Cardiotocography Interpretation Research Articles

Cardiotocography interpretation and timely Intervention: is it possible to reduce neonatal injury and medico-legal risks?

Cardiotocography interpretation and timely Intervention: is it possible to reduce neonatal injury and medico-legal risks?

Improving midwives' management of occiput-posterior fetal positions: a best practice implementation project.

The occiput-posterior (OP) fetal position is the most frequent form of labor dystocia. This position has been associated with delaying the second stage of labor and adverse outcomes. This project aimed to improve the quality of intrapartum care provided by midwives for OP fetal positions during the second stage of labor. This best practice implementation project was conducted at the Río Hortega University Hospital in Valladolid, Spain. The project followed the JBI Evidence Implementation Framework, which is based on an audit, feedback, and re-audit process. Current practices were compared against best practices in a baseline audit using 13 audit criteria. Barriers to compliance with best practices were identified and improvement strategies were implemented. An initial follow-up audit was carried out after 4 months to avoid secondary bias. After another 4 months, a second follow-up audit was conducted. Data were collected and compared using the JBI Practical Application of Clinical Evidence System (JBI PACES). The results revealed an improvement in all structure criteria (1-3), five of the process criteria (4-6, 8, 10), and all results criteria (11-13). One process criterion (8) reached maximum compliance in all audits. A key finding was the inadequate recording of upright positions (criterion 7) and the interpretation of cardiotocography (criterion 9). Evidence-based interventions for managing OP labor improved the quality of care and underlined the importance of ongoing training for midwives. Additional studies are required on positions and fetal monitoring during labor. http://links.lww.com/IJEBH/A279.

International expert consensus statement on physiological interpretation of cardiotocograph (CTG): First revision (2024)

The first international consensus guideline on physiological interpretation of cardiotocograph (CTG) produced by 44 CTG experts from 14 countries was published in 2018. This guideline ensured a paradigm shift from classifying CTG by arbitrarily grouping certain features of the fetal heart rate into different “categories”, and then, randomly combining them to arrive at an overall classification of CTG traces into “Normal, Suspicious and Pathological” (or Category I, II and III) to a classification which is based on the understanding of fetal pathophysiology. The guideline recommended the recognition of different types of fetal hypoxia, and the determination of features of fetal compensatory responses as well as decompensation to ongoing hypoxic stress on the CTG trace. Since its first publication in 2018, there have been several scientific publications relating physiological interpretation of CTG, especially relating to features indicative of autonomic instability due to hypoxic stress (i.e., the ZigZag pattern), and of fetal inflammation. Moreover, emerging evidence has suggested improvement in maternal and perinatal outcomes in maternity units which had implemented physiological interpretation of CTG. Therefore, the guideline on Physiological Interpretation of CTG has been revised to incorporate new scientific evidence, and the interpretation table has been expanded to include features of chorioamnionitis and relative utero-placental insufficiency of labour (RUPI-L).

Reducing perinatal anoxia related to childbirth – A quality improvement project

ABSTRACT Background Hypoxic-ischemic encephalopathy occurs at a rate of 2–9 cases per 1000 births, with intrapartum hypoxia being the primary cause. Therefore, it is crucial to enhance fetal monitoring during labour, focusing on the delivery process and the interpretation of cardiotocography. Method This study aimed to reduce the incidence of perinatal asphyxia from 1.4 to 0.25 per 1000 live births over a 12-month period at a maternity hospital, utilising principles of Quality Quality Improvement. The flow of pregnant women and its vulnerabilities were analysed using the SIPOC tool and Ishikawa diagram. An action plan was developed based on a guiding diagram and executed through PDSA (Plan-Do-Study-Act) cycles, concentrating on four secondary drivers: training, infrastructure, service efficiency, and effective communication. Results The outcomes indicate a reduction in anoxia from 1.4 to 0.2 per 1000 births, along with a decrease in the average rate of APGAR scores below 7 at the fifth minute from 2.07% to 0.45%, with no change in the c-section delivery rate. Conclusion The implementation of a quality improvement model aimed at redesigning the process of assessing fetal vitality during labour resulted in a reduction in perinatal anoxia at a public hospital in Brazil.

