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Fetal manipulation for facilitating tests of fetal wellbeing

  1. Kelvin H Tan1,*,
  2. Antoinette Sabapathy2,
  3. Xing Wei1

Editorial Group: Cochrane Pregnancy and Childbirth Group

Published Online: 7 DEC 2013

Assessed as up-to-date: 30 SEP 2013

DOI: 10.1002/14651858.CD003396.pub2


How to Cite

Tan KH, Sabapathy A, Wei X. Fetal manipulation for facilitating tests of fetal wellbeing. Cochrane Database of Systematic Reviews 2013, Issue 12. Art. No.: CD003396. DOI: 10.1002/14651858.CD003396.pub2.

Author Information

  1. 1

    KK Women's and Children's Hospital, Department of Maternal Fetal Medicine, Singapore, Singapore

  2. 2

    Nanyang Polytechnic, School of Health Sciences, Singapore, Singapore

*Kelvin H Tan, Department of Maternal Fetal Medicine, KK Women's and Children's Hospital, 100 Bukit Timah Road, Singapore, 229899, Singapore. khtan@tan.net. tan.kok.hian@kkh.com.sg.

Publication History

  1. Publication Status: New search for studies and content updated (no change to conclusions)
  2. Published Online: 7 DEC 2013

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Characteristics of included studies [ordered by study ID]
Druzin 1985

MethodsRandomisation method: randomised by odd or even hospital numbers with its attendant bias. Effectiveness of randomisation was assessed by comparison of various indications within the 2 groups.


ParticipantsWomen of gestation ages ranging from < 30 weeks to > 42 weeks. Majority of the tests were done because of suspected postdate pregnancy, diabetes and suspected intrauterine growth retardation. Country: USA, California. 790 women randomised.


InterventionsWomen randomised to manual stimulation group underwent manual stimulation of the fetus for 60 seconds prior to the beginning of 20 minutes of non-stress CTG test. Women randomised to non-manual stimulation group did not undergo manual manipulation prior to the beginning of 20-minute of non-stress CTG test.


OutcomesPrimary outcome: FHR reactivity. This was defined as the presence of 2 accelerations of greater than 15 beats/minute and of 15 seconds' duration or more within a 20-minute period.


NotesManual manipulation involved grasping both poles of the fetus and moving the fetus back and forth in a rocking motion.


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)High riskSequence generated by even or odd hospital number.

Allocation concealment (selection bias)High riskAllocation based on hospital number.

Blinding of participants and personnel (performance bias)
All outcomes
Unclear riskProbably not done.

Blinding of outcome assessment (detection bias)
All outcomes
Unclear riskProbably not done.

Incomplete outcome data (attrition bias)
All outcomes
Low riskFollow-up 100%.

Selective reporting (reporting bias)Low riskAll expected outcomes reported.

Other biasLow riskNo evidence of other forms of bias.

Newnham 1990

MethodsRandomisation: randomised by draw of sealed envelopes. Effectiveness of randomisation was assessed by comparisons of several parameters within the 2 groups which include maternal ages, parities, gestational ages and primary indications.


ParticipantsWomen of at least 34 weeks' gestation. Exclusion criteria - no contraindications to contraction stress tests. Country: Western Australia. 300 women randomised.


InterventionsWomen randomised to fetal acoustic stimulation group were monitored for an initial 5 minutes. If the pattern was non-reactive, a 3-second vibratory acoustic stimulation was applied to the maternal abdomen in the region of the fetal head. The stimulus was repeated a second and a third time, also at 1-minute intervals, if satisfactory FHR accelerations had not occurred.
Women randomised to non-fetal acoustic stimulation group were monitored for an initial 20 minutes. If the trace was non-reactive, the fetus was stimulated manually and the test was continued for a further 20 minutes. If satisfactory accelerations were not found, the women were then sent for a meal. On her return, a nipple stimulation contraction stress was performed if the subsequent test remained non-reactive after a further 20 minutes.


OutcomesPrimary outcome: FHR reactivity. This was defined as the presence of 2 accelerations of greater than 15 beats/minute and of 15 seconds' duration or more within a 20-minute period. In tests in which accelerations had been provoked by fetal acoustic stimulation, the definition of reactivity required 1 of the 2 accelerations to have been unprovoked.


NotesAll tests were performed with Corometrics 115 monitors using Doppler FHR transducers. The tests were performed by specially trained fetal intensive care midwives with a nurse: patient ratio of 1:1. The vibratory acoustic stimulus had an audio frequency of 75 Hz, a sound intensity of 74 db at 1 m in air and a stimulation duration of 3 seconds. Randomisation was performed after informed consent.


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Low riskRandomisation done by draw of sealed envelopes.

Allocation concealment (selection bias)Low riskRandomisation done by draw of sealed envelopes.

Blinding of participants and personnel (performance bias)
All outcomes
Unclear riskNot reported.

