Intervention for Fetal Distress Among.pdf

Intervention for Fetal Distress AmongObstetricians, Registered Nurses, andResidentsSimilarities, Differences, and Determining Factors

Giuseppe Chiossi, MD, Maged M. Costantine, MD, Joy M. Pfannstiel, MD, Gary D. V. Hankins, MD,George R. Saade, MD, and Zhao Helen Wu, PhD

OBJECTIVE: To explore the factors possibly associatedwith the intrapartum management of nonreassuring fetalstatus and the factors affecting the decision to expeditedelivery for fetal distress among different obstetric healthcare providers.

METHODS: In a cross-sectional study, a standardizedhypothetical clinical scenario of management of fetaldistress was presented by a study investigator to laborand delivery personnel, including faculty obstetricians,residents, and registered nurses (N�52). An interventionindex was calculated for each faculty by dividing thenumber of cesarean and operative deliveries for nonre-assuring fetal status by the actual number of laboringpatients supervised by each faculty in 2008.

RESULTS: Selection of the timing of delivery and char-acterization of nonreassuring fetal heart rate patterns wasnot different among the different providers (P�.3). How-ever, compared with residents, registered nurses notifiedthe attending obstetricians at an earlier stage and inresponse to different fetal heart rate tracing scenariossuggestive of fetal distress (P<.001). Personal or profes-sional experience, type of clinical practice, and psycho-logical traits did not affect the management of thestandardized clinical scenario or the intervention index(P�.3–.9).

CONCLUSION: Different providers practicing in thesame environment may develop a similar approach in the

setting of nonreassuring fetal status that overcomes indi-vidual differences and follows the current guidelines onelectronic fetal monitoring.(Obstet Gynecol 2011;118:809–17)DOI: 10.1097/AOG.0b013e31822e00bc

LEVEL OF EVIDENCE: II

Because the percentage of laboring women under-going electronic fetal heart rate monitoring has

increased to more than 80%, the cesarean deliveryrate in the United States increased from 5% in 1970 tomore than 31% in 2007, without a concomitant de-crease in perinatal morbidity or mortality.1–3 Fetalcardiotocography is characterized by poor interob-server (21%) and intraobserver reliability (22%),4 aswell as high false-positive rate (99%) and low positivepredictive value (0.14%) for hypoxic encephalopa-thy.5 Moreover, the foreknowledge of neonatal out-come has been shown to alter the reviewer’s impres-sion of the tracing when reviewed retrospectively.6

The variability in fetal heart rate interpretationand the high false-positive rate of electronic fetal heartrate monitoring in predicting hypoxic encephalopa-thy suggest that decisions made to intervene fornonreassuring fetal status include some degree ofuncertainty and fear of missing a decompensatingfetus. When the threshold for intervention is loweredbecause of fear of a false-negative and the conse-quences of missing an affected fetus, the result is ahigh false-positive rate, a picture similar to that withelectronic fetal heart rate monitoring. Therefore, it isplausible that physician-related factors, such as pro-fessional experience, personal background, and riskattitude, may influence reflexive decisions in elec-tronic fetal heart rate monitoring.

From the Department of Obstetrics and Gynecology, University of Texas MedicalBranch, Galveston, Texas.

Corresponding author: Giuseppe Chiossi, MD, Department of Obstetrics andGynecology, University of Texas Medical Branch, 301 University Boulevard,Galveston, TX 77555-0144; e-mail: [email protected].

Financial DisclosureThe authors did not report any potential conflicts of interest.

© 2011 by The American College of Obstetricians and Gynecologists. Publishedby Lippincott Williams & Wilkins.ISSN: 0029-7844/11

VOL. 118, NO. 4, OCTOBER 2011 OBSTETRICS & GYNECOLOGY 809

Despite the fact that laboring women are oftenmonitored by a team of health care providers thatincludes residents in obstetrics and gynecology andregistered nurses, the published studies on electronicfetal heart rate monitoring mainly have focused onattending physicians.4–6 Therefore, the aim of thisstudy was to determine if the decision to expeditedelivery for fetal indications differs among providersworking in the same environment, and to explore if itdepends on various personal or professional experi-ences, clinical practice patterns, or psychological fac-tors.

