Cardiotocography interpretation skills and the association with size of maternity unit, years of obstetric work experience and healthcare professional background: a national cross-sectional study.

INTRODUCTION: We aimed to examine whether cardiotocography (CTG) knowledge, interpretation skills and decision-making measured by a written assessment were associated with size of maternity unit, years of obstetric work experience and healthcare professional background. MATERIAL AND METHODS: A national cross-sectional study in the setting of a CTG teaching intervention involving all 24 maternity units in Denmark. Participants were midwives (n = 1260) and specialists (n = 269) and residents (n = 142) in obstetrics and gynecology who attended a 1-day CTG course and answered a 30-item multiple-choice question test. Associations between mean test score and work conditions were analyzed using multivariable robust regression, in which the three variables were mutually adjusted. RESULTS: Participants from units with > 3000 deliveries/year scored higher on the test than participants from units with < 1000 deliveries/year (3000-3999 deliveries/year: mean difference 0.8, p < 0.0001; > 4000 deliveries/year: mean difference 0.5, p = 0.006). Participants with < 15 years of work experience scored higher than participants with > 15 years of experience (15-20 years of experience: mean difference - 0.6, p = 0.007; > 20 years experience: mean difference - 0.9, p < 0.0001). No differences were detected concerning professional background. CONCLUSIONS: CTG knowledge, interpretation skills and decision-making measured by a written assessment were positively associated with working in large maternity units and having < 15 years of obstetric work experience. This might indicate a challenge in maintaining CTG skills in small units and among experienced staff but could also reflect different levels of motivation, test familiarity and learning culture. Whether the findings are transferable to the clinical setting was not examined.

Curriculum development for a national cardiotocography education program: a Delphi survey to obtain consensus on learning objectives.

OBJECTIVE: To define learning objectives for a national cardiotocography (CTG) education program based on expert consensus. DESIGN: A three-round Delphi survey. POPULATION AND SETTING: One midwife and one obstetrician from each maternity unit in Denmark were appointed based on CTG teaching experience and clinical obstetric experience. METHODS: Following national and international guidelines, the research group determined six topics as important when using CTG: fetal physiology, equipment, indication, interpretation, clinical management, and communication/responsibility. In the first Delphi round, participants listed one to five learning objectives within the predefined topics. Responses were analyzed by a directed approach to content analysis. Phrasing was modified in accordance with Bloom's taxonomy. In the second and third Delphi rounds, participants rated each objective on a five-point relevance scale. Consensus was predefined as objectives with a mean rating value of ≥ 3. MAIN OUTCOME MEASURES: A prioritized list of CTG learning objectives. RESULTS: A total of 42 midwives and obstetricians from 21 maternity units were invited to participate, of whom 26 completed all three Delphi rounds, representing 18 maternity units. The final prioritized list included 40 objectives. The highest ranked objectives emphasized CTG interpretation and clinical management. The lowest ranked objectives emphasized fetal physiology. Mean ratings of relevance ranged from 3.15 to 5.00. CONCLUSIONS: National consensus on CTG learning objectives was achieved using the Delphi methodology. This was an initial step in developing a valid CTG education program. A prioritized list of objectives will clarify which topics to emphasize in a CTG education program.

Laboratory reference intervals during pregnancy, delivery and the early postpartum period.

BACKGROUND: Physiological changes during pregnancy may affect laboratory parameters. Reference values based on samples from non-pregnant women are not necessarily useful for clinical decisions during pregnancy. There is a need to establish reference values during pregnancy in order to recognize pathological conditions. METHODS: Eight hundred and one women with expected normal pregnancies were included in the study. Of these, 391 had no complications during pregnancy, delivery, or the early postpartum period. Blood samples were obtained at gestational weeks 13-20, 21-28, 29-34, 35-42, at labor, and 1 and 2 days postpartum. Reference intervals were calculated for 36 tests as recommended by the International Federation of Clinical Chemistry and Laboratory Medicine. RESULTS: Many tests showed such large variations indicating that gestational age-specific reference intervals were necessary. Other tests had different but stable values when compared to non-pregnant women. A minor decrease in albumin levels was observed. This was not only due to pregnancy-associated hemodilution, since other components with the same or a larger molecular diameter did not show a similar decrease. Many tests exhibited a broad distribution around vaginal delivery and in the early postpartum period. CONCLUSIONS: Only a few parameters were unaffected during uncomplicated pregnancy, delivery, and the early postpartum period suggesting that implementation of gestational age-specific reference intervals is necessary.

Haemostatic reference intervals in pregnancy.

Haemostatic reference intervals are generally based on samples from non-pregnant women. Thus, they may not be relevant to pregnant women, a problem that may hinder accurate diagnosis and treatment of haemostatic disorders during pregnancy. In this study, we establish gestational age-specific reference intervals for coagulation tests during normal pregnancy. Eight hundred one women with expected normal pregnancies were included in the study. Of these women, 391 had no complications during pregnancy, vaginal delivery, or postpartum period. Plasma samples were obtained at gestational weeks 13-20, 21-28, 29-34, 35-42, at active labor, and on postpartum days 1 and 2. Reference intervals for each gestational period using only the uncomplicated pregnancies were calculated in all 391 women for activated partial thromboplastin time (aPTT), fibrinogen, fibrin D-dimer, antithrombin, free protein S, and protein C and in a subgroup of 186 women in addition for prothrombin time (PT), Owren and Quick PT, protein S activity, and total protein S and coagulation factors II, V, VII, VIII, IX, X, XI, and XII. The level of coagulation factors II, V, X, XI, XII and antithrombin, protein C, aPTT, PT remained largely unchanged during pregnancy, delivery, and postpartum and were within non-pregnant reference intervals. However, levels of fibrinogen, D-dimer, and coagulation factors VII, VIII, and IX increased markedly. Protein S activity decreased substantially, while free protein S decreased slightly and total protein S was stable. Gestational age-specific reference values are essential for the accurate interpretation of a subset of haemostatic tests during pregnancy, delivery, and puerperium.