH value and consequently of neonatal outcome on the basis of a present CTG seems to be difficult. Therefore, not only CTG training but also clinical experience and the collaboration and consultation within the whole team is important.

Stimulating conversation: does cold water wake babies in utero? Part 1.

The Royal College of Obstetricians and emerged in these discussions. Overall, the majority of respondents were open to using this practice in Gynaecologists (RCOG) library recently responded to a question about whether there was any evidence about the practice of offering a cold drink to a pregnant woman in order to encourage fetal movement or improve the reactivity of a cardiotocograph (CTG) trace. Their search conversations with midwives and other practice, which led me to have a number of practitioners about their experience of this. In the highlighted a dearth of research into this common first of two articles on this topic, I explain the theory and describe the range of responses that certain situations, but they felt it vital that it was used within a framework of providing individualised care and applying common sense.

Single versus pairwise interpretation of cardiotochography, a comparative study from six Swedish delivery units.

OBJECTIVE: The aim of the study was to evaluate whether interpreting CTG pairwise brings about a higher level of correctly classified CTG recordings in a non-selected population of midwives and physicians. STUDY DESIGN: A comparative study. SETTING: Five delivery units in Stockholm and one delivery unit in Uppsala, with 1589, 3740, 3908, 4539, 6438, and 7331 deliveries in 2011, respectively. SUBJECTS: 536 midwives and physicians classified one randomly selected CTG recording individually followed by a pairwise classification. The pairs consisted of two midwives (119 pairs) or one midwife and one physician (149 pairs), a total of 268 pairs. MAIN OUTCOME MEASURE: The proportion of individually correctly classified CTG recordings versus the proportion of pairwise correctly classified CTG recordings. RESULTS: The proportion of individually correctly classified CTG's was 75% and the proportion of pairwise correctly classified CTG's was 80% (difference 5%, p = 0.12). CONCLUSIONS: There was no statistically significant difference when CTG's were classified pairwise compared to individual classifications. The proportion of individually correctly classified CTG's was high (75%). There were differences in the proportion of correctly classified CTG recordings between the delivery units, indicating potential areas of improvement.

Fetal vibroacoustic stimulation for facilitation of tests of fetal wellbeing.

BACKGROUND: Acoustic stimulation of the fetus has been suggested to improve the efficiency of antepartum fetal heart rate testing. OBJECTIVES: To assess the advantages and disadvantages of the use of fetal vibroacoustic stimulation in conjunction with tests of fetal wellbeing. SEARCH METHODS: We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (30 September 2013). SELECTION CRITERIA: All published and unpublished randomised controlled trials assessing the merits of the use of fetal vibroacoustic stimulation in conjunction with tests of fetal wellbeing. DATA COLLECTION AND ANALYSIS: All review authors independently extracted data and assessed trial quality. Authors of published and unpublished trials were contacted for further information. MAIN RESULTS: Altogether 12 trials with a total of 6822 participants were included. Fetal vibroacoustic stimulation reduced the incidence of non-reactive antenatal cardiotocography test (nine trials; average risk ratio (RR) 0.62, 95% confidence interval (CI) 0.48 to 0.81). Vibroacoustic stimulation compared with mock stimulation evoked significantly more fetal movements when used in conjunction with fetal heart rate testing (one trial, RR 0.23, 95% CI 0.18 to 0.29). AUTHORS' CONCLUSIONS: Vibroacoustic stimulation offers benefits by decreasing the incidence of non-reactive cardiotocography and reducing the testing time. Further randomised trials should be encouraged to determine not only the optimum intensity, frequency, duration and position of the vibroacoustic stimulation, but also to evaluate the efficacy, predictive reliability, safety and perinatal outcome of these stimuli with cardiotocography and other tests of fetal wellbeing.

Fetal vibroacoustic stimulation in computerized cardiotocographic analysis: the role of short-term variability and approximate entropy.