ENhancinG vAGinal dElivery in Greece through educational and behavioral interventions among maternity care providers regarding labor management: the ENGAGE stepped-wedge randomized prospective trial protocol

BackgroundThere is an emerging need to systematically investigate the causes for the increased cesarean section rates in Greece and undertake interventions so as to substantially reduce its rates. To this end, the ability of the participating Greek obstetricians to follow evidence-based guidelines and respond to other educational and behavioral interventions while managing labor will be explored, along with barriers and enablers. Herein discussed is the protocol of a stepped-wedge designed intervention trial in Greek maternity units with the aforementioned goals in mind, named ENGAGE (ENhancinG vAGinal dElivery in Greece).MethodsTwenty-two selected maternity units in Greece will participate in a multicenter stepped-wedge randomized prospective trial involving 20,000 to 25,000 births, with two of them entering the intervention period of the study each month (stepped randomization). The maternity care units entering the study will apply the suggested interventions for a period of 8–18 months depending on the time they enter the intervention stage of the study. There will also be an initial phase of the study lasting from 8 to 18 months including observation and recording of the routine practice (cesarean section, vaginal birth, and maternal and perinatal morbidity and mortality) in the participating units. The second phase, the intervention period, will include such interventions as the application of the HSOG (the Hellenic Society of Obstetrics and Gynecology) Guidelines on labor management, training on the correct interpretation of cardiotocography, and dealing with emergencies in vaginal deliveries, while the steering committee members will be available to discuss and implement organizational and behavioral changes, answer questions, clarify relevant issues, and provide practical instructions to the participating healthcare professionals during regular visits or video conferences. Furthermore, during the study, the results will be available for the participating units in order for them to monitor their own performance while also receiving feedback regarding their rates. Τhe final 2-month phase of the study will be devoted to completing follow-up questionnaires with data concerning maternal and neonatal morbidities that occurred after the completion of the intervention period. The total duration of the study is estimated at 28 months. The primary outcome assessed will be the cesarean section rate change and the secondary outcomes will be maternal and neonatal morbidity and mortality.DiscussionThe study is expected to yield new information on the effects, advantages, possibilities, and challenges of consistent clinical engagement and implementation of behavioral, educational, and organizational interventions described in detail in the protocol on cesarean section practice in Greece. The results may lead to new insights into means of improving the quality of maternal and neonatal care, particularly since this represents a shared effort to reduce the high cesarean section rates in Greece and, moreover, points the way to their reduction in other countries.Trial registrationNCT 04504500 (ClinicalTrials.gov). The trial was prospectively registered.Ethics Reference No: 320/23.6.2020, Bioethics and Conduct Committee, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece

Neonatal Outcome in Relation to Cardiotocography Interpretation During Pregnancy

Neonatal Outcome in Relation to Cardiotocography Interpretation During Pregnancy

Large-scale analysis of interobserver agreement and reliability in cardiotocography interpretation during labor using an online tool

BackgroundWhile the effectiveness of cardiotocography in reducing neonatal morbidity is still debated, it remains the primary method for assessing fetal well-being during labor. Evaluating how accurately professionals interpret cardiotocography signals is essential for its effective use. The objective was to evaluate the accuracy of fetal hypoxia prediction by practitioners through the interpretation of cardiotocography signals and clinical variables during labor.Material and methodsWe conducted a cross-sectional online survey, involving 120 obstetric healthcare providers from several countries. One hundred cases, including fifty cases of fetal hypoxia, were randomly assigned to participants who were invited to predict the fetal outcome (binary criterion of pH with a threshold of 7.15) based on the cardiotocography signals and clinical variables. After describing the participants, we calculated (with a 95% confidence interval) the success rate, sensitivity and specificity to predict the fetal outcome for the whole population and according to pH ranges, professional groups and number of years of experience. Interobserver agreement and reliability were evaluated using the proportion of agreement and Cohen’s kappa respectively.ResultsThe overall ability to predict a pH level below 7.15 yielded a success rate of 0.58 (95% CI 0.56-0.60), a sensitivity of 0.58 (95% CI 0.56-0.60) and a specificity of 0.63 (95% CI 0.61-0.65). No significant difference in the success rates was observed with respect to profession and number of years of experience. The success rate was higher for the cases with a pH level below 7.05 (0.69) and above 7.20 (0.66) compared to those falling between 7.05 and 7.20 (0.48). The proportion of agreement between participants was good (0.82), with an overall kappa coefficient indicating substantial reliability (0.63).ConclusionsThe use of an online tool enabled us to collect a large amount of data to analyze how practitioners interpret cardiotocography data during labor. Despite a good level of agreement and reliability among practitioners, the overall accuracy is poor, particularly for cases with a neonatal pH between 7.05 and 7.20. Factors such as profession and experience level do not present notable impact on the accuracy of the annotations. The implementation and use of a computerized cardiotocography analysis software has the potential to enhance the accuracy to detect fetal hypoxia, especially for ambiguous cardiotocography tracings.

