A C TA Obstetricia et Gynecologica
AOGS M A I N R E SE A RC H A R TI C LE
Curriculum development for a national cardiotocography education program: a Delphi survey to obtain consensus on learning objectives LINE THELLESEN1, MORTEN HEDEGAARD1, THOMAS BERGHOLT2, NINA P. COLOV1, STINNE HOEGH1 & JETTE L. SORENSEN1 1
Department of Obstetrics, Juliane Marie Center for Children, Women, and Reproduction, Rigshospitalet University Hospital/University of Copenhagen, Copenhagen, and 2Department of Gynecology and Obstetrics, Nordsjaellands Hospital/University of Copenhagen, Hillero€d, Denmark
Key words Cardiotocography, fetal monitoring, obstetrics, Delphi technique, curriculum, consensus, medical education Correspondence Line Thellesen, Department of Obstetrics, Juliane Marie Center for Children, Women, and Reproduction, Rigshospitalet University Hospital/University of Copenhagen, Blegdamsvej 9, Copenhagen 2200, Denmark. E-mail: [email protected] Conflict of interest The authors have stated explicitly that there are no conflicts of interest in connection with this article. Please cite this article as: Thellesen L, Hedegaard M, Bergholt T, Colov NP, Hoegh S, Sorensen JL. Curriculum development for a national cardiotocography education program: a Delphi survey to obtain consensus on learning objectives. Acta Obstet Gynecol Scand 2015; 94: 869–877. Received: 10 December 2014 Accepted: 12 April 2015 DOI: 10.1111/aogs.12662
Abstract Objective. To define learning objectives for a national cardiotocography (CTG) education program based on expert consensus. Design. A three-round Delphi survey. Population and setting. One midwife and one obstetrician from each maternity unit in Denmark were appointed based on CTG teaching experience and clinical obstetric experience. Methods. Following national and international guidelines, the research group determined six topics as important when using CTG: fetal physiology, equipment, indication, interpretation, clinical management, and communication/responsibility. In the first Delphi round, participants listed one to five learning objectives within the predefined topics. Responses were analyzed by a directed approach to content analysis. Phrasing was modified in accordance with Bloom’s taxonomy. In the second and third Delphi rounds, participants rated each objective on a five-point relevance scale. Consensus was predefined as objectives with a mean rating value of ≥3. Main outcome measures. A prioritized list of CTG learning objectives. Results. A total of 42 midwives and obstetricians from 21 maternity units were invited to participate, of whom 26 completed all three Delphi rounds, representing 18 maternity units. The final prioritized list included 40 objectives. The highest ranked objectives emphasized CTG interpretation and clinical management. The lowest ranked objectives emphasized fetal physiology. Mean ratings of relevance ranged from 3.15 to 5.00. Conclusions. National consensus on CTG learning objectives was achieved using the Delphi methodology. This was an initial step in developing a valid CTG education program. A prioritized list of objectives will clarify which topics to emphasize in a CTG education program. Abbreviation:
CTG, cardiotocography.
Introduction In severe cases, fetal hypoxia can lead to brain injury and death. Cardiotocography (CTG) is a widely used surveillance method that aims to identify fetal hypoxia to decide whether additional fetal assessment or accelerated delivery is required. However, studies show that misinterpretation of, and delayed clinical actions to, an abnormal CTG are significant etiological factors for hypoxic brain injuries
Key Message Learning objectives are essential when planning and developing an educational intervention. A prioritized list of CTG learning objectives based on national consensus will clarify which topics to emphasize in a CTG education program.
