Table 6, GRADE findings for predictive value of tachycardia and bradycardia for adverse neonatal outcomes - Addendum to intrapartum care: care for healthy women and babies

Table 6GRADE findings for predictive value of tachycardia and bradycardia for adverse neonatal outcomes

Quality assessment						Definition of outcome	Stage of labour	Total number of women & baby pairs	Measure of diagnostic accuracy (95% CI)				Quality
Number of studies	Design	Risk of bias	Inconsistency	Indirectness	Imprecision	Definition of outcome	Stage of labour	Total number of women & baby pairs	Sensitivity	Specificity	Positive likelihood ratio	Negative likelihood ratio	Quality
Tachycardia (> 150 bpm)(FIGO classification 1987)
1 study (Holzmann 2015)	Prospective cohort	Very serious¹	No serious inconsistency	No serious indirectness	Serious imprecision²	Fetal lactacidaemia (lactate > 4.8 mmol/l)	NR; 60 minutes prior to first fetal blood sampling	1070	62.50% (35.87 to 83.72)^a	67.43% (62.21 to 72.26)^a	1.92 (1.28 to 2.89)^a	0.56 (0.29 to 1.05)^a	Very low
1 study (Holzmann 2015)	Prospective cohort	Very serious¹	No serious inconsistency	No serious indirectness	Serious imprecision²	Fetal lactacidaemia (lactate > 4.8 mmol/l)	NR; 60 minutes prior to last fetal blood sampling	888	64.0% (42.6 to 81.3)^a	66.4% (60.4 to 72.0)^a	1.91 (1.36 to 2.67)^a	0.54 (0.32 to 0.92)^a	Very low
Tachycardia (> 160 bpm) (duration not reported)
1 study (Nelson 1996)	Case control	Serious³	No serious inconsistency	No serious indirectness	No serious imprecision	Cerebral palsy	NR	378	28.2% (19.4 to 39)^b	71.7% (66.3 to 76.5)^b	0.99 (0.66 to 1.48)^b	1.0 (0.85 to 1.17)^b	Low
1 study (Gilstrap 1984)	Cohort	Serious⁴	No serious inconsistency	No serious indirectness	No serious imprecision	Umbilical cord arterial pH < 7.20	NR	583	47.2% (30.9 to 63.5)^b	80.4% (76.9 to 83.87)^b	2.41 (1.63 to 3.55)^b	0.65 (0.48 to 0.89)^b	Moderate
Tachycardia (> 180 bpm) (duration not reported)
1 study (Nelson 1996)	Case control	Serious³	No serious inconsistency	No serious indirectness	No serious imprecision	Cerebral palsy	NR	378	6.4% (2.8 to 14.1)^b	94.7% (91.5 to 96.7)^b	1.20 (0.45 to 3.17)^b	0.98 (0.92 to 1.05)^b	Low
Bradycardia (< 110 bpm) (NICHD classification) (duration not reported)
1 study (Williams 2004)	Case series	Serious⁵	No serious inconsistency	No serious indirectness	No serious imprecision	Seizure	1 hour before birth	50	46.7% (30.2 to 63.9)^b	19.2% (8.5 to 37.9)^b	0.57 (0.37 to 0.88)^b	2.77 (1.17 to 6.52)^b	Low
FHR baseline (< 110 bpm) (NICHD classification) (duration not reported)
1 study (Larma 2007)	Case control	Serious⁶	No serious inconsistency	Serious⁷	No serious imprecision	Moderate HIE	Last hour of tracing	214	15.4 %	98.9%	7.50	0.86	Very low
Bradycardia (“terminal deceleration”)^c
1 study (Cahill 2013)	Case control	No serious risk of bias	No serious inconsistency	No serious inconsistency	No serious imprecision	Umbilical cord arterial pH < 7.10	30 minutes before birth	5388	21.0% (11.3 to 33.9)^b	82.3% (81.3 to 93.4)^b	1.20 (0.72 to 1.98)^b	0.96 (0.84 to 1.10)^b	Low
Bradycardia (“terminal deceleration”)^c
1 study (Cahill 2013)	Case control	No serious risk of bias	No serious inconsistency	No serious inconsistency	No serious imprecision	Umbilical cord arterial pH < 7.10 and base excess < −8.0	30 minutes before birth	5388	22.0% (11.5 to 36.0)^b	82.3% (81.3 to 83.4)^b	1.25 (0.47 to 2.11)^b	0.95 (0.82 to 1.10)^b	Low
Bradycardia (“terminal deceleration”)^c
1 study (Cahill 2013)	Case control	No serious risk of bias	No serious inconsistency	No serious inconsistency	No serious imprecision	NICU admission	30 minutes before birth	5388	06.67% (1.11 to 32.0)^b	82.3% (81.2 to 83.3)^b	0.38 (0.06 to 2.51)^b	1.13 (0.99 to 1.30)	Low
Prolonged bradycardia (< 110 bpm) (≥ 10 min)^d
1 study (Cahill 2013)	Case control	No serious risk of bias	No serious inconsistency	No serious inconsistency	No serious imprecision	Umbilical cord arterial pH < 7.10	30 minutes before birth	951	33.3% (10.13 to 65.5)^b	97.12% (95.84 to 98.1)^b	11.6 (4.80 to 28.0)^b	0.69 (0.46 to 1.02)^b	Low
Bradycardia (< 100 bpm) (duration not reported)
1 study (Nelson 1996)	Case control	Serious³	No serious inconsistency	No serious indirectness	No serious imprecision	Cerebral palsy	NR	378	34.6% (25 to 45.7)^b	75% (69.8 to 79.6)^b	1.38 (0.96 to 1.99)^b	0.87 (0.73 to 1.03)^b	Low
Mild bradycardia (90 – 119 bpm) (duration not reported)
1 study (Gilstrap 1984)	Cohort	Serious⁴	No serious inconsistency	No serious indirectness	No serious imprecision	Umbilical cord arterial pH < 7.20	10 minutes before birth	595	61.2% (47.5 to 74.87)^b	75.2% (71.6 to 78.8)^b	2.47 (1.89 to 3.23)^b	0.51 (0.36 to 0.73)^b	Very low
Bradycardia (< 80 bpm) (duration not reported)
1 study (Nelson 1996)	Case control	Serious³	No serious inconsistency	No serious indirectness	No serious imprecision	Cerebral palsy	NR	378	16.7% (10 to 26.5)^b	88.3% (84.2 to 91.5)^b	1.42 (0.79 to 2.56)^b	0.94 (0.84 to 1.05)^b	Low
Moderate/marked bradycardia (60 – 89 bpm) (duration not reported)
1 study (Gilstrap 1984)	Cohort	Serious⁴	No serious inconsistency	No serious indirectness	No serious imprecision	Umbilical cord arterial pH < 7.20	NR	551	63.4% (50.3 to 76.5)^b	82.3% (79 to 85.7)^b	3.59 (2.71 to 4.76)^b	0.44 (0.30 to 0.63)^b	Moderate
Bradycardic episode (<110 bpm as in FIGO classification 1987)
1 study (Holzmann 2015)	Prospective cohort	Very serious¹	No serious inconsistency	No serious indirectness	Serious imprecision⁸	Fetal lactacidaemia (lactate > 4.8 mmol/l)	NR; 60 minutes prior to first fetal blood sampling	1070	62.50 % (35.87 to 83.72)^a	86.76% (82.02 to 90.44)^a	4.72 (2.90 to 7.68)^a	0.43 (0.23 to 0.81)^a	Very low
1 study (Holzmann 2015)	Prospective cohort	Very serious¹	No serious inconsistency	No serious indirectness	Serious imprecision⁸	Fetal lactacidaemia (lactate > 4.8 mmol/l)	NR; 60 minutes prior to last fetal blood sampling	888	57.1% (34.4 to 77.4)^a	88.1% (82.6 to 92.1)^a	4.81 (2.84 to 8.15)^a	0.49 (0.30 to 0.80)^a	Very low