Hybrid-FHR: a multi-modal AI approach for automated fetal acidosis diagnosis

BackgroundIn clinical medicine, fetal heart rate (FHR) monitoring using cardiotocography (CTG) is one of the most commonly used methods for assessing fetal acidosis. However, as the visual interpretation of CTG depends on the subjective judgment of the clinician, this has led to high inter-observer and intra-observer variability, making it necessary to introduce automated diagnostic techniques.MethodsIn this study, we propose a computer-aided diagnostic algorithm (Hybrid-FHR) for fetal acidosis to assist physicians in making objective decisions and taking timely interventions. Hybrid-FHR uses multi-modal features, including one-dimensional FHR signals and three types of expert features designed based on prior knowledge (morphological time domain, frequency domain, and nonlinear). To extract the spatiotemporal feature representation of one-dimensional FHR signals, we designed a multi-scale squeeze and excitation temporal convolutional network (SE-TCN) backbone model based on dilated causal convolution, which can effectively capture the long-term dependence of FHR signals by expanding the receptive field of each layer’s convolution kernel while maintaining a relatively small parameter size. In addition, we proposed a cross-modal feature fusion (CMFF) method that uses multi-head attention mechanisms to explore the relationships between different modalities, obtaining more informative feature representations and improving diagnostic accuracy.ResultsOur ablation experiments show that the Hybrid-FHR outperforms traditional previous methods, with average accuracy, specificity, sensitivity, precision, and F1 score of 96.8, 97.5, 96, 97.5, and 96.7%, respectively.ConclusionsOur algorithm enables automated CTG analysis, assisting healthcare professionals in the early identification of fetal acidosis and the prompt implementation of interventions.

Recognition of Chorioamnionitis on the Cardiotocograph (CTG): The role of the “Chorio Duck Score”

Chorioamnionitis refers to the inflammation of the chorion and amnion by the bacteria and their toxins as well as by the inflammatory cytokines. Therefore, it is a fetal disease with the bacteria, their toxins as well as the fetal immunological responses involving inflammatory cytokines (interleukins, interferons, and tumour necrosis factor-alpha) exerting their detrimental effects within the fetal compartment (i.e., amniotic fluid, fetal membranes, the placenta, and fetal tissues and organs). The vast majority of fetal inflammation occurs as a result of an ascending infection (i.e., entry of the bacteria from the maternal genital tract through the cervix). Therefore, maternal signs (tachycardia and pyrexia) may not be observed until the late stages of the disease. Cardiotocograph (CTG) trace was introduced into clinical practice in the 1960s as a tool to timely recognise ongoing fetal hypoxic stress so that immediate action could be taken to avoid hypoxic ischaemic encephalopathy (HIE) and/ or intrapartum hypoxia-related perinatal deaths. Unfortunately, the CTG was introduced into clinical practice without any prior randomised controlled trials, which resulted in panicking and reacting to the observed morphology of fetal heart rate decelerations, which reflect an ongoing fetal compensatory response to reduce the myocardial workload. A sudden and reflex reduction of the heart rate in response to ongoing intermittent hypoxic stress (i.e., repetitive compression of the umbilical cord or interruptions in uteroplacental oxygenation due to uterine contractions) would ensure a reduction in myocardial oxygen demand and maintenance of aerobic metabolism to avoid the onset of anaerobic metabolism and production of lactic acid within the myocardium. Lack of understanding of fetal compensatory responses resulted in the illogical approach of grouping arbitrary features into different categories and then randomly combining them to classify the CTG traces into “Normal, Suspicious, and Pathological”. The same parameters were used in fetuses with chorioamnionitis with an alternative, inflammatory pathway of neurological injury. The international consensus guidelines of physiological interpretation of CTG produced by 44 CTG experts from 14 countries in 2018 ensured a paradigm shift and recommended classification of CTG traces based on the type of fetal hypoxia and fetal response to stress, by applying the knowledge of fetal physiology whilst interpreting CTG traces. During the last 5 years, research has highlighted CTG features in fetal neuro-inflammation, which include an absence of fetal heart rate cycling, the ZigZag Pattern, and sinusoidal patterns. The proposed “Chorio Duck Score” is a scoring system based on recently published scientific evidence on CTG features in subclinical and clinical chorioamnionitis to enable timely diagnosis of fetal systemic inflammatory response syndrome (FIRS). This will help avoid the continuation of super-imposed hypoxic stress (i.e., progressive increasing frequency, duration, and strength of uterine contractions) on the background fetal inflammation, to prevent fetal neurological injury.