ª 2015 Nordic Federation of Societies of Obstetrics and Gynecology, Acta Obstetricia et Gynecologica Scandinavica 94 (2015) 869–877
869
Objectives for a CTG education program
during labor (1–3). In addition to the considerable effect on families and obstetric staff, these cases also result in large financial costs. A 10-year report on maternity claims from the English National Health Service Litigation Authority was published in 2012 (4). The total amount of compensation awarded was £3.1 billion. The three most frequent categories of claims were those relating to management of labor (including CTG interpretation), cerebral palsy, and cesarean section. The two former accounted for 70% of the total value of all the claims. It was concluded from these studies that CTG training and education are essential. To reduce the incidence of hypoxic injuries during labor, a comprehensive national obstetric intervention (Safe deliveries) was initiated in Denmark in September 2012 (5). The Danish regions, the Danish Society of Obstetrics and Gynecology, the Danish Association of Midwives, the Danish Society of Pediatrics, the Danish Society for Patient Safety and the Patient Compensation Association all support the initiative. As part of the intervention, all midwives and physicians working at a maternity unit in Denmark must complete a CTG education program. The education program consists of a CTG e-learning program, a 1-day CTG course, and a CTG multiple-choice question test. There are several publications concerning the impact of CTG education but a lack of validated assessment methods has been indicated (6). Learning objectives based on national consensus will increase the validity of the education program, including both the course and the assessment. There are detailed CTG curricula, descriptions of CTG examination contents, and reports on content validation from CTG education programs in Australia and the USA (7,8) but we were unable to identify published articles concerning the development of CTG learning objectives. Objectives are essential when planning and developing an education program. They constitute the foundation of the content, the teaching strategies, and the assessment (9). We aimed to develop learning objectives for the national CTG education program based on a systematic consensus methodology. To induce joint ownership of the national teaching intervention and detect possible differences between the individual maternity units, we involved experienced midwives and obstetricians from all maternity units in Denmark in the developing process.
Material and methods The study originated in the Department of Obstetrics, at the Juliane Marie Center for Children, Women and Reproduction, Rigshospitalet University Hospital, University of Copenhagen. The study took place from December 2012 to April 2013. All 24 Danish maternity units were invited to participate. The maternity units were distrib-
870
L. Thellesen et al.
uted over five regions and the number of deliveries varied from 238 to 6659 per year (10). The research group consisted of one obstetric resident conducting research on education in CTG (L.T.), one obstetrician with a master’s degree and research experience in medical education (J.L.S.), two obstetricians with several years of clinical and research experience (M.H., T.B.), one obstetrician with extensive experience in CTG teaching (N.P.C.), and one midwife experienced in perinatal audit (S.H.).
Delphi methodology We used a Delphi survey to obtain national consensus on learning objectives for a national CTG education program. The Delphi methodology attempts to obtain expert opinion in a systematic manner (11). The group of experts is generally referred to as the Delphi panel or the expert panel, and the experts’ opinions are usually collected by self-administered questionnaires. The survey is characterized by a systematic group communication process that involves a number of rounds, feedback of responses to participants between rounds, opportunities for participants to modify their responses, and anonymity of responses (12). The aim is to combine expert opinion into a group consensus (13). The method benefits from being anonymous and so avoids disproportional dominance from influential persons (14). Geographic limitations are reduced, which enables responses from a large group of experts, and the expenses are low if the survey is electronically conducted. This methodology has been used to develop evaluation tools (15,16), diagnostic criteria (17), research questions (18), curricula (19), and learning objectives (20) in health care research.
Selection of participants to the Delphi panel The Delphi panel in the present study consisted of experienced midwives and obstetricians from all Danish maternity units. Experience was defined as midwives and obstetricians with CTG teaching experience and more than 5 years of clinical obstetric experience. The obstetric management (chief physician or chief midwife) from each maternity unit was contacted and asked to appoint a midwife and an obstetrician, following the given inclusion criteria.
Questionnaire content and Delphi consensus Prior to the first Delphi round, the research group determined six important topics for using CTG, based on national and international guidelines on electronic fetal monitoring (21–25): fetal physiology, equipment,
ª 2015 Nordic Federation of Societies of Obstetrics and Gynecology, Acta Obstetricia et Gynecologica Scandinavica 94 (2015) 869–877
L. Thellesen et al.
Objectives for a CTG education program
indication, interpretation, clinical management, and communication/responsibility. For each of the topics we asked questions to clarify the task of developing learning objectives: ‘What knowledge about fetal physiology do you find essential to have as a midwife or an obstetrician responsible for CTG monitoring?’ and ‘Which CTG interpretation skills do you find essential to have as a midwife or obstetrician responsible for CTG monitoring?’ The participants were informed that objectives could address knowledge, attitudes, and skills. In subsequent Delphi rounds the participants were asked to rate the relevance of the objectives on a five-point scale (1 = not relevant, 2 = less relevant, 3 = relevant, 4 = very relevant and 5 = extremely relevant). The study was predefined to go through three rounds. Consensus was predefined as objectives with a mean rating value of ≥3.
