title: Reliability in cardiotocography interpretation - impact of extended on-site education in addition to web-based learning: an observational study.
abstract: BACKGROUND
  Previous studies have shown poor reproducibility in cardiotocography (CTG) interpretation. Studies evaluating the Swedish web-based CTG-education program have not proven to increase accurate CTG assessments. The aim of this study was to evaluate whether an extended education can improve inter- and intra-observer reliability in CTG interpretation.
  
  
  METHODS
  Six obstetricians from two different departments interpreted 106 CTG tracings on two occasions. Both departments used a Swedish national web-based CTG education and test for training. One department had, in addition, an extended education program consisting of on-site lectures and oral examinations. Inter- and intra-observer agreements were calculated by simple or weighted kappa (κ) values for the five parameters assessed on CTG.
  
  
  RESULTS
  In both departments inter-observer and intra-observer κ showed moderate to excellent agreement (ranges for κ 0.41-0.76 and 0.65-0.93, respectively). Obstetricians at the department with extended CTG education had better inter-observer reliability for variability and accelerations. This was also the case for intra-observer reliability with the addition of baseline frequency. Both inter- and intra-observer agreement increased from moderate to substantial in both departments when decelerations were dichotomized into harmless (including early and simple variable decelerations) or hypoxic (including late, severe variable, prolonged and combined decelerations) (κ 0.63-0.78) compared with the current sub-classification of decelerations (κ 0.42-0.65).
  
  
  CONCLUSIONS
  Agreement in CTG interpretation was better than expected in both departments, especially when divided into harmless/hypoxic changes. Combination of different learning methods (web-based, on-site lectures and case discussion) might result in a better CTG interpretation agreement compared with web-based learning solely.
authors.affiliation: Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden.|Department of Obstetrics and Gynecology, Östersund Hospital, Östersund, Sweden.
authors.forename: Erika
authors.initials: E
authors.lastname: Gyllencreutz
authors.affiliation: Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden.|Department of Obstetrics and Gynecology, Karolinska University Hospital, Solna, Stockholm, Sweden.
authors.forename: Ingela
authors.initials: I
authors.lastname: Hulthén Varli
authors.affiliation: Clintec, Karolinska Institutet, Karolinska University Hospital, Huddinge, Stockholm, Sweden.
authors.forename: Pelle G
authors.initials: PG
authors.lastname: Lindqvist
authors.affiliation: Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden.|Department of Obstetrics and Gynecology, Karolinska University Hospital, Solna, Stockholm, Sweden.
authors.forename: Malin
authors.initials: M
authors.lastname: Holzmann
mesh_terms: D015148:Cardiotocography; D005260:Female; D006801:Humans; D007318:Inservice Training; D020407:Internet; D008427:Maternal Health Services; D015588:Observer Variation; D011247:Pregnancy; D015203:Reproducibility of Results; D013548:Sweden
keywords: Cardiotocography; fetal heart rate; inter-observer agreement; inter-observer reliability; intra-observer agreement; intra-observer reliability; learning