Performance of five cardiotocography classification templates in labor: a cohort study

Objective New guidelines for the interpretation of cardiotocography (CTG) have been presented by FIGO in 2015 (FIGO-15) and by NICE in 2017 (NICE-17) and 2022 (NICE-22) In Sweden, a previous template from 2009 (SWE-09) was replaced in 2017 (SWE-17). The objective of the study was to compare these five different templates for CTG classification regarding sensitivity, specificity, positive and negative predictive values in identifying neonates with acidemia at birth (cord artery pH <7.10). Methods This is a historical cohort study including singleton births in Lund November 2015–February 2016, after spontaneous or induced labor at ≥34 completed gestational weeks with validated umbilical cord acid-base samples. Characteristics of cardiotocographic traces during the last hour before birth were reviewed by two independent assessors blinded to outcome. Each template was then used to classify the CTG as normal, suspicious, or pathological. Traces for which classification differed between the two assessors for any of the templates were assessed by a third assessor. The classification by majority (at least 2 of 3) was used for analyses. Main outcome measures were the sensitivity, specificity, and positive and negative predictive values for each template to identify neonates with cord artery pH <7.10 by the classification pathological. In a secondary analysis, these outcome measures were calculated for the classifications suspicious + pathological together. Results SWE-09 and NICE-22 had significantly higher sensitivity (both 92%; 95% CI 79-98%) than NICE-17 (68%; 51–82%), FIGO-15 (42%; 26–59%) and SWE-17 (39%; 24–57%) to identify neonates with acidemia by the classification pathological. Specificity was significantly higher for SWE-17 (91%; 88–93%), FIGO-15 (90%; 88–93%) and NICE-17 (78%; 74–81%) than for NICE-22 (63%; 59–67%) and SWE-09 (62%; 58–66%). The positive predictive value of a pathological pattern ranged between 15% (SWE-09 and NICE-22) and 24% (FIGO-15), and negative predictive values between 95% (SWE-17) and 99% (SWE-09 and NICE-22). Combining suspicious and pathological patterns increased the sensitivity and decreased the specificity for all templates. Conclusions Current CTG interpretation templates either have low sensitivity to identify fetal acidemia or low specificity. Among current guidelines, NICE 2022 had the highest sensitivity to identify neonates with acidemia and is considered the safest current classification system. Efforts to further improve diagnostic precision are warranted.