Questionnaire design and administration All participants were contacted by e-mail. The mail contained study information and a link to the Delphi Method and analyses
• The management of each Danish maternity unit appointed the Delphi panel members
questionnaire in Google Drive. The questionnaire was constructed in six steps, according to the predefined topics. In the second and third Delphi rounds, in order to avoid missing data, restrictions in the questionnaire made it impossible to continue to the next step without completing the previous one. For each round, the participants had 4 weeks to respond. Within that period three e-mail reminders where sent at 1-week intervals. The flowchart in Figure 1 describes the three Delphi rounds. Supplementary details are outlined in Supporting Information Appendix S1. Study description and participatory conditions were sent by e-mail. The first author (L.T.) was not blinded to participants and their individual responses. Otherwise, the study was anonymously conducted. Participation agreement was given by activating a link in the mail to the Delphi questionnaire. The study was evaluated by the Regional Ethical Committee of the Capital Region of Denmark, and ethical approval was not required according to Danish regulations (Protocol number: H-1-2012FSP).
Delphi panel members (number of maternity units)
Delphi rounds
42 (21) 21 midwives 21 obstetricians
The research group • stated six topics important when using CTG founded on national and international guidelines • E-mailed panel members the first Delphi round questionnaire
The research group • Condensed data based on a directed approach to content analysis • Developed objectives based on Bloom’s taxonomy • E-mailed panel members the objectives
The research group • Revised the objectives • Assessed the ratings of the objectives by means and distribution of ratings in percent for each objective • E-mailed panel members the revised objectives, including the ratings • The research group developed a prioritized list of objectives based on mean values
31 (20) 15 midwives 16 obstetricians
29 (19) 14 midwives 15 obstetricians
26 (18) 13 midwives 13 obstetricians
1. Panel members listed one to five learning objectives within each predefined topic
2. Panel members rated the relevance of each objective on a five-point scale, suggested new objectives and commented on existing ones.
3. Panel members re-rated the relevance of each objective. Comments were not encouraged.
Figure 1. Description of the three Delphi rounds, number of respondents, and analyses.
ª 2015 Nordic Federation of Societies of Obstetrics and Gynecology, Acta Obstetricia et Gynecologica Scandinavica 94 (2015) 869–877
871
Objectives for a CTG education program
Data analyses A directed approach to content analysis was applied in processing the data (26). The structure and phrasing of the objectives were based on Bloom’s taxonomy to secure meaningful and consistent use of verbs (27). Supplementary details are outlined in Appendix S1. The rating of the objectives was assessed by means, and the variances of responses were presented as the distribution of ratings in percent for each objective. Data were compiled and assessed in EXCEL 2010 (Microsoft Corp., Redmond, WA, USA).
Results Figure 1 depicts an overview of the study. Joint management occurred in six of the 24 maternity units, which meant that in three cases, two units had common obstetric management. A total of 21 units were therefore included. The inclusion criteria of CTG teaching experience could not be sufficiently honored at three of the maternity units (two midwives and two obstetricians) due to small size of maternity unit and/or lack of coordinated local CTG courses. All participants had more than 5 years of clinical experience. Of the 42 invited participants 33 responded in the first round, representing 20 maternity units. Two participants did not write any text in the questionnaire and were therefore excluded, so the total number of first round participants equaled 31. A total of 29 participants responded in the second round, and 26 participants in the third round, representing 19 and 18 maternity units, respectively. The overall participant response rate was 62% (26 of 42). The distribution of midwives and obstetricians who responded was equal in the three rounds, and all five regions of Denmark were represented. Six maternity units function as highly specialized units in Denmark and manage approximately half of all Danish births. All six were represented in the first two Delphi rounds and five were represented in the third round. A total of 536 responses were collected after the first Delphi round. The responses varied from well-constructed learning objectives, to cues, long descriptive sentences, questions, and reflective remarks. The responses were condensed to 41 learning objectives during the content analysis. No new objectives were suggested. Of the 29 respondents in the second round, only four obstetricians and two midwives from the Delphi panel commented on the objectives. The comments emphasized the cognitive level of knowledge, and objectives concerning ST analysis of fetal electrocardiography and fetal scalp-blood sampling. The research group evaluated the comments and made
