A multicentre comparative study of 17 experts and an intelligent computer system for managing labour using the cardiotocogram

Abstract

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.

Inter-observer variation in assessment of 845 labour admission tests: comparison between midwives and obstetricians in the clinical setting and two experts

“…An average of 21% of the CTG traces were assessed different at the second observation, and only 22% of the traces were equally assessed by all of the four obstetricians at both observations. In another study 4 , intra-observer agreement varied from moderate to good (n (kappa) ¼ 0.43 to 0.77). In eight studies assessing ante-and intrapartum CTG traces 4 -11 , inter-observer agreement varied from poor to very good (n ¼ 0.11 to 1.00).…”

S1-Guideline on the Use of CTG During Pregnancy and Labor

“…Studies on inter-and intra-observer variability have shown that the introduction of computer-assisted classifications of CTG readings has resulted in a more reliable categorization of CTG patterns overall [37,46]. The benefit of "online" CTG analysis is that asssessment can be done almost in realtime.…”

An overview of central fetal monitoring systems in labour

“…In 1995, a similar comparison was made of 50 intrapartum cases evaluated by 17 experts from 16 different centres [26] . The system agreed with experts in the management of 67.3 % of cases, for a κ value of 0.31.…”