Blinding of outcome assessment (detection bias)
All outcomes
Unclear riskNot reported.

Incomplete outcome data (attrition bias)
All outcomes
Low riskFollow-up 100%.

Selective reporting (reporting bias)Unclear riskNot clear.

Other biasLow riskNo evidence of other form of bias.

Piyamongkol 2006a

MethodsRandomisation: 308 patients were included for 540 FHR testings, assigned to either non-stress test or manual stimulation test using blocked randomisation, 270 in each group.


ParticipantsSingleton pregnant women with gestational age of 28 or more weeks. Country: Thailand.


InterventionsIn the MST group, the presenting part of the fetus was held through the maternal abdomen by the operator with 1 hand and the upper pole of the fetus with the other hand. After 3-minute baseline recording of the FHR tracing, the fetus was then gently shaken left-and-right, up-and-down and forward-and-backward each procedure twice, making 6 manipulations. The procedure was repeated up to 3 times (4 times in total) if no qualifying acceleration was observed within 15 seconds. A new cycle of stimulation was carried out if no reactive criteria were fulfilled in 10 minutes. The same procedure was extended for another 30 minutes if no reactive criteria were achieved within 20 minutes for both MST and NST. All FHR tracings were read blindly by 1 independent perinatologist.


OutcomesTests were interpreted as reactive when there were 2 or more FHR accelerations of at least 14 beats/minute lasting at least 15 seconds in any 20-minute period. 1 prolonged FHR acceleration of at least 15 beats/minute lasting 2 or more minutes was also interpreted as reactive. The test was diagnosed as non-reactive when these criteria were not met within 40 minutes of monitoring and contraction stress test, biophysical profile, Doppler velocity or delivery determination was conducted as the hospital standard practice guideline.


Notes


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskPatients were assigned to either non-stress test or manual stimulation test using blocked randomisation, 270 in each group.

Allocation concealment (selection bias)Unclear riskUnclear

Blinding of participants and personnel (performance bias)
All outcomes
Unclear riskUnclear.

Blinding of outcome assessment (detection bias)
All outcomes
Low riskAll FHR tracings were read blindly by 1 independent perinatologist.

Incomplete outcome data (attrition bias)
All outcomes
Low riskFollow-up rate 100%.

Selective reporting (reporting bias)Low riskAll outcomes in the methods section have been reported on.

Other biasLow riskNo evidence of other forms of bias.

Visser 1983

MethodsRandomisation: randomised by draw of sealed envelopes.


Participants10 healthy nulliparous women with normal pregnancies of 37 to 40 weeks.


Interventions10 envelopes were prepared, half of which indicated that shaking procedure should be performed during the first observed FHR low variation episode and the remainder indicated that the procedure should be postponed until the second low variation episode. For each participant, an envelope was opened after the first non-reactive trace lasting 10 minutes. Shaking was performed immediately thereafter or postponed until the second such occasion. In this way 2 episodes of low variation were examined in each fetus, 1 serving as control and the other as an experimental observational period.


OutcomesPrimary outcome: FHR reactivity.


NotesManual manipulation involved external stimulation over a 20-second period by the same investigators in all participants. The stimulation consisted of strong shaking movements of the uterus, from 1 side to the other.


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Low riskRandomisation done by draw of sealed envelopes.

Allocation concealment (selection bias)Low riskRandomisation done by draw of sealed envelopes.

Blinding of participants and personnel (performance bias)
All outcomes
Unclear riskUnclear.

Blinding of outcome assessment (detection bias)
All outcomes
Unclear riskUnclear.

Incomplete outcome data (attrition bias)
All outcomes
Low riskFollow-up 100%.

Selective reporting (reporting bias)Low riskAll outcomes in the methods section have been reported on.

Other biasLow riskNo evidence of other forms of bias.

 
Comparison 1. Manual fetal manipulation versus no or mock stimulation

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Non-reactive cardiotocography22350Risk Ratio (M-H, Random, 95% CI)0.31 [0.02, 6.20]

2 Perinatal deaths00Risk Ratio (M-H, Fixed, 95% CI)0.0 [0.0, 0.0]

3 Maternal satisfaction00Risk Ratio (M-H, Fixed, 95% CI)0.0 [0.0, 0.0]

4 Maternal anxiety00Risk Ratio (M-H, Fixed, 95% CI)0.0 [0.0, 0.0]

 5 Mean time of fetal heart rate remaining unreactive2560Mean Difference (IV, Random, 95% CI)-2.29 [-9.61, 5.03]

 
Comparison 2. Manual fetal manipulation versus vibroacoustic stimulation

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Non-reactive cardiotocography1300Risk Ratio (M-H, Fixed, 95% CI)1.47 [0.83, 2.61]

 2 Need for contraction-stress test1300Risk Ratio (M-H, Fixed, 95% CI)2.67 [0.72, 9.86]