: BPM beats per minute; CI confidence interval; FIGO International Federation of Gynecology and Obstetrics; HIE hypoxic ischaemic encephalopathy; NICHD National Institute of Child Health and Human Development; NICU Neonatal Intensive Care Unit; NR not reported
a: Calculated by the 2017 NGA technical team
b: Calculated by the 2014 NCC-WCH technical team
c: The term ‘terminal deceleration’ used in the paper for this bradycardia defined as a prolonged deceleration (15 bpm or more below baseline for 2 minutes – 10 minutes)
d: Bradycardia < 10 minutes compared with prolonged bradycardia > 10 minutes
1: All women in the study had received fetal blood sampling (FBS) therefore may not be representative of the whole population. CTGs were classified by a single observer
2: Confidence interval for the negative likelihood ratio crosses 0.5
3: Unclear if assessor was blinded to group allocation. No monitoring traces were available; data were collected from medical notes recorded by physicians who attended the birth
4: Unclear analysis
5: Unclear if babies identified as cases were born to women with a low risk pregnancy
6: Exclusion criteria not specified, high risk of selection bias
7: Unclear if women with pre-existing medical condition were excluded
8: Confidence interval for the positive likelihood ratio crosses 5; confidence interval for the negative likelihood ratio crosses 0.5

From: Appendix I, GRADE tables

Addendum to intrapartum care: care for healthy women and babies.

Clinical Guideline, No. 190.1.

National Guideline Alliance (UK).

London: National Institute for Health and Care Excellence (NICE); 2017 Feb.

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