MATERIALS AND METHODSIn this cross-sectional study designed following theSTROBE guidelines, a questionnaire was presentedby an investigator to the labor and delivery personnelat the University of Texas Medical Branch in Galves-ton, Texas, after obtaining Institutional Review Boardapproval. Respondents included attending physi-cians, third- and fourth-year residents in obstetricsand gynecology, and registered nurses.

All the attending physicians who worked in laborand delivery and had more than 20% of their effortsallocated to clinical practice were included in thestudy. All the current third- and fourth-year residents(11 out of 15 residents) who were not on externalrotations at the time of the survey (December 2009)and the registered nurses who worked in labor anddelivery for more than 2 day shifts per month wereasked to participate, and all agreed and completed thequestionnaire.

In the first part of the questionnaire, the 9-hourlabor course (from hospital admission to delivery) of ahypothetical patient was summarized at 30-minuteintervals by a series of 19 vignettes. Each vignetteopened with the time of fetal assessment and showedan 8- to 10-minute recording representative of thefetal heart rate pattern in the previous 30 minutes.Information on cervical dilatation and effacement, aswell as fetal descent, was provided every 60 minutesin the first stage of labor and every 30 minutes in thesecond stage. Respondents were confronted with onlyone vignette at a time; the total number of vignetteswas not disclosed. After reviewing each vignette,health care professionals were asked to specify ifthey recommended prompt delivery because offetal distress or if they would rather continue tomonitor labor progression. When expectant man-agement was chosen, respondents were allowed toreview the subsequent vignette; if delivery waselected, then they were asked to specify the recom-mended route and the fetal heart rate feature that

prompted such intervention (Appendixes 1 and 2,available online at http://links.lww.com/AOG/A257and http://links.lww.com/AOG/A258, respectively).Of note, cesarean delivery was the only possibleoption before complete cervical dilatation; afterward,cesarean and operative vaginal deliveries were possi-ble choices. Registered nurses and residents also wereasked to specify the timing when they considered itnecessary to notify the attending obstetrician aboutpossible fetal distress and the fetal heart rate featurethat lead them to notify the faculty. Because vignetteswere progressively numbered from 1 to 19, the re-sponses to the questions about the time of deliveryand time of physician notification were indicated withthe number of the chosen vignettes. The “time ofdelivery” was codified by the vignette number thatprompted respondents to expedite delivery, whereasthe “time of physician notification” was indicated bythe vignette number that was selected to inform theattending physician about a concerning fetal heartrate tracing. The identity of the interviewees was notrecorded; only attending obstetricians were classifiedwith an alphabetical code to correlate their answerswith the actual number of cesarean and operativedeliveries performed for fetal distress.

The second part of the questionnaire included aset of social–psychological measures. A section onsociodemographic background was followed by aseries of questions on providers’ professional experi-ence and clinical practice, including a specific inquiryabout involvement in medical lawsuits. Depressionand anxiety symptoms were assessed in the thirdsection of the questionnaire using the short psychiat-ric diagnostic screening questionnaire, a modificationof the original self-report instrument that screens for13 Diagnostic and Statistical Manual of Mental Disorders,Fourth Edition, axis I psychiatric disorders.7 Thepsychiatric diagnostic screening questionnaire has 15yes-and-no questions that address symptoms that de-veloped in the previous 2 weeks and 10 additionalitems that screen for symptoms occurring in theprevious 6 months. Each positive answer was countedas 1 point, and negative answers were counted as 0points. The scores were added into an index, respec-tively, ranging from 0 to 15 and from 0 to 10.Screening for obsessive compulsive disorder was ad-opted from the Yale-Brown Obsessive CompulsiveScale, a 10-item scale in which each item rated from 0(no symptoms) to 4 (extreme symptoms).8 The scaleincludes questions on the amount of time spent onobsessions, how much impairment or distress obses-sions generate, and how much resistance and controlindividuals have over these thoughts. The same types

