A MULTICENTER COMPARATIVE-STUDY OF 17 EXPERTS AND AN INTELLIGENT COMPUTER-SYSTEM FOR MANAGING LABOR USING THE CARDIOTOCOGRAM

Objectives To investigate 1. whether an intelligent computer system co uld obtain a performance in labour management comparable with experts when using cardiotocograms (CTGs), patient information, and fetal bloo d sampling and 2. whether experts could be consistent and agree in the ir management of labour. Subjects An intelligent computer system and 1 7 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 occas ions, 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 rat es, intervention in cases with poor outcome and intervention in cases with good clinical outcome. Results The system: 1. Agreed with experts well and significantly better than chance (67.33%, kappa = 0.31, P < 0.001). 2, Was highly consistent (99.16%, kappa = 0.98, P < 0.001) whe n used by two operators independently. 3. Recommended no unnecessary i ntervention in cases with normal delivery and good condition (cord art ery pH > 7.15, vein pH > 7.20, 5 min Apgar greater than or equal to 9 and no resuscitation). This was better than all but two of the experts . 4, Recommended delivery by caesarean section in 11 cases; at least 1 5 of the 17 experts in each review also recommended caesarean section delivery in these cases. The majority did so within 15 min of the syst em and two-thirds did so within 30 min. 5. Identified as many of the b irth asphyxiated cases (cord arterial pH < 7.05 and BDecf greater than or equal to 12, and Apgar score at 5 min less than or equal to 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 caesare an section recommendations. The majority of experts did not recommend operative intervention in cases which had a normal delivery and good o utcome, but did recommend operative interventions in 10 of 12 cases de livered with cord arterial pH < 7.05. However, in one of the cases del ivered with birth asphyxia, 14 of the 17 experts and the system failed to recommend intervention. Conclusions The system's performance was f ound to be indistinguishable from the experts' in the 50 cases examine d, but it was more consistent. This demonstrates the potential for an intelligent computer system to improve the interpretation of the CTG a nd decrease intervention. Furthermore, the good performance of most ex perts in this study demonstrates the potential effectiveness of the CT G and raises important questions regarding why the CTG has fallen shor t of expectations in current practice.