Devane Declan, Lalor Joan
Midwifery Doctoral Student, University of Dublin Trinity College, Dublin, Ireland.
J Adv Nurs. 2005 Oct;52(2):133-41. doi: 10.1111/j.1365-2648.2005.03575.x.
This paper reports an examination of intra- and inter-observer agreement in midwives' visual interpretation of intrapartum cardiotocographs (CTGs).
The issue of intra- and inter-observer agreement in the interpretation of CTG interpretation has serious implications for the validity of electronic fetal heart rate monitoring and subsequent decisions on intrapartum management. However, no studies were found that assessed intra- and inter-observer agreement in midwives' interpretations of CTG tracings.
Twenty-eight midwives independently interpreted three intrapartum CTG tracings on two separate occasions using a self-administered Cardiotocograph Interpretation Skills Test. Inter-rater agreement in interpretation was assessed by cross-tabulating the two sets of raw data obtained at time 1 and time 2 and computing Cohen's Kappa (kappa). Intra-rater agreement was assessed by computing kappa for each rater with the two sets of raw data (time 1 and time 2) obtained from each individual. The data were collected in 2000.
Overall intra-rater agreement ranged from 'fair to good' (kappa = 0.48) to 'excellent' (kappa = 0.92). Raters' classifications altered in 18% (n = 5) of cases for the normal tracing, in 29% (n = 8) for the suspicious tracing and in 11% (n = 3) for the pathological tracing. Inter-rater agreement was fair to good, with kappa statistics ranging from 0.65 to 0.74, respectively. Agreement was highest in the classification of decelerations (kappa = 0.79) and lowest in the assessment of baseline variability (kappa = 0.50). Overall inter-rater agreement was highest in the suspicious tracing (kappa = 0.77, excellent) and lowest in the normal tracing (kappa = 0.54, fair to good).
Inter- and intra-observer variability are intrinsic characteristics of the interpretation of intrapartum CTGs. Levels of agreement revealed degrees of variation that expose room for improvement. Efforts are needed to reduce inter- and intra-observer variation in interpretation of intrapartum CTG tracings. In addition, research should focus on the development and evaluation of non-invasive, low observer variability methods of intrapartum assessment of fetal well-being. The subjectivity of CTG interpretation and inconsistencies in interpretation should also be considered in intrapartum management, clinical audit and in medico-legal settings.
本文报告了一项关于助产士对产时胎心监护图（CTG）视觉解读的观察者内和观察者间一致性的研究。
CTG解读中观察者内和观察者间一致性的问题对电子胎儿心率监测的有效性以及随后的产时管理决策具有严重影响。然而，未发现有研究评估助产士对CTG描记图解读的观察者内和观察者间一致性。
28名助产士在两个不同时间分别独立解读三张产时CTG描记图，使用自我管理的胎心监护图解读技能测试。通过将在时间1和时间2获得的两组原始数据交叉制表并计算科恩kappa系数（kappa）来评估解读中的评分者间一致性。通过计算每个评分者与从每个个体获得的两组原始数据（时间1和时间2）的kappa来评估评分者内一致性。数据于2000年收集。
总体评分者内一致性范围从“中等至良好”（kappa = 0.48）到“优秀”（kappa = 0.92）。对于正常描记图，18%（n = 5）的病例中评分者分类发生改变；对于可疑描记图，29%（n = 8）的病例中发生改变；对于病理性描记图，11%（n = 3）的病例中发生改变。评分者间一致性为中等至良好，kappa统计值分别在0.65至0.74之间。减速分类的一致性最高（kappa = 0.79），基线变异评估的一致性最低（kappa = 0.50）。总体评分者间一致性在可疑描记图中最高（kappa = 0.77，优秀），在正常描记图中最低（kappa = 0.54，中等至良好）。
观察者间和观察者内的变异性是产时CTG解读的固有特征。一致性水平揭示了变异程度，表明有改进空间。需要努力减少产时CTG描记图解读中观察者间和观察者内的变异。此外，研究应专注于开发和评估用于产时胎儿健康评估的无创、低观察者变异性方法。在产时管理、临床审计和法医学环境中，也应考虑CTG解读的主观性和解读不一致性。
