Objectives To investigate 1. whether an intelligent computer system could obtain a performance in labour management comparable with experts when using cardiotocograms (CTGs), patient information, and fetal blood sampling and 2. whether experts could be consistent and agree in their management of labour. Subjects An intelligent computer system and 17 clinicians experienced in fetal monitoring from 16 centres in the UK. Design Fifty cases with complete intrapartum CTGs and clinical data were reviewed by each expert and the system independently on two occasions, at least one month apart. Each CTG was scored in 15 min segments according to a protocol and estimates of the cervical dilatation and fetal scalp blood pH were given when requested. Main outcome measures Consistency and agreement in the recorded scores, agreement and timing of cases recommended for caesarean sections, fetal blood sampling rates, intervention in cases with poor outcome and intervention in cases with good clinical outcome. Results The system: Agreed with experts well and significantly better than chance (67.33%, kappa = 0.31, P 0.001). Was highly consistent (99.16%, kappa = 0.98, P 4.0001) when used by two operators independently. Recommended no unnecessary intervention in cases with normal delivery and good condition (cord artery pH > 7.15, vein pH > 7.20, 5 min Apgar ≥ 9 and no resuscitation). This was better than all but two of the experts. Recommended delivery by caesarean section in 11 cases; at least 15 of the 17 experts in each review also recommended caesarean section delivery in these cases. The majority did so within 15 min of the system and two‐thirds did so within 30 min. Identified as many of the birth asphyxiated cases (cord arterial pH < 7.05 and BDecf ≥ 12, and Apgar score at 5 min ≤ 7 with neonatal morbidity) as the majority of experts and one more than was acted upon clinically. The experts were found to be consistent and to agree. There was good agreement in the cases and the timing of caesarean section recommendations. The majority of experts did not recommend operative intervention in cases which had a normal delivery and good outcome, but did recommend operative interventions in 10 of 12 cases delivered with cord arterial pH c 7.05. However, in one of the cases delivered with birth asphyxia, 14 of the 17 experts and the system failed to recommend intervention. Conclusions The system's performance was found to be indistinguishable from the experts' in the 50 cases examined, but it was more consistent. This demonstrates the potential for an intelligent computer system to improve the interpretation of the CTG and decrease intervention. Furthermore, the good performance of most experts in this study demonstrates the potential effectiveness of the CTG and raises important questions regarding why the CTG has fallen short of expectations in current practice.

Objective The development and evaluation of a computer-assisted teaching programme of cardiotocography and acid-base balance.Design Randomised controlled trial.Participants One hundred and seventeen midwifery and obstetric staff at Derriford Hospital, Plymouth.Methods The obstetricians and midwives were randomly allocated to use the teaching programme, either early or late. The late group (control) used the teaching programme three months after the early group.To assess the effect of the teaching programme, participants were tested on four occasions over eight months by a multiple choice questionnaire. Two questionnaires on ease of use were also completed. Main outcome measuresMultiple choice questionnaire scores and opinion questionnaire results. ResultsThe mean score in the early group improved from 504% (test 1, pre-teaching programme) to 70.2% (test 2, post-teaching programme). The mean score in the control group was 50.3% (test 1) and 54.8% (test 2). Knowledge was retained up to seven months. ConclusionsThe teaching programme was effective in improving knowledge of acid-base balance and cardiotocography and can be used by all staff whilst on duty on the labour ward.

Summary. A series of 12 trials of scar associated with scar rupture is reviewed. Uterine activity patterns were assessable in 10 of them. Clinical features and characteristics of the intrauterine pressure waveform and uterine activity are discussed in relation to the integrity of the scar.

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