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of questions are asked on compulsions. In the fourthsection of the questionnaire, risk attitude was mea-sured with six items from the Jackson PersonalityInventory, revised,9,10 as described by Fuglenes et al.11

All items were scored on a 6-point scale, and thescores were added into an index, with a possiblerange from 6 (very risk-averse) to 36 (very risk-seeking). The “fear index” was adapted from theoriginal description by Fuglenes et al11 and repre-sented a measurement of the perceived risk of com-plaints and malpractice litigation. Respondents wereasked to rank the degree to which their decisionsabout delivery were influenced by concerns aboutfive different situations: complaints to employers or tothe State Medical Board, criticism by colleagues or inthe media, and litigation threats. The responses werecaptured on a 4-point scale (0, never; 1, seldom; 2,sometimes; 3, often).11

Although all the providers were interrogated onthe same topics, two slightly different formats of thesame questionnaire were tailored to properly addressmedical doctors compared with registered nurses(Appendixes 1 and 2, http://links.lww.com/AOG/A257and http://links.lww.com/AOG/A258, respectively).

For each attending physician, an interventionindex was calculated as the ratio between the numberof cesarean and operative deliveries for fetal distressand the actual number of laboring patients managedunder the supervision of each provider over thecourse of the year 2008. Because the attending phy-sician is ultimately responsible for all the decisionsabout timing and route of delivery, the interventionindex reflects his or her decision-making capacity. Allthe information was obtained from a review of themedical records. After identifying the labor and de-livery shifts that each physician worked during theyear 2008, the number of term laboring patients caredfor during those shifts was calculated by reviewing thelabor and delivery charge nurse flow sheets. Accord-ing to the hospital policy, such official documentsaccurately summarize the basic information about thepatients admitted or transferred to the labor anddelivery unit on every shift, including demographics,admission diagnosis, parity, and gestational age. Thenumber of operative vaginal and cesarean deliveriesperformed for nonreassuring fetal status as the soleindication was then determined for each attendingobstetrician.

Data were analyzed with SAS 9.1. Data wereevaluated for normality using the Shapiro-Wilk test.Continuous variables were analyzed using the Stu-dent t test or Mann-Whitney rank-sum as appropriate.For multigroup comparisons, only the nonparametric

Kruskal-Wallis test was used, followed by the Dunntest for post hoc pairwise comparisons. Univariableanalysis of categorical variables was conducted with�2 or Fischer exact test as appropriate. Correlationbetween continuous variables was assessed usingSpearman correlation. Observations with missing val-ues for any of the variables were excluded. Two-tailedP�.05 was considered statistically significant; obser-vations with missing values for any of the variableswere excluded.

RESULTSTwenty-five registered nurses, 11 senior residents (ie,third- and fourth-year residents in obstetrics andgynecology), and 16 attending physicians participatedin the survey. Attending physicians included sevenfellows (six in maternal and fetal medicine, one ingynecological oncology) who took labor and deliverycalls, eight maternal and fetal medicine specialists,and one board-certified obstetrician-gynecologist. Ta-ble 1 summarizes the demographic characteristics ofthe study population. The vignette representing thetime of delivery (delivery vignette) of the standard-ized patient, the fetal heart rate feature prompting

Table 1. Demographic Characteristics of theStudy Population

RegisteredNurses(n�25)

Physicians(n�16)

Residents(n�11)

Age (y) 35.8�8 39.2�6.9 32.8�4.3Sex

Male 0 (0) 9 (56.3) 1 (9.1)Female 25 (100) 7 (43.7) 10 (90.9)

EthnicityWhite 21 (84) 12 (75) 7 (63.6)Black 1 (4) 0 0Hispanic 0 2 (12.5) 1 (9.1)Other 3 (12) 2 (12.5) 3 (27.3)

Country of graduationfrom medical ornursing school

American graduate 24 (96) 9 (52.2) 8 (72.7)Foreign graduate 1 (4) 7 (43.8) 3 (27.3)

Years of training afterresidency ornursing school

8.6�6.8 6.1�0.5 NA

Marital statusMarried or

cohabitating20 (80) 13 (81.2) 7 (63.7)

Other 5 (20) 3 (18.8) 4 (36.3)Children

Yes 18 (72) 12 (75) 6 (36.3)No 7 (28) 4 (25) 7 (63.7)

NA, not applicable.Data are mean�standard deviation or n (%).