The aim of this study was to evaluate the impact of vibroacoustic stimulation (VAS) on computerized cardiotocography short-term variability (STV) and approximate entropy (ApEn) in both low- and high-risk pregnancies. VAS was performed on 121 high- and 95 low-risk pregnancies after 10 minutes of continuous quiet, while their FHR parameters were monitored and recorded by cCTG analysis. Fetal heart rate was recorded using a computer-assisted equipment. Baseline FHR, accelerations, decelerations, STV, long-term irregularity (LTI), ApEn, and fetal movements (FMs) were calculated for defined observational periods before VAS and after 10 minutes. Data were also investigated in relationship with the perinatal outcome. In each group of patients, FHR after VAS remained almost unmodified. Fetal movements significantly increased after VAS in both groups. Results show that only in the high-risk pregnancies, the increase of STV and the decrease of ApEn after VAS were significantly associated with favorable perinatal outcomes.

Side-effects of moxibustion for cephalic version of breech presentation.

OBJECTIVES: Moxibustion, a Traditional Chinese Medicine technique related to acupuncture, was proposed to facilitate cephalic version of breech presentation. Several trials were conducted to evaluate the efficacy, but there are few reports on the safety of moxibustion. Our objective was to assess the side-effects and acceptability of this intervention. DESIGN: We are conducting a randomized controlled trial to evaluate the efficacy of moxibustion for breech version. The first 12 participants randomized in the moxibustion group had additional fetal surveillance by electronic monitoring. SUBJECTS: Pregnant women with a fetus in breech presentation are included in the trial between 34 and 36 weeks of gestation. INTERVENTIONS: We performed a cardiotocogram during 10 minutes before, 20 minutes during, and 10 minutes after each session. A maximum of 9 sessions were scheduled every other day, and stopped when cephalic version was diagnosed. The recordings were assessed by 3 independent readers using the Fischer scoring system. OUTCOME MEASURES: Fetal well-being was evaluated by the cardiotocogram; effect on the mother was evaluated by blood pressure recorded before and after each session; maternal views, contractions, and perceived changes in fetal movements were assessed using a questionnaire. RESULTS: A total of 65 cardiotocograms were analyzed. All scores were considered as normal, being at 8 or more on a 0-10 scale. Acceptability for the women and compliance to the intervention were good. No significant maternal or fetal side-effect was observed. CONCLUSIONS: We have not detected alterations of fetal and maternal well-being or other side-effects associated with moxibustion applied to the BL 67 for cephalic version of breech presentations. Moxibustion appears to be safe for both the mother and the fetus.

Estimated cardiac vagal tone predicts fetal responses to mother's and stranger's voices.

Heart rate responses of 84 near-term fetuses to recorded female voices were examined in 166 trials of auditory stimulation. Each fetus was presented with a 2-min recording of their mother's voice and a 2-min recording of a female stranger's voice, in counterbalanced order, with a 10-min rest period between trials. High frequency heart rate variability during a 2-min baseline period was used to estimate cardiac vagal tone for each trial. Differential heart rate responses to familiar and unfamiliar voice recordings were observed during a 2-min poststimulus period, only when estimated cardiac vagal tone was high. This finding suggests that vagal tone plays a moderating role in the cardiac responses of term fetuses to familiar and unfamiliar stimuli.

Monitorização materno-fetal da portadora de doença valvar reumática durante procedimento odontológico sob anestesia local / Maternal-fetal monitoring of patients with rheumatic heart disease during dental procedure under local anesthesia

