Interobserver agreement in analysis of cardiotocograms recorded during trial of labor after cesarean

M. M. Caning, D. L. A. Thisted, I Amer-Wahlin, G. H. Laier, L. Krebs, Lise Lotte Torvin Andersen (Member of author group), the Danish CTG Monitoring During VBAC study group

Research output: Contribution to journalJournal articleResearchpeer-review


Introduction: To examine interobserver agreement in intrapartum cardiotocography (CTG)
classification in women undergoing trial of labor after a cesarean section (TOLAC) at term with
or without complete uterine rupture.
Materials and methods: Nineteen blinded and independent Danish obstetricians assessed CTG
tracings from 47 women (174 individual pages) with a complete uterine rupture during TOLAC
and 37 women (133 individual pages) with no uterine rupture during TOLAC. Individual pages
with CTG tracings lasting at least 20 min were evaluated by three different assessors and
counted as an individual case. The tracings were analyzed according to the modified version of
the Federation of Gynaecology and Obstetrics (FIGO) guidelines elaborated for the use of STAN
(ST-analysis). Occurrence of defined abnormalities was recorded and the tracings were classified
as normal, suspicious, pathological, or preterminal. The interobserver agreement was evaluated
using Fleiss’ kappa.
Results: Agreement on classification of a preterminal CTG was almost perfect. The interobserver
agreement on normal, suspicious or pathological CTG was moderate to substantial. Regarding
the presence of severe variable decelerations, the agreement was moderate. No statistical
difference was found in the interobserver agreement between classification of tracings from
women undergoing TOLAC with and without complete uterine rupture.
Conclusions: The interobserver agreement on classification of CTG tracings from high-risk
deliveries during TOLAC is best for assessment of a preterminal CTG and the poorest for the
identification of severe variable decelerations.
Original languageEnglish
JournalThe Journal of Maternal-Fetal & Neonatal Medicine
Issue number22
Pages (from-to)3778-3783
Publication statusPublished - 17. Nov 2019


  • Cardiotocography
  • Fleiss’ kappa
  • interobserver agreement
  • trial of labor after cesarean (TOLAC)
  • uterine rupture
  • Acidosis/blood
  • Predictive Value of Tests
  • Cardiotocography/statistics & numerical data
  • Fetal Monitoring/methods
  • Humans
  • Vaginal Birth after Cesarean/adverse effects
  • Case-Control Studies
  • Pregnancy
  • Heart Rate, Fetal/physiology
  • Trial of Labor
  • Fetal Distress/blood
  • Sensitivity and Specificity
  • Adult
  • Female
  • Retrospective Studies
  • Observer Variation


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