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intervention, and the route of delivery were notcompleted by two nurses and one physician.

The time of delivery and the specific fetal heartrate features indicative of fetal distress did not differamong the respondents (P�.3). The distribution of thedelivery time among the respondents ranged fromvignette 3 to 20. After reviewing the fifth fetal heartrate tracing (median of the distribution), the propor-tions of nurses, residents, and physicians who decidedto expedite delivery because of nonreassuring fetalstatus were similar. Absent variability and recurrentlate decelerations were the most frequent fetal heartrate characteristics that prompted delivery (P�.3;Table 2). A decision to expedite delivery before themedian of the distribution was made by 32.6% (16 of49) of the providers, whereas 12.2% (6 of 49) chose tointervene afterward. Residents selected vacuum-as-sisted vaginal delivery more frequently than didnurses and attending obstetricians (18.2%, 8.7%, and0%, respectively, P�.001; Table 2), whereas physi-cians chose cesarean delivery as the ideal deliveryroute more often than nurses and residents (93.3%,82.6%, and 81.8%, respectively, P�.001; Table 2).

Registered nurses notified obstetricians abouttheir concern for the fetal status earlier than residents,and the median notification vignettes were, respec-tively, 4 and 5 (P�.001); minimal and absent variabil-ity were the fetal heart rate features more oftenprompting physician notification among residents asopposed to intermittent decelerations among nurses(P�.001, Table 2).

Sociodemographic factors such as sex, country ofgraduation from medical or nursing school, maritalstatus, and parenthood had no effects on the selectionof the delivery vignette (P�.3–.8; Table 3). Similarly,previous negative professional experiences, includinghistory of a permanent adverse neonatal outcome,involvement in a medical lawsuit, and license limita-tions or restrictions, did not influence the choice ofthe delivery vignette (P�.3–.9; Table 3). Perception ofthe respondents’ labor and delivery skills was alsoirrelevant in determining the timing of delivery (P�.3and .8, respectively; Table 3). Most of the medicalprofessionals considered gravidity, parity, and pa-tients’ education relevant in the decision of how toexpedite delivery in the second stage of labor, but no

Table 2. Respondents’ Timing of Delivery and Indication to Expedite Delivery

Registered Nurses(n�23)

Physicians(n�15)

Residents(n�11) P

Delivery vignette 0.3*Median 5 5 525th percentile 5 4.5 575th percentile 9 6.5 6

Notification vignette n�25 n�11 �.001†

Median 4 525th percentile 3 575th percentile 4 5

Fetal heart rate reason for delivery 0.3‡

Absent variability 11 (47.8) 7 (46.8) 6 (54.6)Recurrent late decelerations 8 (34.8) 4 (26.6) 3 (27.2)Other 4 (17.4) 4 (26.6) 2 (18.2)Total 23 (100) 15 (100) 11 (100)

Fetal heart rate reason for notification �0.001‡

Intermittent late decelerations 14 (56) 0 (0)Minimal variability 5 (20) 3 (27.3)Absent variability 0 (0) 6 (54.5)Other 6 (24) 2 (18.2)Total 25 (100) 11 (100)

Route of delivery �.001‡

Cesarean 19 (82.6) 14 (93.3) 9 (81.8)Forceps 2 (8.7) 1 (6.7) 0 (0)Vacuum 2 (8.7) 0 (0) 2 (18.2)

23 (100) 15 (100) 11 (100)

Data are n (%) unless otherwise specified.Information on the vignette representing the time of delivery, the fetal heart rate feature prompting intervention, and the route of

delivery were not submitted by two nurses and one attending physician.* Kruskal-Wallis one-way analysis of variance on ranks.† Mann-Whitney rank-sum test.‡ �2.


relation with the delivery vignette was identified(Table 3).