Modificações na fisiologia do organismo da mulher ocorrem durante a gravidez em consequência às alterações hormonais, anatômicas e metabólicas. No sistema circulatório a modificação mais significativa é o aumento do débito cardíaco a partir do primeiro trimestre da gestação. Mulheres portadoras de cardiopatias podem apresentar graves complicações durante o período gestacional devido à inapropriada adaptação à sobrecarga hemodinâmica, mesmo em pacientes consideradas em capacidade funcional favorável, no início da gestação. A literatura carece de estudos dos efeitos dos anestésicos locais com ou sem vasoconstritor utilizados nos procedimentos odontológicos, sobre os parâmetros cardiovasculares de mulheres gestantes portadoras de valvopatias e seus conceptos. A escassez científica fez deste tema nosso objetivo de estudo: avaliar e analisar parâmetros da cardiotocografia, como frequência cardíaca, motilidade fetal e contrações uterinas e de pressão arterial e eletrocardiográficos da gestante portadora de doença valvar reumática quando submetida à anestesia local com lidocaína, com e sem vasoconstritor, durante procedimento odontológico restaurador. Para tanto, a monitorização ambulatorial da pressão arterial (MAPA) e a eletrocardiografia ambulatorial (Holter) materna, ambas obtidas durante 24 horas e a cardiotografia (CTG) de 31 portadoras de cardiopatia reumática entre a 28ª e 37ª semana de gestação, nos períodos: (1) basal - 60 minutos antes do procedimento para MAPA e Holter e 20 minutos para CTG; (2) procedimento - 56+15,5minutos (média+desvio padrão); (3) pós-procedimento - 20 minutos; e (4) média das 24 horas para frequência cardíaca e extra-sístoles e média da vigília e do sono para pressão arterial, permitiu a análise da variação desses parâmetros, utilizando-se lidocaína 2% sem vasoconstritor e lidocaína 2% com epinefrina 1:100.000, compondo-as em dois grupos. Demonstrou-se redução significativa nos valores de frequência cardíaca materna...

During pregnancy, the organic systems of a woman are subjected to physiological modifications consequential to hormonal, anatomic and metabolical alterations. The most significant modification in the circulatory system is an increased cardiac output from the first three months of gestation. Women with heart disease may present with severe complications during the gestational period, because of inappropriate adaptation of her body to this hemodynamic overload, even those patients who are thought to have an appropriate functional capacity during early pregnancy. There are scant studies in the literature on the effects of local anesthetics, with and without vasoconstrictor, used in dental procedures on the cardiovascular variables of pregnant women with valvar disease, as well as on their concepti. Driven by this shortage, we decided to have this subject studied, by assessing and analyzing cardiotachographic parameters, such as heart rate, fetal motility and uterine contractions, in addition to blood pressure and electrocardiographic variables, in pregnant women with rheumatic valvar disease who undergo local anesthesia with lidocaine, with and without vasoconstrictor, during restorative dental procedure. For this, 31 rheumatic heart disease patients who were in their 28th to 37th week of gestation, had 24-hour ambulatory monitoring of their blood pressure (BP) and Holter electrocardiography (Holter-ECG), and cardiotocography (CTG), performed during: (1) baseline - 60 minutes before the procedure for BP and Holter- ECG monitoring, and 20 minutes before the procedure for CTG; (2) procedure - 56±15.5 minutes (mean±SD); (3) post-procedure - 20 minutes; and (4) mean 24-hour heart rate and extrasystoles measurement, and mean wake and sleeping periods BP monitoring. Variation of the above variables was analyzed in two groups, one with infusion of a 2% solution of lidocaine with vasoconstrictor, and the other with infusion of a 2% solution of lidocaine...

A randomised controlled trial of admission electronic fetal monitoring in normal labour.

AIM: To test the hypothesis that the use of admission Electronic Fetal Monitoring (EFM) for healthy pregnant women in spontaneous labour would result in an increase in continuous EFM when compared to women who have had no admission EFM. DESIGN: A randomised controlled trial. SETTING: The Midwives Birth Unit in Glasgow Royal Maternity Hospital, a major urban teaching hospital with approximately 5000 births per year. PARTICIPANTS: Healthy pregnant women admitted in normal labour, deemed low risk based on the midwives' birth unit admission criteria. INTERVENTION: Women were randomly allocated either to receive a routine 20-minute period of EFM at the time of admission (control group), or to receive no routine admission EFM (study group). OUTCOME MEASURES: Primary study outcomes, use of continuous EFM; and use of EFM additional to the admission test. SECONDARY OUTCOMES: artificial rupture of membranes, use of fetal scalp electrode, fetal blood sample, syntocinon, epidural analgesia, number of vaginal examinations, rate of transfer to labour ward, and reason for transfer. KEY FINDINGS: There was no statistically significant difference between the groups for use of continuous monitoring, but significantly more women in the control group did receive additional EFM. There was no statistically significant difference between groups for any of the interventions studied. CONCLUSION: The use of admission EFM did not in itself lead to a cascade of intervention. Other factors including setting of care and philosophy of caregivers may have an effect on the rate of intervention in labour.