872
L. Thellesen et al.
minor revisions. A list of comments and modifications is available from the authors on request. Ratings of relevance over two Delphi rounds resulted in a prioritized list of objectives presented in Table 1. There were no missing values within respondents. One objective was excluded due to a mean rating value
AOGS M A I N R E SE A RC H A R TI C LE
Curriculum development for a national cardiotocography education program: a Delphi survey to obtain consensus on learning objectives LINE THELLESEN1, MORTEN HEDEGAARD1, THOMAS BERGHOLT2, NINA P. COLOV1, STINNE HOEGH1 & JETTE L. SORENSEN1 1
Department of Obstetrics, Juliane Marie Center for Children, Women, and Reproduction, Rigshospitalet University Hospital/University of Copenhagen, Copenhagen, and 2Department of Gynecology and Obstetrics, Nordsjaellands Hospital/University of Copenhagen, Hillero€d, Denmark
Key words Cardiotocography, fetal monitoring, obstetrics, Delphi technique, curriculum, consensus, medical education Correspondence Line Thellesen, Department of Obstetrics, Juliane Marie Center for Children, Women, and Reproduction, Rigshospitalet University Hospital/University of Copenhagen, Blegdamsvej 9, Copenhagen 2200, Denmark. E-mail: [email protected] Conflict of interest The authors have stated explicitly that there are no conflicts of interest in connection with this article. Please cite this article as: Thellesen L, Hedegaard M, Bergholt T, Colov NP, Hoegh S, Sorensen JL. Curriculum development for a national cardiotocography education program: a Delphi survey to obtain consensus on learning objectives. Acta Obstet Gynecol Scand 2015; 94: 869–877. Received: 10 December 2014 Accepted: 12 April 2015 DOI: 10.1111/aogs.12662
Abstract Objective. To define learning objectives for a national cardiotocography (CTG) education program based on expert consensus. Design. A three-round Delphi survey. Population and setting. One midwife and one obstetrician from each maternity unit in Denmark were appointed based on CTG teaching experience and clinical obstetric experience. Methods. Following national and international guidelines, the research group determined six topics as important when using CTG: fetal physiology, equipment, indication, interpretation, clinical management, and communication/responsibility. In the first Delphi round, participants listed one to five learning objectives within the predefined topics. Responses were analyzed by a directed approach to content analysis. Phrasing was modified in accordance with Bloom’s taxonomy. In the second and third Delphi rounds, participants rated each objective on a five-point relevance scale. Consensus was predefined as objectives with a mean rating value of ≥3. Main outcome measures. A prioritized list of CTG learning objectives. Results. A total of 42 midwives and obstetricians from 21 maternity units were invited to participate, of whom 26 completed all three Delphi rounds, representing 18 maternity units. The final prioritized list included 40 objectives. The highest ranked objectives emphasized CTG interpretation and clinical management. The lowest ranked objectives emphasized fetal physiology. Mean ratings of relevance ranged from 3.15 to 5.00. Conclusions. National consensus on CTG learning objectives was achieved using the Delphi methodology. This was an initial step in developing a valid CTG education program. A prioritized list of objectives will clarify which topics to emphasize in a CTG education program. Abbreviation:
CTG, cardiotocography.
Introduction In severe cases, fetal hypoxia can lead to brain injury and death. Cardiotocography (CTG) is a widely used surveillance method that aims to identify fetal hypoxia to decide whether additional fetal assessment or accelerated delivery is required. However, studies show that misinterpretation of, and delayed clinical actions to, an abnormal CTG are significant etiological factors for hypoxic brain injuries
Key Message Learning objectives are essential when planning and developing an educational intervention. A prioritized list of CTG learning objectives based on national consensus will clarify which topics to emphasize in a CTG education program.
ª 2015 Nordic Federation of Societies of Obstetrics and Gynecology, Acta Obstetricia et Gynecologica Scandinavica 94 (2015) 869–877
869
Objectives for a CTG education program
during labor (1–3). In addition to the considerable effect on families and obstetric staff, these cases also result in large financial costs. A 10-year report on maternity claims from the English National Health Service Litigation Authority was published in 2012 (4). The total amount of compensation awarded was £3.1 billion. The three most frequent categories of claims were those relating to management of labor (including CTG interpretation), cerebral palsy, and cesarean section. The two former accounted for 70% of the total value of all the claims. It was concluded from these studies that CTG training and education are essential. To reduce the incidence of hypoxic injuries during labor, a comprehensive national obstetric intervention (Safe deliveries) was initiated in Denmark in September 2012 (5). The Danish regions, the Danish Society of Obstetrics and Gynecology, the Danish Association of Midwives, the Danish Society of Pediatrics, the Danish Society for Patient Safety and the Patient Compensation Association all support the initiative. As part of the intervention, all midwives and physicians working at a maternity unit in Denmark must complete a CTG education program. The education program consists of a CTG e-learning program, a 1-day CTG course, and a CTG multiple-choice question test. There are several publications concerning the impact of CTG education but a lack of validated assessment methods has been indicated (6). Learning objectives based on national consensus will increase the validity of the education program, including both the course and the assessment. There are detailed CTG curricula, descriptions of CTG examination contents, and reports on content validation from CTG education programs in Australia and the USA (7,8) but we were unable to identify published articles concerning the development of CTG learning objectives. Objectives are essential when planning and developing an education program. They constitute the foundation of the content, the teaching strategies, and the assessment (9). We aimed to develop learning objectives for the national CTG education program based on a systematic consensus methodology. To induce joint ownership of the national teaching intervention and detect possible differences between the individual maternity units, we involved experienced midwives and obstetricians from all maternity units in Denmark in the developing process.
