PONE-D-24-48368AI-Driven Fetal Distress Monitoring in AI-Native 6G Networks: An SDN-IoMT Framework for Enhanced Medical ConnectivityPLOS ONE

Dear Dr. Haq,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

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Agnese Sbrollini

Academic Editor

PLOS ONE

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: No

Reviewer #2: Yes

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2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: N/A

Reviewer #2: Yes

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3. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #2: Yes

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4. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: No

Reviewer #2: Yes

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5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: The paper describes the implementation of SDN and DL for fetal data streaming and classification. In the current form, it is very unclear the main contribution of the paper. It seems to tackle too many complex problems and not one in detail. For example, many information about the 6G network and SDN are provided but no formal tests have been reported. A Generative model is said to be developed for handling data imbalance, but no results on the quality of the generated data are reported. Finally, DL models are compared to determine fetal distress but i) no clear information about the gold standard are reported; ii) performance metrics not clear; and iii) model selection performed on the test set, which is a well-known methodological mistake. In addition, the paper requires extensive revision for clarity. Please find below other concerns.

-Not clear who and how were defined the categories for fetal distress.

-The performance metrics reported are suitable for binary classification. However, the problem tackled was a 3-class classification problem. Not sure authors computed exactly these quantitities. At a certain point, the problem becomes a binary one. Not clear at all.

-What is the objective of the authors with "we published the results based on the model that achieved the best detection rate in the test dataset"? Doing so, the test set becomes another validation set because selection is performed on these data. It is a methodological mistake if not well motivated.

-Figure 1 is never mentioned in the text.

-Figure 2 shows many CTG devices connected and able to stream their data. However, I am not aware of any commercial device which can do that.

-Please check the instruction for authors since the table of acronyms is rarely allowed by journals. Also, check all acronyms are instantiated once and in the right order (e.g. DL is used before instantiation)

-What is BV?

-Are authors sure that the GAN proposed in [21] is called "Reconstruction Error"?

-What is FHR's decentralization?

Reviewer #2: 1. The Sensing layer described is only meant to detect fetal cardiac activity and some maternal vital signs. It does not

detect uterine contractions. While fetal cardiac activity is interpreted based on uterine contraction. The sensing

should be able or developed to detect uterine contractions as well.

2. Why did was median used against mean to replace the missing data dst and bst?

3. Blood pressure (BP) of 139/99 is not normal (Table 2). Any diastolic BP greater that 89mmHg is High. With this AI

devise women with hypertensive disorders of pregnancy may be missed in the antenatal or labour period.

4. For more information on Blood pressure in pregnancy, check guidelines by International Society for the Study of Hypertension in Pregnancy and FIGO.

5. Other comments and corrections are in the text

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Reviewer #1: No

Reviewer #2: Yes: Dr Bilal Sulaiman

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Attachments

Attachment

Submitted filename: PONE-D-24-48368_reviewer.pdf

PONE-D-24-48368R1AI-Driven Fetal Distress Monitoring SDN-IoMT NetworksPLOS ONE

Dear Dr. Haq,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

Please submit your revised manuscript by Jun 18 2025 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:

• A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.
• A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.
• An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: https://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols. Additionally, PLOS ONE offers an option for publishing peer-reviewed Lab Protocol articles, which describe protocols hosted on protocols.io. Read more information on sharing protocols at https://plos.org/protocols?utm_medium=editorial-email&utm_source=authorletters&utm_campaign=protocols.

We look forward to receiving your revised manuscript.

Kind regards,

Agnese Sbrollini

Academic Editor

PLOS ONE

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #2: (No Response)

Reviewer #3: All comments have been addressed

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2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #2: Yes

Reviewer #3: Yes

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3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #2: Yes

Reviewer #3: Yes

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4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #2: Yes

Reviewer #3: No

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5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #2: Yes

Reviewer #3: Yes

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6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #2: 1. The revised manuscript neither have highlight nor tract changes to indicated changes made on it. This made it so difficult to identify changes made on the article.

2. There is no accompanying document explaining the responses line by line made by the reviewers.

Reviewer #3: Dear Authors,

Thank you for the opportunity to review your revised manuscript. Overall, you have strengthened the technical presentation and addressed many of the points from the previous round. Below, I summarize my key comments and remaining concerns:

Technical Rigor & Data Support

Your SDN-IoMT simulation using Mininet/ONOS and the GAN-AE models is well described, and your reported performance metrics (Accuracy, Precision, Recall, F1-score) are supported by the underlying data.

Repeating each experiment 100 times improves confidence in stability, and your binary and multiclass comparisons clearly demonstrate the benefit of GAN-based augmentation.

Statistical Analysis

Please include measures of variability (e.g., standard deviations or 95% confidence intervals) for your key metrics across the 100 runs.

Consider a formal paired statistical test (e.g., McNemar’s test or bootstrap confidence intervals) when comparing your GAN-AE models against baseline models to demonstrate significance.

Data Availability

While the CTU-UHB public dataset is fully accessible, the synthetic and clinical data generated in your SDN-IoMT simulations remain unpublished. Please deposit these source files (simulation scripts, anonymized clinical recordings, and any synthesized data) in a public repository or provide clear instructions for controlled access.

If data sharing is constrained by patient confidentiality, describe the anonymization process and specify how qualified researchers can obtain full datasets under an appropriate agreement.

CTG Scoring & Clinical Context

Clarify the intended application window: your framework has been trained on antepartum data. If you intend it for intrapartum (labor) monitoring, please discuss how uterine activity and labor stress patterns might affect performance.

Although you define custom thresholds for FHR, variability, accelerations, and decelerations, please justify these relative to established clinical guidelines (Fisher/Krebs, FIGO, or Dawes-Redman). If STV/LTV or sinusoidal pattern detection was not feasible, explain why and discuss the potential impact on detection of rare but critical pathologies.

Minor Points

In Table 1, please add Celsius equivalents for body temperature (36.1–37.2 °C).

Correct minor language issues (e.g., “heterogeneity” vs. “heterogeneous”) and ensure consistent figure axis labels.

Once these points are addressed, I believe your manuscript will be suitable for publication.

Best regards,

Yuliia Balycheva

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7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #2: Yes: Bilal Sulaiman

Reviewer #3: No

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[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step.

Attachments

Attachment

Submitted filename: review.pdf

AI-Driven Fetal Distress Monitoring SDN-IoMT Networks

PONE-D-24-48368R2

Dear Dr. Haq,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

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If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they’ll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org.

Kind regards,

Agnese Sbrollini

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #3: All comments have been addressed

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2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #3: Yes

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #3: Yes

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #3: Yes

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #3: Yes

**********

6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #3: The authors have adequately addressed all major comments from the previous review round. In particular, they clarified the clinical rationale for their CTG classification thresholds by aligning them with FIGO and Fisher/Krebs standards, and they explained the justified exclusion of STV, LTV, and sinusoidal patterns due to dataset limitations. Statistical validation has been improved with confidence intervals and appropriate significance testing. The revised manuscript is technically sound, clinically relevant, and ready for publication.

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7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #3: No

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