Inter-observer variation in assessment of 845 labour admission tests: comparison between midwives and obstetricians in the clinical setting and two experts.

OBJECTIVE: To assess the inter-observer agreement in assessment of the labour admission test between midwives and obstetricians in the clinical setting and two experts in the non-clinical setting, the inter-observer agreement between two experts in the non-clinical setting and to what degree fetal distress in labour could be predicted by the two experts. DESIGN: Observational study. SETTING: The maternity unit of Hammerfest Hospital, Norway. POPULATION: Eight hundred and forty-five high and low risk women. METHOD: The labour admission test was first assessed by the midwife or obstetrician in the clinical setting, and was later assessed by two experts. The traces were assessed as normal, equivocal or ominous. Weighted kappa (kappaw), proportion of agreement (Pa) and predictive values were calculated. MAIN OUTCOME MEASURES: Weighted kappa, proportion of agreement, sensitivity, positive predictive value and likelihood ratios. RESULTS: Inter-observer agreement between Expert 1 and Expert 2: kappaw 0.38 (CI 0.31-0.46), Pa for reactive labour admission test 0.86 (CI 0.83-0.88) and Pa for equivocal/ominous test 0.33 (CI 0.26-0.40). Agreement between Expert 1 and midwives/obstetricians: kappaw 0.25 (CI 0.15-0.36), Pa for reactive labour admission test 0.89 (CI 0.87-0.91) and Pa for equivocal/ominous labour admission test 0.18 (CI 0.11-0.25). Agreement between Expert 2 and midwives/obstetricians: kappaw 0.28 (CI 0.20-0.37), Pa for reactive labour admission test 0.85 (CI 0.82-0.88) and Pa for equivocal/ominous test 0.20 (CI 0.14-0.26). Totally 5.9% of the newborns had fetal distress. At cutoff equivocal test, sensitivity was 0.22 and 0.31 in the two observers. Positive predictive values were 0.13 and 0.11. Likelihood ratio for a positive test was 2.30 and 1.92 and likelihood ratio for a negative test 0.86 and 0.83. CONCLUSION: A labour admission test is still routine practice in most obstetric units in the Western world when there is little evidence on its benefits. The results from this study may provide some reconsideration for such practice, and for more research.

Fetal vibroacoustic stimulation for facilitation of tests of fetal wellbeing.

BACKGROUND: Acoustic stimulation of the fetus has been suggested to improve the efficiency of antepartum fetal heart rate testing. OBJECTIVES: The objective of this review was to assess the merits or adverse effects of the use of fetal vibroacoustic stimulation in conjunction with tests of fetal wellbeing. SEARCH STRATEGY: We searched the Cochrane Pregnancy and Childbirth Group trials register. Date of last search: October 2000. SELECTION CRITERIA: All published and unpublished randomized controlled trials assessing the merits of the use of fetal vibroacoustic stimulation in conjunction with tests of fetal wellbeing. DATA COLLECTION AND ANALYSIS: Both reviewers independently extracted data and assessed trial quality. Authors of published and unpublished trials were contacted for further information. MAIN RESULTS: A total of seven trials with a total of 4325 participants were included. Fetal vibroacoustic stimulation reduced the incidence of non-reactive antenatal cardiotocography test (odds ratio (OR) 0.61, 95% confidence interval (CI) 0.49-0.75) and reduced the overall mean cardiotocography testing time (weighted mean difference (WMD) -4.55 minutes, 95% CI -5.96 minutes to -3.14 minutes). Vibroacoustic stimulation evoked more than mock stimulation when used in conjunction with fetal heart rate testing (OR 0.08, 95% CI 0.06-0.12). REVIEWER'S CONCLUSIONS: Vibroacoustic stimulation offers benefits by decreasing the incidence of non-reactive cardiotocography and reducing the testing time. Further randomized trials should be encouraged to determine not only the optimum intensity, frequency, duration and position of the vibroacoustic stimulation, but also to evaluate the efficacy, predictive reliability, safety and perinatal outcome of these stimuli with cardiotocography and other tests of fetal wellbeing.