Interobserver agreement of intrapartum cardiotocography interpretation by midwives using current FIGO and physiology-based guidelines

Objectives To investigate the interobserver agreement among midwives for the interpretation of intrapartum CTG traces, using both the 2015 FIGO guidelines and the physiology-based guidelines. Material and methods Retrospective, single-center, observational study conducted at the Maternity Hospital of the University of Parma, Italy, between November 2022 and July 2023. We selected 100 nonconsecutive intrapartum CTG traces from women undergoing operative delivery (cesarean or instrumental vaginal delivery). Participating midwives received the last 60 min of CTG recording prior to the decision for an operative delivery was made. Five midwives with different professional experience classified the CTG tracing according to the 2015 FIGO guidelines and the physiology-based guidelines at the time of the decision for the operative delivery. Each midwife was categorized as senior or junior if her clinical experience was equal or more or less than 5 years. All participating midwives were blinded to the demographic and clinical variables of each case, as well as to the labor and neonatal outcome. The main outcome of the study was the interobserver agreement among the 5 midwives with either guideline. The secondary outcome was the interobserver agreement based on clinical experience. The agreement between the observers was estimated through the Krippendorff’s alpha statistics. Results The interobserver agreement for the interpretation of intrapartum CTG traces according to the 2015 FIGO guideline was in the upper limit of the “unacceptable” classification, with a Krippendorff’s alpha of 0.632 (95% CI, 0.545–0.723). The interobserver agreement of the physiology-based CTG guideline was classified as “unacceptable” with a Krippendorff’s alpha of 0.359 (95% CI, 0.125–0.582). The interobserver agreement among senior midwives according to the 2015 FIGO guidelines was considered as “tentative acceptable agreement” with a Krippendorff’s alpha of 0.724 (95% CI, 0.636–0.805). Among junior midwives, the interobserver agreement according to the latter guideline was classified as “unacceptable” with a Krippendorff’s alpha of 0.569 (95% CI, 0.359–0.751). Using the physiology-based guideline, the interobserver agreement of the senior midwives – Krippendorff’s alpha 0.493 (95% CI, 0.320–0.623) – and “junior” midwives – Krippendorff’s alpha 0.359 (95% CI, 0.100–0.581) – were considered both “unacceptable”. Conclusions Our study showed that intrapartum CTG interpretation is characterized by an overall unacceptable level of interobserver agreement among midwives, with the 2015 FIGO guidelines showing better agreement compared to physiology-based guidelines. The interpretation of intrapartum CTG by “senior” midwives using the 2015 FIGO guidelines showed the highest, interobserver agreement, indicating a “tentative acceptable agreement”.

Updated NICE Cardiotocograph (CTG) Guideline: Is it Suspicious or Pathological?

Cardiotocograph (CTG) trace was introduced into clinical practice in 1960s as a tool to record the changes in the fetal heart rate (cardio) in response to ongoing uterine contractions (toco). The intention was to timely recognise the features of fetal decompensation so that immediate action could be taken to avoid hypoxic ischaemic encephalopathy (HIE) and/ or intrapartum hypoxia-related perinatal deaths, without increasing unnecessary operative interventions to the mother. However, very unfortunately, unlike other tools in clinical medicine, CTG was introduced into clinical practice without any randomised controlled trials or robust scientific studies not only to confirm its effectiveness, but to determine the CTG features which actually reflected fetal central organ oxygenation. This chasm of deficiency of knowledge of fetal physiology created a vacuum of understanding regarding what features were reflecting fetal compromise. Regrettably, this vacuum was soon filled by prominent obstetricians from national societies who were presumed to have the knowledge, but they began the arduous journey of classifying decelerations which are normal fetal cardioprotective reflexes, and they misclassified them as signs of “fetal distress”. Classification of these decelerations based on the observed morphology into “reassuring” and “nonreasoning” categories has resulted in disastrous consequences for women and babies. In the UK, since the publication of the first CTG guideline in 2001, due to continuing lack of knowledge and confusion, these guidelines were repetitively revised in 2007, 2014, 2017 and 2022. Despite the international consensus guidelines of physiological interpretation of CTG produced by 44 CTG experts from 14 countries which recommended classification of CTG traces based on the type of fetal hypoxia and fetal response to stress, the latest revised guideline produced by the National Institute of Health and Care Excellence (NICE), had continued the illogical approach of grouping arbitrary features into different categories and then randomly combining them to classify the CTG traces into “Normal, Suspicious and Pathological”. Therefore, all practising clinicians who are focussed on protecting their patients from harm have a responsibility to ask the question whether the revised NICE CTG Guideline itself is suspicious or pathological from a patient safety perspective.

