Doctora
Páginas: 15 (3511 palabras)
Publicado: 27 de febrero de 2013
REVIEW
CURRENT OPINION
Human factors affecting the interpretation of fetal heart rate tracings: an update
Susana Santo a and Diogo Ayres-de-Campos b
Purpose of review Human factors can have an important impact on cardiotocography (CTG) interpretation and management decisions, and therefore may directly affect obstetrical outcomes. Recent findings It has been well demonstrated that thereis wide observer disagreement over CTG interpretation, particularly in the evaluation of variability, decelerations, and overall tracing classification. The reasons behind this are still incompletely understood, but poor reproducibility can have a profound impact on the technology’s accuracy and on its efficacy. Some scientific societies have recently revised their guidelines for CTGinterpretation, but no up-to-date universally accepted recommendation exists. In spite of some approximation between the major guideline sets, important differences still exist between them, and they remain complex and prone to memory decay. Regular training in CTG interpretation appears to result in increased knowledge, better observer agreement, and improved quality of care. Computer analysis has also beendeveloped, but remains heavily dependent on staff to confirm interpretation and to decide clinical management. Summary An international consensus, comprising simpler and more objective interpretation guidelines, together with regular staff training, and improved decision support systems seem to be the way forward for this technology. Keywords cardiotocography, electronic fetal monitoring, fetalheart rate, fetal monitoring guidelines, observer agreement
INTRODUCTION
Cardiotocography (CTG) was introduced into clinical practice during the 1960s for assessment of fetal well being during late pregnancy and labor. Expectations at the time were that it would lead to a decreased incidence of perinatal death and cerebral palsy. Reality has fallen very short of these expectations, perhaps not sosurprisingly, as it was not known then that these outcomes are rarely caused by intrapartum hypoxia [1]. Nevertheless, it has been difficult to demonstrate that intrapartum CTG has any major impact on important obstetric indicators, with the exception of increasing operative delivery rates [2]. Despite these discouraging results, the technology remains widely used in industrialized countries[3,4]. Acquisition of tracings, their interpretation, and the resulting clinical decision continues to be almost entirely dependent on healthcare professionals, and this may constitute the weakest link of the technology. In this review we will focus on human factors that affect CTG interpretation, and
www.co-obgyn.com
identify possible ways of overcoming these limitations.
OBSERVER AGREEMENT ONCARDIOTOCOGRAPHY INTERPRETATION
It is well known that CTG interpretation is subject to high intraobserver and interobserver disagreement [5,6]. This disagreement involves both the identification of individual CTG features [7–9] and overall tracing classification [5,6]. Classification
Department of Obstetrics, Gynecology and Reproductive Medicine, School of Medicine, University of Lisbon, SantaMaria Hospital, Lisbon and bDepartment of Obstetrics and Gynecology, School of Medicine, Institute of Biomedical Engineering, University of Porto, S. Joao Hospital, Porto, Portugal Correspondence to Prof. Diogo Ayres-de-Campos, Departamento de Ginecologia e Obstetrıcia, Faculdade de Medicina da Universidade do ´ Porto, Alameda Hernani Monteiro, 4200-319 Porto, Portugal. Tel: +351 966707112; e-mail:dcampos@med.up.pt Curr Opin Obstet Gynecol 2012, 24:84–88 DOI:10.1097/GCO.0b013e3283505b3c Volume 24 Number 2 April 2012
a
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Interpretation of fetal heart rate tracings Santo and Ayres-de-Campos
KEY POINTS
Human factors are critical issues affecting cardiotocography (CTG)...
CURRENT OPINION
Human factors affecting the interpretation of fetal heart rate tracings: an update
Susana Santo a and Diogo Ayres-de-Campos b
Purpose of review Human factors can have an important impact on cardiotocography (CTG) interpretation and management decisions, and therefore may directly affect obstetrical outcomes. Recent findings It has been well demonstrated that thereis wide observer disagreement over CTG interpretation, particularly in the evaluation of variability, decelerations, and overall tracing classification. The reasons behind this are still incompletely understood, but poor reproducibility can have a profound impact on the technology’s accuracy and on its efficacy. Some scientific societies have recently revised their guidelines for CTGinterpretation, but no up-to-date universally accepted recommendation exists. In spite of some approximation between the major guideline sets, important differences still exist between them, and they remain complex and prone to memory decay. Regular training in CTG interpretation appears to result in increased knowledge, better observer agreement, and improved quality of care. Computer analysis has also beendeveloped, but remains heavily dependent on staff to confirm interpretation and to decide clinical management. Summary An international consensus, comprising simpler and more objective interpretation guidelines, together with regular staff training, and improved decision support systems seem to be the way forward for this technology. Keywords cardiotocography, electronic fetal monitoring, fetalheart rate, fetal monitoring guidelines, observer agreement
INTRODUCTION
Cardiotocography (CTG) was introduced into clinical practice during the 1960s for assessment of fetal well being during late pregnancy and labor. Expectations at the time were that it would lead to a decreased incidence of perinatal death and cerebral palsy. Reality has fallen very short of these expectations, perhaps not sosurprisingly, as it was not known then that these outcomes are rarely caused by intrapartum hypoxia [1]. Nevertheless, it has been difficult to demonstrate that intrapartum CTG has any major impact on important obstetric indicators, with the exception of increasing operative delivery rates [2]. Despite these discouraging results, the technology remains widely used in industrialized countries[3,4]. Acquisition of tracings, their interpretation, and the resulting clinical decision continues to be almost entirely dependent on healthcare professionals, and this may constitute the weakest link of the technology. In this review we will focus on human factors that affect CTG interpretation, and
www.co-obgyn.com
identify possible ways of overcoming these limitations.
OBSERVER AGREEMENT ONCARDIOTOCOGRAPHY INTERPRETATION
It is well known that CTG interpretation is subject to high intraobserver and interobserver disagreement [5,6]. This disagreement involves both the identification of individual CTG features [7–9] and overall tracing classification [5,6]. Classification
Department of Obstetrics, Gynecology and Reproductive Medicine, School of Medicine, University of Lisbon, SantaMaria Hospital, Lisbon and bDepartment of Obstetrics and Gynecology, School of Medicine, Institute of Biomedical Engineering, University of Porto, S. Joao Hospital, Porto, Portugal Correspondence to Prof. Diogo Ayres-de-Campos, Departamento de Ginecologia e Obstetrıcia, Faculdade de Medicina da Universidade do ´ Porto, Alameda Hernani Monteiro, 4200-319 Porto, Portugal. Tel: +351 966707112; e-mail:dcampos@med.up.pt Curr Opin Obstet Gynecol 2012, 24:84–88 DOI:10.1097/GCO.0b013e3283505b3c Volume 24 Number 2 April 2012
a
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Interpretation of fetal heart rate tracings Santo and Ayres-de-Campos
KEY POINTS
Human factors are critical issues affecting cardiotocography (CTG)...
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