Strengths and Limitations
The main strength of this study was the careful selection of medical
records. Ten medical records were selected among forty others by four
reviewers, including one expert in court. Clear instructions were given
beforehand to the reviewers to only retain records whose outcome was
unequivocal. In other words, the four reviewers had to agree that the
actual mode of delivery (either a caesarean section or a vaginal
delivery) was the best possible outcome in the clinical context with
knowledge of the entire medical record, including the results of the
foetal scalp blood sampling and the neonatal status. This rigorous
selection process legitimises the claim that choosing an alternative
mode of delivery without using a second-line method would at least
result in a nonoptimal outcome for the patient or her newborn. The
exhaustive and careful presentation of all the information necessary for
the participants to make a decision should also be emphasized. Real CTGs
were presented either entirely since the beginning of labour or
partially since before the beginning of CTG abnormalities (when the
tracings exceeded three hours). Hence, this online questionnaire allowed
an original simulation of real clinical situations, and we believe that
it is a reliable evaluation of the participants’ professional attitudes.
However, several considerations mitigate the conclusions that can be
drawn from the results of this study. Despite the aforementioned
precautions, it is impossible to assert with absolute certainty the
outcome of an alternative scenario. Although we consider it unlikely, it
is not formally impossible that among the 4 records that resulted in a
caesarean section, one or more records could have ended differently.
Several participants also pointed out that reducing the choice to three
options was too restrictive and did not give a fair representation of
reality. In particular, it is possible that some participants would have
opted to continue labour only for some time before ultimately performing
a caesarean section or a second-line method. Similarly, some
participants suggested that other options were available, such as
positioning the patient differently or stopping oxytocic administration.
As stated before, although four reviewers deemed that the actual outcome
was the best possible option, alternative scenarios cannot formally be
excluded.
In addition, there is no way of verifying that the participants would
have actually made the stated decision in a real-life situation. It is
possible that the context of the anonymous questionnaire, devoid of any
stress related to the consequences and presented as a test, encouraged
participants to take more risks in their decision-making. It is also
worth mentioning that the majority of the participants of this online
survey were residents. Although we only included residents in their
fourth year or higher who are ordinarily already self-reliant in
obstetrical decision-making, we can hardly extrapolate the results to
more experienced physicians.
Furthermore, all modes of training for the CTG physiology-based
interpretation were placed on an equal footing in the training group.
The number of participants was insufficient to provide subgroup analysis
for each type of training. Although the vast majority of the
participants from the training group declared that they used the
precepts of CTG physiology-based interpretation in their daily practice,
it is possible that our results are biased by the insufficient training
of some participants.