Inter‐observer agreement in clinical decision‐making for abnormal cardiotocogram (CTG) during labour: a comparison between CTG and CTG plus STAN

We performed multifractal analysis of fetal heart rate (FHR) variability in fetuses with and without acidosis during labor. Multifractal analysis was performed on fetal electrocardiograms in 10-minute sliding windows within the last 2 hours before delivery in 45 term fetuses divided in three groups according to umbilical arterial pH and FHR pattern: group A had pH !7.30 and normal FHR, group B had pH !7.30 and intermediate or abnormal FHR, and group C had acidosis (pH 7.05) and intermediate or abnormal FHR. Six multifractal parameters were compared using Wilcoxon rank sum test. Multifractal parameters were significantly different between the three groups in the last 10 minutes before delivery (p <0.05). Two parameters (h min , zeta(2)) exhibited a significant difference 70 minutes before delivery, and one parameter (C 2 ) was different 10 minutes before birth (p <0.05). Multifractal parameters were significantly different in acidotic and nonacidotic fetuses, independently from FHR pattern.

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“…And last, multifractal analysis should provide objective information, whatever the FHR patterns, limiting subjective observer interpretation. 34 …”

Section: Discussionmentioning

confidence: 99%

Multifractal Analysis of Fetal Heart Rate Variability in Fetuses with and without Severe Acidosis during Labor

et al. 2010

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“…1 His comments raise the issue of the difficulty of choosing judgment criteria for evaluating decisions made during labour. Hypoxic-ischaemic encephalopathy is indisputably a severe complication that we must aim to prevent.…”

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confidence: 99%

“…1 1. The authors use as the denominators for the estimation of the 95% confidence intervals the number of trials of agreement.…”

Section: G Dondersmentioning

confidence: 99%

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Inter‐observer agreement in clinical decision‐making for abnormal cardiotocogram during labour: a comparison between CTG and CTG plus STAN

Vayssière

Arnaud

Pirrello³

et al. 2009

BJOG

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vaginal flora types, whether these are AV, partial BV, Atopobium vaginae, Mycoplasma sp. or other flora.We agree that specific tests may be necessary for some pathogens that cannot be seen by microscopy, such as mycoplasmata. Indeed, quantification of these bacteria could add additional value, probably more so for Ureaplasma urealyticum than for Mycoplasma hominis, the latter of which has always been annotated as having pathogenic activity in both our present and previous studies. 4 Although often associated with BV, the finding of M. hominis may be of equal importance if found in association with other flora types than BV. We hope our study stimulates more research to determine the precise risk factors for preterm birth. j G DondersHeilig Hart Regional Hospital, Tienen, Belgium Sir, There are two main problems with this study. 1 1. The authors use as the denominators for the estimation of the 95% confidence intervals the number of trials of agreement. But these trials of agreement are not independent of one another. It is the number of the subjects that should be the denominator. The correct 95% confidence interval for the overall agreement of cardiotocography (CTG) is 0.78 (0.64, 0.93); and for CTG plus ST waveform analysis (STAN) is 0.83 (0.70, 0.97). With the number of subjects as the denominator, none of the comparisons carried out by the authors reach the conventional level of statistical significance. We are not justified in concluding that CTG plus STAN is inferior to cardiotocography alone in the decision to deliver, or is superior to cardiotocography alone in the decision not to deliver.2. The authors estimate the proportions of agreement for justified intervention and for justified non-intervention, but these estimates are confounded by the design of their study. Ten cases were selected where the infants had a pH at birth of <7.05, and there were 20 cases where the pH at birth was >7.05. In these 20 cases there were eight cases with a pH of 7.05-7.10, still a significant degree of acidosis, and usually indicating delivery. Obviously these were cases indicated by STAN as not indicating delivery. Was the cutoff value between normal and abnormal chosen arbitrarily? Was it chosen post hoc? Why choose pH as the outcome at all, when we know that metabolic acidosis alone is a poor predictor of cerebral palsy?The preferred method of performing this study would be to select a group of infants with hypoxic-ischaemic encephalopathy, and a group of infants who do not have hypoxicischaemic encephalopathy. This is preferable to a random sample of all infants delivered. In well-grown infants at term, progressive fetal hypoxia and metabolic acidosis can occur, until a critical boundary is crossed when cardiovascular collapse results, with consequent spastic quadriplegia. If that critical boundary is not crossed, complete recovery of the infant is the rule, despite severe metabolic acidosis. It is an 'all-or-nothing' phenomenon. Therefore, this study should be repeated in a group of infants who have seizures with sev...

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“…A supplementary test is often necessary and the current British practice recommends fetal blood sampling when vaginal delivery can be anticipated. ST analysis (STAN) has shown a limited promise [37] but a meaningful and valid conventional CTG interpretation seems a prerequisite.…”

Section: Implications For Future Clinical Practicetiming or Shape?mentioning

confidence: 99%

Interpretation of British experts’ illustrations of fetal heart rate (FHR) decelerations by Consultant Obstetricians, registrars and midwives: A prospective study—Reasons for major disagreement with experts and implications for clinical practice

Sholapurkar¹

2013

OJOG

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Inter‐observer agreement in clinical decision‐making for abnormal cardiotocogram (CTG) during labour: a comparison between CTG and CTG plus STAN

Cited by 44 publications

References 33 publications

Multifractal Analysis of Fetal Heart Rate Variability in Fetuses with and without Severe Acidosis during Labor

Multifractal Analysis of Fetal Heart Rate Variability in Fetuses with and without Severe Acidosis during Labor

Inter‐observer agreement in clinical decision‐making for abnormal cardiotocogram during labour: a comparison between CTG and CTG plus STAN

Interpretation of British experts’ illustrations of fetal heart rate (FHR) decelerations by Consultant Obstetricians, registrars and midwives: A prospective study—Reasons for major disagreement with experts and implications for clinical practice

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