The health care professionals’ age, number ofyears of practice, and percentage of professionaltime spent working in labor and delivery were notrelated to the delivery vignette (P�.1–.9; Table 4).The decision on timing of delivery was not associ-ated with the number of complications from oper-ative deliveries or shoulder dystocia encounteredby the respondents or their colleagues and mentors(P�.6 and .7, respectively; Table 4). Similarly, thedecision on when to expedite delivery was notaffected by the specific characteristics of the differ-ent providers’ practice, such as the rate of laboring

patients requiring intervention because of fetal dis-tress and the rate of patients without health insur-ance or those insured with Medicaid (P�.8 –.8;Table 4).

Providers’ psychological backgrounds were notassociated with the delivery vignette. The short psy-chiatric diagnostic screening questionnaire score at 2weeks and 6 months, the Yale-Brown ObsessiveCompulsive Scale score, the risk attitude scale score,and the fear index scale score were not related totiming of intervention (P�.1–.4; Table 4).

Additionally, no differences in sociodemographicbackground, professional experience, health care pro-fession, clinical practice, and personality traits were

Table 3. Respondents’ Characteristics and Delivery of the Standardized Patient

Delivery Vignette

P*Median 25th Percentile 75th Percentile

Sex .5Female (40) 5 5 5Male (10) 5 5 9

Country of graduation .3Foreign (13) 5 5 5United States (37) 5 5 9.5

Marital status .8Never married (4) 5 5 5.5Other (46) 5 5 9

Children .6Yes (31) 5 5 8.75No (19) 5 5 6

Role of gravidity and parity in deciding how to expedite secondstage of labor because of nonreassuring fetal status

.3

Relevant (46) 5 5 8Irrelevant (4) 10.5 5 16

Role of patients’ education in deciding how to expedite secondstage of labor

.6

Because of nonreassuring fetal statusYes (47) 5 4.25 7.25No (3) 5 5 8.75

Self-perceived labor and delivery skills .3Excellent (12) 5 5 8.5Good (36) 5 5 8.5Fair (2) 4.5 4 5

Labor and delivery skills as perceived by others .8Excellent (10) 5 5 9Good (34) 5 5 6Fair (2) 5 5 5Not sure (4) 6.5 4.5 9.5

Previous permanent negative neonatal outcome to subjector colleagues

.9

Yes (24) 5 5 7No (26) 5 5 9

Malpractice, limitation, or restriction of activity .3Yes (11) 5 5 16No (39) 5 5 9

In the first column, numbers in parentheses are the actual number of respondents (n).* Mann-Whitney rank-sum test.


observed in the study population, even after dichoto-mizing the delivery time of the standardized patient asvignette 5 or lower or higher than vignette 5 (data notincluded).

Table 5 summarizes the total number of cesareanand operative vaginal deliveries performed by theattending obstetricians for nonreassuring fetal statusin the study period, as well as their respective inter-vention indices. The number of interventions for fetaldistress directly correlated with the number of termlaboring patients (correlation coefficient 0.6, P�.02;

Table 6). The obstetrician’s intervention index wasnot associated with any specific personal or profes-sional experience, aspect of clinical practice, or psy-chological trait (P�.06–.9; Table 6). The operativevaginal delivery rate and the cesarean delivery ratewere not related to the number of complications fromvacuum and forceps deliveries, or to the type ofpatient insurance (P�.2–.5; Table 6).

Only 4% of respondents (2 of 50) were notfamiliar with the new three-tier system for fetalheart rate tracing interpretation;12 86% (45 of 50) of

Table 4. Delivery of the Standardized Patient According to Respondents’ Personal and ProfessionalExperiences

Delivery Vignette

Correlation Coefficient P

Providers’ age 0.05 .7Years of postgraduate training after medical school completion �0.02 .9Years of practice after residency or nursing school completion �0.08 .6Professional time spent in labor and delivery (%) 0.2 .1Laboring patients requiring intervention because of nonreassuring fetal status (%) 0.2 .08Laboring patients requiring cesarean delivery to expedite the second stage of labor

because of nonreassuring fetal status (%)0.1 .4

Laboring patients requiring vacuum operative delivery to expedite the second stageof labor because of nonreassuring fetal status (%)