Neonatal factors associated with immediate low Apgar score in newborn babies in an intermediate hospital in Namibia: a case control study.

Apgar score is conducted to a baby immediately after birth checking how the baby tolerated the birth process and outside the uterus. To describe the neonatal factors associated with immediate low Apgar score and analysing the associations among factors associated with low Apgar score in new-born babies. A quantitative, case-control, descriptive research design was used. Study population were all maternal records of deliveries conducted between 01 January 2019 and 31 December 2019. Simple random sampling was used to select the sample size for 194 cases and 194 controls using a 1:1 case-control ratio. Records indicating low Apgar scores were the cases while normal Apgar scores were the controls. A total of 388 maternal files were reviewed. Data were collected using a document review checklist and analysed using SPSS version 26. The study found that, neonatal factors associated with immediate low Apgar score are; gestational age, foetal presentation, cord prolapse, cord around the neck and the importance of cardiotocography interpretation as they had a P-value > 0.005. Gestational age, birth weight, foetal presentation, cord around the neck and lack of cardiotocography assessment were found to be associated with immediate low Apgar score.

Immediate and longer-term impacts of fetal surveillance education on workforce knowledge and cognitive skills.

Background: Following the development of the Royal Australian College of Obstetricians and Gynaecologists Intrapartum Fetal Surveillance Guideline in 2003, an education program was developed to support guideline implementation and clinical practice. It was intended that improved clinician knowledge, particularly of cardiotocography, would reduce rates of intrapartum fetal morbidity and mortality. The program contains a multiple-choice assessment, designed to assess fetal surveillance knowledge and the application of that knowledge. We used the results of this assessment over time to evaluate the impact of the education program on clinicians' fetal surveillance knowledge and interpretive skills, in the immediate and longer-term. Methods: We undertook a retrospective analysis of the assessment results for all participants in the Fetal Surveillance Education Program, between 2004 and 2018. Classical Test Theory and Rasch Item Response Theory analysis were used to evaluate the statistical reliability and quality of the assessment, and the measurement invariance or stability of the assessments over time. Clinicians' assessment scores were then reviewed by craft group and previous exposure to the program. Results: The results from 64,430, broadly similar assessments, showed that participation in the education program was associated with an immediate improvement in clinician performance in the assessment. Performance improvement was sustained for up to 18 months following participation in the program and recurrent participation was associated with progressive improvements. These trends were observed for all craft groups (consultant obstetricians, doctors in training, general practitioners, midwives, student midwives). Conclusions: These findings suggest that the Fetal Surveillance Education Program has improved clinician knowledge and the associated cognitive skills over time. The stable difficulty of the assessment tool means any improvement in clinician's results, with ongoing exposure to the program, can be reliably assessed and demonstrated. Importantly this holds true for all craft groups involved in intrapartum care and the interpretation of cardiotocography.

Knowledge and Attitudes of Midwives Concerning the Interpretation and Use of Cardiotocographs in Jordan

Introduction: A midwife needs to know how to assess fetal heart rates, recognize and interpret fetal heart patterns, report any substandard patterns, and initiate supportive measures as necessary. Objective: This study aims to assess the knowledge and attitudes of midwives concerning the interpretation and use of cardiotocographs. Materials and Methods: This cross-sectional study involves 183 midwives working in maternity units across all Jordanian regions. An online survey was used to collect data, including 6 demographic questions, 10 questions about knowledge, and 25 questions about attitude. The data were analyzed using descriptive statistics (Mean±SD, No. [%]), ANOVA, and the Pearson correlation tests. The significance level was set to be &lt;0.05. Results: Most participants were 21 to 30 years old, and most midwives (59.6%) had no more than six years of experience. The result showed that the total scores for the knowledge and attitude regarding cardiotocographs (CTGs) interpretation and usage were 68.7% and 73.0%, respectively. There is a significant relationship between the knowledge about the interpretation and use of CTGs and the years of experience (P=0.003), with higher knowledge scores among midwives with fewer than 6 years of experience. Furthermore, there is a significant relationship between the knowledge of CTGs and level of education (P=0.002), indicating higher knowledge scores among midwives with a degree. The knowledge about classifying the CTG traces was significantly correlated with the region of work (P=0.018), with higher scores among midwives from the southern region. Finally, there was a positive correlation between knowledge and attitude (r=0.007, P&lt;0.05). Conclusion: Based on the study result, the participant’s knowledge and attitudes are not satisfactory; thus, comprehensive education and training should be prioritized to improve midwives’ knowledge and attitudes toward using cardiotocograph.

