***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: Background . In a large Swedish multicenter r and omized controlled trial ( RCT ) on intra partum fetal monitoring with automatic analysis of fetal ECG waveform ( STAN ) in combination with cardiotocography ( CTG )  ( 4966 parturients , 300 obstetricians and midwives managing the patients ) , interim analysis revealed protocol violations . By a post hoc analysis of the results over time , factors affecting the acceptance of the new technique were analyzed . Methods . The rates of primary and secondary outcome measures ( fetal outcome , operative deliveries ) were compared in the two study groups ( CTG + ST and CTG only ) . Changes over time were statistically evaluated using a test for homogeneity between the two periods . Results . After retraining , the CTG + ST group showed the lowest rates of operative delivery for fetal distress , fetal blood sampling and admissions to neonatal intensive care unit . Operative deliveries ( p = 0.02 ) and the number of fetal blood sampling decreased significantly over time ( p = 0.001 ) . Conclusions . Training and education probably predisposed the clinicians to a change and reinforced it when it occurred as a result of increased personal experience . The audit and feedback together with the influence of opinion leaders and inter-collegial interactions seem to have been of importance for the successively increasing acceptance of the new method during the RCT Abstract Objective : The aim of this study was to investigate the possible relationship between cord bloodalpha-fetoprotein ( AFP ) level and development of subsequent neonatal hyperbilirubinemia . Study design : The term newborns born between March 2005 and October 2005 were included in the study . Infants with Coombs-positive ABO and /or Rh incompatibility and /or hemolytic jaundice , asphyxia , congenital anomaly and signs of bleeding were excluded from the study .  Cord blood AFP levels  were measured in 504 full term newborns in this period . Infants were followed-up for possible neonatal hyperbilirubinemia . The  capillary bilirubin level ( CBL )  was examined expeditiously in newborns developing jaundice and in other infants at the time discharge while the screening test was being performed . Results : The mean umbilical cord AFP level was 49.1 ± 44.9 mg/L ( range 1.1–396.2 mg/L ) , mean CBL was 5.8 ± 3.1 mg/dL ( range 1–19.4 mg/dL ) , and the mean bilirubin detection time was 37 ± 23.2 hours ( range 12–144 h ) of age . Although a significant positive correlation was found between umbilical cord AFP and CBL levels , it was weak ( r = 0.187 , p < 0.001 ) . Comparison of AFP levels in terms of bilirubin percentile values appropriate for postnatal age also showed a significant weak positive correlation ( r = 0.113 , p < 0.001 ) . Conclusion : The umbilical cord AFP levels may not be used as a strong predictor for the determination of newborns at risk for hyperbilirubinemia Objective . To undertake a renewed analysis of data from the previously published Swedish r and omized controlled trial on intrapartum fetal monitoring with cardiotocography ( CTG‐only ) vs. CTG plus ST analysis of fetal electrocardiogram ( CTG+ST ) , using current st and ards of intention‐to‐treat ( ITT ) analysis and to compare the results with those of the modified ITT ( mITT ) and per protocol analyses . Methods . Renewed extraction of data from the original data base including all cases r and omized according to primary case allocation ( n=5 049 ) . Main outcome measure . Metabolic acidosis in umbilical artery at birth ( pH < 7.05 , base deficit in extracellular fluid > 12.0mmol/l ) including sample s of umbilical vein blood or neonatal blood if umbilical artery blood was missing . Results . The metabolic acidosis rates were 0.66 % ( 17 of 2 565 ) and 1.33 % ( 33 of 2 484 ) in the CTG+ST and CTG‐only groups , respectively [ relative risk ( RR ) 0.50 ; 95 % confidence interval ( CI ) 0.28–0.88 ; p=0.019 ] . The original mITT gave RR 0.47 , 95%CI 0.25–0.86 ( p=0.015 ) , mITT with correction for 10 previously misclassified cases RR 0.48 , 95%CI 0.24–0.96 ( p=0.038 ) and per protocol analysis RR 0.40 , 95%CI 0.20–0.80 ( p=0.009 ) . The level of significance of the difference in metabolic acidosis rates between the two groups remained unchanged in all analyses . Conclusion . Re‐ analysis of data according to the ITT principle showed that regardless