�0.004 .7

Laboring patients requiring forceps to expedite the second stage of labor because ofnonreassuring fetal status (%)

0.04 .8

Number of complications encountered by the interviewee or colleagues or mentorsduring operative deliveries

0.08 .6

Patients with Medicaid, CHIP, or uninsured (%) �0.1 .4Number of complications from shoulder dystocia 0.05 .7Short psychiatric diagnostic screening questionnaire score at 2 wk 0.1 .3Short psychiatric diagnostic screening questionnaire score at 6 mo 0.2 .3Yale-Brown obsessive compulsive scale score 0.1 .4Risk attitude scale score �0.1 .4Fear index scale score 0.2 .1

CHIP, Children’s Health Insurance Program.

Table 5. Obstetricians’ Coefficient of Intervention

IdentificationCesareanDelivery Vacuum Forceps Total

LaboringPatients

Obstetricians’ InterventionIndex (%)

A 6 5 1 12 440 2.7B 1 6 0 7 388 1.8C 7 3 0 10 516 1.9D 3 1 1 5 411 1.2E 8 3 1 12 829 1.4F 5 0 0 5 297 1.7G 0 1 0 1 108 0.9I 3 5 1 9 292 3.1L 9 7 0 16 327 4.9N 12 5 1 18 996 1.8P 4 2 7 13 344 3.8Q 7 3 1 11 861 1.3R 10 1 0 11 594 1.8

Data are n unless otherwise specified.


the providers agreed with the new recommenda-tions, and only 20% (10 of 50) stated that theintroduction of the new guidelines affected theirclinical practice.

DISCUSSIONWhen confronted with a hypothetical standardizedpatient, attending physicians, residents, and registerednurses selected the same timing for delivery and fetalheart rate features indicative of nonreassuring fetal sta-tus. Registered nurses notified physicians about their

concern for fetal well-being earlier than residents and fordifferent types of fetal heart rate tracings. Residentschose vacuum-assisted vaginal delivery more frequentlythan the other medical professionals; obstetricians se-lected cesarean delivery instead. Personal or profes-sional experience, clinical practice, psychological traits,or actual physicians’ intervention index did not affectthe respondents’ timing of delivery. The number ofinterventions for fetal distress was directly correlatedwith the number of laboring patients.

The following limitations should be consideredwhen interpreting the data. Although standardizedcases previously have been used to test obstetricians’responses,11,13,14 their validity is not unequivocal.Some studies showed that these “paper patients” maybe valid surrogates for clinical decision-making,15 butother surveys have showed conflicting results.16,17 Forat least some of the tested variables, causality cannotbe established by the cross-sectional study design; forexample, specific personality traits may influence theobstetrician’s tendency to intervene for fetal distress,but previous decisions to expedite delivery also mayhave affected physician’s personality. The intention toinvestigate providers working in the same environ-ment lead to the selection of a population sampledfrom the same environment, and this may havelimited the generalizability of our findings. Anotherlimitation of our study is that the negative findingsmay have been attributable to the relatively smallsample size. Whereas the research setting may havetheoretically affected the decision made by the par-ticipants in the study, the specific study design limitedsuch influence. The questionnaire was anonymous,and interviewees were free to provide true statementsabout their previous personal experiences, their clin-ical practice, and the decision to expedite the deliveryof the standardized patient. Moreover, the interven-tion index was calculated using data obtained fromthe labor and delivery unit medical records.

A major strength of this survey is our ability tocorrelate obstetricians’ responses to a theoretical casescenario with their actual clinical practice. The sametiming of delivery indicated by the different providersprobably reflects the acquisition of similar standardsof practice from working in the same teaching environ-ment and adherence to the latest electronic fetal heartrate monitoring guidelines. In fact, the majority of themedical professionals identified absent fetal heart ratevariability and recurrent late decelerations as the mostcommon delivery indications.12

Residents notified physicians about their con-cerns for fetal well-being later than nurses did, whenimminent intervention was perceived as necessary,

Table 6. Obstetricians’ Characteristics andCoefficient of Intervention

Coefficient ofIntervention P

No. of interventions 13Laboring patients (n) 0.6 .02Intervention index (n�13)

