Abstract
Continuous electronic fetal monitoring is widely used to guide intrapartum decision-making, yet variability in how clinicians interpret cardiotocography (CTG) remains a persistent quality-of-care concern. In settings where midwives are the first interpreters of CTG, inconsistent readings may delay recognition of fetal compromise.
To appraise the consistency and completeness of CTG interpretation recorded by midwives against a researcher's independent re-assessment and to infer training needs for intrapartum fetal surveillance.
A quantitative, retrospective record review was undertaken at a secondary-level public hospital in Gauteng, South Africa, covering March 2023 to February 2024.
Using a pre-specified checklist, we abstracted CTG-related documentation and variables, including baseline fetal heart rate, short-term variability, accelerations, decelerations, and overall trace classification, from randomly selected maternity files (n = 366) that met predefined inclusion criteria for high-risk intrapartum care. Midwives' notes were compared with a blinded researcher's reinterpretation. Agreement metrics included percent agreement and intraclass correlation coefficients; an inter-rater substudy (researcher vs operational manager) evaluated rating reliability on a random subset.
Documentation by midwives was frequently incomplete, particularly for accelerations, and agreement with the researcher's assessments was limited across several parameters. Midwives most often rated traces as reassuring, whereas the researcher identified more non-reassuring and pathological features than were recorded in routine notes. Inter-rater analysis on a subset supported the internal consistency of the independent re-read process. Collectively, findings indicate gaps in both documentation and interpretive alignment.
Within this high-risk intrapartum cohort, CTG interpretation recorded by midwives showed notable divergence from an independent reassessment and omissions in key variables. The patterns point to a need for targeted CTG education, routine audit/feedback on documentation quality, and agreement-oriented calibration using local protocols.
The study provides file-based evidence of where interpretive alignment breaks down in everyday practice and offers a practical baseline for training, supervision, and quality improvement cycles in intrapartum monitoring at the secondary care level.