of the method of analysis , the Swedish r and omized controlled trial maintained its ability to demonstrate a significant reduction in metabolic acidosis rate when using CTG+ST analysis for fetal surveillance in labor OBJECTIVE Cardiotocography plus automatic ST analysis of the fetal electrocardiography has been shown recently to reduce both the operative delivery rate for fetal distress and the cord artery metabolic acidosis rate . The purpose of this study was to analyze findings that were related to cases with a complicated/adverse neonatal outcome in the Swedish r and omized controlled trial . STUDY DESIGN Of the 4966 term fetuses that were included in the trial , all 351 newborn infants who required special neonatal care were identified . Cases of perinatal death , neonatal encephalopathy , or metabolic acidosis at birth were review ed . RESULTS Of the 29 fetuses with adverse/complicated neonatal outcome , 22 fetuses had cardiotocography and ST patterns that indicated a need for intervention , according to the cardiotocography plus ST clinical guidelines . The number of live-born with moderate or severe neonatal encephalopathy showed a significant decrease from 0.33 % ( 8/2447 fetuses ) in the cardiotocography-only group to 0.04 % ( 1/2519 fetuses ) in the cardiotocography plus ST group . CONCLUSION Cardiotocography plus ST analysis provides accurate information about intrapartum hypoxia and may prevent intrapartum asphyxia and neonatal encephalopathy by giving a clear alert to the staff members who are in charge OBJECTIVE : To estimate the effectiveness of intrapartum fetal monitoring by cardiotocography plus ST analysis using a strict protocol for performance of fetal blood sampling . METHODS : We performed a multicenter r and omized trial among laboring women with a high-risk singleton pregnancy in cephalic presentation beyond 36 weeks of gestation . Participants were assigned to monitoring by cardiotocography with ST analysis ( index ) or cardiotocography only ( control ) . Primary outcome was metabolic acidosis , defined as an umbilical cord artery pH below 7.05 combined with a base deficit calculated in the extracellular fluid compartment above 12 mmol/L. Secondary outcomes were metabolic acidosis in blood , operative deliveries , Apgar scores , neonatal admissions , and hypoxic – ischemic encephalopathy . RESULTS : We r and omly assigned 5,681 women to the two groups ( 2,832 index , 2,849 control ) . The fetal blood sampling rate was 10.6 % in the index compared with 20.4 % in the control group ( relative risk 0.52 ; 95 % [ CI ] 0.46–0.59 ) . The primary outcome occurred 0.7 % in the index compared with 1.1 % in the control group ( relative risk 0.70 ; 95 % CI 0.38–1.28 ; number needed to treat 252 ) . Using metabolic acidosis calculated in blood , these rates were 1.6 % and 2.6 % , respectively ( relative risk 0.63 ; 95 % CI 0.42–0.94 ; number needed to treat 100 ) . The number of operative deliveries , low Apgar scores , neonatal admissions , and newborns with hypoxic – ischemic encephalopathy was comparable in both groups . CONCLUSION : Intrapartum monitoring by cardiotocography combined with ST analysis does not significantly reduce the incidence of metabolic acidosis calculated in the extracellular fluid compartment . It does reduce the incidence of metabolic acidosis calculated in blood and the need for fetal blood sampling without affecting the Apgar score , neonatal admissions , hypoxic – ischemic encephalopathy , or operative deliveries . CLINICAL TRIAL REGISTRATION : IS RCT N Register , www.is rct n.org , IS RCT N95732366 . LEVEL OF EVIDENCE : BACKGROUND It is unclear whether using fetal electrocardiographic ( ECG ) ST-segment analysis as an adjunct to conventional intrapartum electronic fetal heart-rate monitoring modifies intrapartum and neonatal outcomes . METHODS We performed a multicenter trial in which women with a singleton fetus who were attempting vaginal delivery at more than 36 weeks of gestation and who had cervical dilation of 2 to 7 cm were r and omly assigned to " open " or " masked " monitoring with fetal ST-segment analysis . The masked system functioned as a normal fetal heart-rate monitor . The open system displayed additional information for use when uncertain fetal heart-rate patterns were detected . The primary outcome was a composite of intrapartum fetal death , neonatal death , an Apgar score of 3 or less at 5 minutes , neonatal seizure , an umbilical-artery blood pH of 7.05 or less with a base deficit of 12 mmol per liter or more , intubation for ventilation at delivery , or neonatal encephalopathy . RESULTS A total of 11,108 patients underwent r and omization ; 5532 were assigned to the open group , and 5576 to the masked group . The primary outcome occurred in 52 fetuses or neonates of women in the open group ( 0.9 % ) and 40 fetuses or neonates of women in the masked group ( 0.7 % ) ( relative risk , 1.31 ; 95 % confidence interval , 0.87 to 1.98 ; P=0.20 ) . Among the individual components of the primary outcome , only the frequency of a 5-minute Apgar score of 3 or less differed significantly between neonates of women in the open group and those in the masked group ( 0.3 % vs. 0.1 % , P=0.02 ) . There were no significant between-group differences in the rate of cesarean delivery ( 16.9 % and 16.2 % , respectively ; P=0.30 ) or any operative delivery ( 22.8 % and 22.0 % , respectively ; P=0.31 ) . Adverse events were rare and occurred with similar frequency in the two groups . CONCLUSIONS Fetal ECG ST-segment analysis used as an adjunct to conventional intrapartum electronic fetal heart-rate monitoring did not improve perinatal outcomes or decrease operative-delivery rates . ( Funded by the Eunice Kennedy Shriver National Institute of Child Health and Human Development and Neoventa Medical ; Clinical Trials.gov number , NCT01131260 . ) OBJECTIVE To determine the possibilities of ST analysis of fetal ECG ( STAN ) in premature deliveries between 30th to 36th week of pregnancy . To compare the results of a group of premature deliveries monitored by ST analysis with a control group of premature deliveries monitored by means of cardiotocography ( CTG ) and intrapartum fetal pulse oxymetry ( IFPO ) . TYPE OF STUDY A prospect i ve study . SETTING Department of Gynecology-Obstetrics , Masaryk University and Faculty Hospital Brno . METHODS The authors evaluated 39 women with premature delivery between 30th and 36th week of pregnancy from a total cohort of 239 high-risk pregnant women , who had been monitored by means of ST analysis of fetal ECG . The control group included 229 pregnant women who gave birth between 30th and 36th week of pregnancy under the monitoring with CTG and IFPO .  The allocation into individual groups was at r and om order . The authors evaluated the duration and way of termination of delivery , pH in arterial umbilical blood , Apgar score in the first , fifth and tenth minute , total duration of hospitalization , necessity and duration of stay at the Neonatologic Intensive Care Unit , Intermediatry Intensive Care Unit , the presence of sepsis , hyperbilirubinemia and neurological state of the newborn . The statistical analysis was performed by means of the Fisher 's exact test , Kruskal-Wallis test , chi2 test and the parametric test Anova . RESULTS Almost none of the observed parameters in both categories of premature deliveries ( STAN vs. CTG+IFPO ) exhibited a statistically significant difference except a mild neurological affection of the newborn . In the group of premature deliveries monitored by ST analysis there are only 33.3 % of newborns with signs of light neurological damage as compared with the control group , where 56.3 % subjects were so affected ( p<0.01 ) . CONCLUSION It has become obvious that the ST analysis of fetal ECG in premature deliveries between 30th and 36th week of pregnancy provides the same results as the so far used monitoring by CTG and IFPO . In the group of premature deliveries monitored by the ST analysis , there 
    Output:
    
There was little evidence that monitoring by PR interval analysis conveyed any benefit of any sort .
The modest benefits of fewer  fetal scalp samplings  during labour ( in setting s in which this procedure is performed ) and fewer instrumental vaginal births have to be considered against the disadvantages of needing to use an internal scalp electrode , after membrane rupture , for ECG waveform recordings .
We found little strong evidence that ST waveform analysis had an effect on the primary outcome measures in this systematic review .There was a lack of evidence showing that PR interval analysis improved any outcomes ; and a larger future trial may possibly demonstrate beneficial effects .
There is little information about the value of fetal ECG waveform monitoring in preterm fetuses in labour .