Age 0.002 .9Years of practice after

residency completion�0.5 .06

Professional time spent inlabor and delivery (%)

�0.3 .3

Patients with Medicaid, CHIP,or uninsured (%)

�0.2 .4

Short psychiatric diagnosticscreening questionnairescore at 2 wk

0.2 .5

Short psychiatric diagnosticscreening questionnairescore at 6 months

�0.04 .9

Yale-Brown obsessivecompulsive scale score

�0.09 .8

Risk attitude scale score �0.1 .6Fear index scale score �0.07 .7Permanent negative

neonatal outcomes.6*

Present 2.3�0.4Absent 1.9�0.6

Professional activity .5*Named in malpractice suit 2.4�0.4Never named in

malpractice suits2�0.5

Sex .3*Male 2.3�0.5Female 2�0.3

Operative delivery rate (n�13)No. of complications from

operative deliveries�0.2 .5

Patients with Medicaid, CHIP,or uninsured (%)

�0.4 .2

Cesarean delivery rate (n�13)Patients with private

insurance (%)�0.2 .5

CHIP, Children’s Health Insurance Program.Data are correlation coefficient or average�standard error of the

mean unless otherwise specified.* t test.


whereas nursing personnel would inform the attend-ing of records earlier, when the typical features of acategory I tracing were no longer detected. This maybe related to the need of residents to develop inde-pendent decision-making skills as part of their trainingto become experienced clinicians. Despite differencesbetween residents and nurses, the fetal heart rate trac-ings prompting physician notification were all categoryII, therefore requiring constant surveillance and possiblycorrective measures according to the American Collegeof Obstetricians and Gynecologists.12

Differences in the route of delivery can, at least inpart, reflect variations in delivery time; however, themore frequent choice of vacuum-assisted deliveriesamong residents also could be related their desire tolearn and practice new procedures as a part of theirtraining.

The change in clinical practice over the past 20years was driven to a minor extent by pure medicalfactors. For example, the increase of the cesareandelivery rate to 30.5%18 has been attributed to amultifactorial process influenced minimally by pa-tients’ clinical status, but mostly by changes in obstet-rical practice, training, family and social pressures,legal system, availability of technology, and women’srequests and role models.18–20 Fear of litigation alsohas contributed to the increase in the cesarean deliv-ery rate11,13 and has affected provision of care.21

Because of the dramatic increase in emergency cesar-ean deliveries and the variability in fetal heart rateinterpretation, we wanted to investigate the factorsthat could affect the decision to expedite delivery forfetal distress other than fetal heart rate tracing.20–22

The time of delivery indicated in the case scenarioand the actual obstetrician’s intervention index werenot affected by the respondent’s personal history,professional experience, and psychological traits.Such findings may reflect a similar clinical approachdeveloped by professionals working in the same envi-ronment and adherence to the latest electronic fetalheart rate monitoring guidelines. Moreover, the positivecorrelation between the number of laboring patients andthe number of interventions also supports this hypothe-sis, because the tendency to identify fetal distress issimilar among obstetricians and appears independent ofclinicians’ specific characteristics.

A review of the different delivery modes inWestern Australia during 1984–2003 showed a 6.6%rate of emergency cesarean deliveries for fetal distressamong women spontaneously in labor as opposed to10.8% in case of labor induction.20 The 10th and 90th

percentiles of the emergency caesarean delivery ratein England were 10.7% and 18.9%, respectively.22

Instead, the lower intervention rates for fetal distressencountered in our study population are likely relatedto the selection of stricter inclusion criteria. In fact, thenumerator of the intervention index consisted ofoperative and cesarean deliveries exclusively indi-cated by fetal distress, whereas the denominatorincluded only laboring women at 37 or more weeks ofgestation.

In conclusion, the results of this study indicatethat different providers may develop a uniform ap-proach to fetal distress when they practice in the sameenvironment and follow the available electronic fetalheart rate monitoring guidelines, overcoming theeffects of different personal experiences, professionalbackground, clinical practice, and psychologicaltraits.

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