Cardiotocography in practice: a qualitative study to explore obstetrical care professionals’ experiences with using cardiotocography information in Dutch practice

ObjectiveThis study aimed to explore obstetric care professionals’ experiences with using cardiotocograph (CTG) information and how they employ this tool in their practice.DesignQualitative study, involving 30 semi-structured interviews and two...

Physiological Interpretation of Cardiotocograph: Does the Emerging Scientific Evidence Suggest a Reversal in the “Thunder and Lightning” Phenomenon?

Physiological interpretation of Cardiotocograph (CTG) involves incorporation of the knowledge of fetal physiological response to intrapartum hypoxic and mechanical stresses and diagnosing different types of fetal hypoxia, to individualise care.

Does a physiology-based interpretation of cardiotocography allow to dispense with second-line methods? A cross-sectional online survey.

Second line methods are used to help obstetricians to identify abnormalities that reflect fetal acidosis. Since the use of a new technique of cardiotocography (CTG) interpretation based on the pathophysiology of the fetal period, the use of second-line tests has been questioned. To evaluate the impact of specific training in CTG physiology-based interpretation on professional attitudes towards the use of second-line methods. This cross-sectional study included 57 French obstetricians divided into two groups: the trained group (obstetricians who had already participated in a training course in physiology-based interpretation of CTG) and the control group. Ten medical records of patients who had abnormal CTG tracings and underwent fetal blood sampling pH measurement during labour were presented to the participants. They were given three choices: use a second-line method, continue labour without using second-line method, or perform a caesarean section. The main outcome measures was the median number of decisions to use second-line method. Forty participants were included in the trained group and 17 in the control group. The median number of recourses to second-line method was significantly inferior for the trained group (4/10 second-line methods) than for the control group (6/10, p=0.040). Regarding the 4 records for which a caesarean section was the real outcome, the median number of decisions of continuing labour was significantly superior in the trained group than in the control group (p=0.032). Participation in a training course in physiology-based interpretation of CTG could be associated with a less frequent use of second-line method at the cost of more frequently continuing labour with the risk compromising fetal and maternal well-being. Additional studies are required to determine whether this change in attitude is safe for the fetal well-being.

Computerized cardiotocography analysis during labor - A state-of-the-art review.

Cardiotocography is defined as the recording of fetal heart rate and uterine contractions and is widely used during labor as a screening tool to determine fetal wellbeing. The visual interpretation of the cardiotocography signals by the practitioners, following common guidelines, is subject to a high interobserver variability, and the efficiency of cardiotocography monitoring is still debated. Since the 1990s, researchers and practitioners work on designing reliable computer-aided systems to assist practitioners in cardiotocography interpretation during labor. Several systems are integrated in the monitoring devices, mostly based on the guidelines, but they have not clearly demonstrated yet their usefulness. In the last decade, the availability of large clinical databases as well as the emergence of machine learning and deep learning methods in healthcare has led to a surge of studies applying those methods to cardiotocography signals analysis. The state-of-the-art systems perform well to detect fetal hypoxia when evaluated on retrospective cohorts, but several challenges remain to be tackled before they can be used in clinical practice. First, the development and sharing of large, open and anonymized multicentric databases of perinatal and cardiotocography data during labor is required to build more accurate systems. Also, the systems must produce interpretable indicators along with the prediction of the risk of fetal hypoxia in order to be appropriated and trusted by practitioners. Finally, common standards should be built and agreed on to evaluate and compare those systems on retrospective cohorts and to validate their use in clinical practice.

Outstanding research paper awards of the Journal of the Chinese Medical Association in 2021.

Outstanding research paper awards of the Journal of the Chinese Medical Association in 2021.