Material and methods The study originated in the Department of Obstetrics, at the Juliane Marie Center for Children, Women and Reproduction, Rigshospitalet University Hospital, University of Copenhagen. The study took place from December 2012 to April 2013. All 24 Danish maternity units were invited to participate. The maternity units were distrib-
870
L. Thellesen et al.
uted over five regions and the number of deliveries varied from 238 to 6659 per year (10). The research group consisted of one obstetric resident conducting research on education in CTG (L.T.), one obstetrician with a master’s degree and research experience in medical education (J.L.S.), two obstetricians with several years of clinical and research experience (M.H., T.B.), one obstetrician with extensive experience in CTG teaching (N.P.C.), and one midwife experienced in perinatal audit (S.H.).
Delphi methodology We used a Delphi survey to obtain national consensus on learning objectives for a national CTG education program. The Delphi methodology attempts to obtain expert opinion in a systematic manner (11). The group of experts is generally referred to as the Delphi panel or the expert panel, and the experts’ opinions are usually collected by self-administered questionnaires. The survey is characterized by a systematic group communication process that involves a number of rounds, feedback of responses to participants between rounds, opportunities for participants to modify their responses, and anonymity of responses (12). The aim is to combine expert opinion into a group consensus (13). The method benefits from being anonymous and so avoids disproportional dominance from influential persons (14). Geographic limitations are reduced, which enables responses from a large group of experts, and the expenses are low if the survey is electronically conducted. This methodology has been used to develop evaluation tools (15,16), diagnostic criteria (17), research questions (18), curricula (19), and learning objectives (20) in health care research.
Selection of participants to the Delphi panel The Delphi panel in the present study consisted of experienced midwives and obstetricians from all Danish maternity units. Experience was defined as midwives and obstetricians with CTG teaching experience and more than 5 years of clinical obstetric experience. The obstetric management (chief physician or chief midwife) from each maternity unit was contacted and asked to appoint a midwife and an obstetrician, following the given inclusion criteria.
Questionnaire content and Delphi consensus Prior to the first Delphi round, the research group determined six important topics for using CTG, based on national and international guidelines on electronic fetal monitoring (21–25): fetal physiology, equipment,
ª 2015 Nordic Federation of Societies of Obstetrics and Gynecology, Acta Obstetricia et Gynecologica Scandinavica 94 (2015) 869–877
L. Thellesen et al.
Objectives for a CTG education program
indication, interpretation, clinical management, and communication/responsibility. For each of the topics we asked questions to clarify the task of developing learning objectives: ‘What knowledge about fetal physiology do you find essential to have as a midwife or an obstetrician responsible for CTG monitoring?’ and ‘Which CTG interpretation skills do you find essential to have as a midwife or obstetrician responsible for CTG monitoring?’ The participants were informed that objectives could address knowledge, attitudes, and skills. In subsequent Delphi rounds the participants were asked to rate the relevance of the objectives on a five-point scale (1 = not relevant, 2 = less relevant, 3 = relevant, 4 = very relevant and 5 = extremely relevant). The study was predefined to go through three rounds. Consensus was predefined as objectives with a mean rating value of ≥3.
Questionnaire design and administration All participants were contacted by e-mail. The mail contained study information and a link to the Delphi Method and analyses
• The management of each Danish maternity unit appointed the Delphi panel members
questionnaire in Google Drive. The questionnaire was constructed in six steps, according to the predefined topics. In the second and third Delphi rounds, in order to avoid missing data, restrictions in the questionnaire made it impossible to continue to the next step without completing the previous one. For each round, the participants had 4 weeks to respond. Within that period three e-mail reminders where sent at 1-week intervals. The flowchart in Figure 1 describes the three Delphi rounds. Supplementary details are outlined in Supporting Information Appendix S1. Study description and participatory conditions were sent by e-mail. The first author (L.T.) was not blinded to participants and their individual responses. Otherwise, the study was anonymously conducted. Participation agreement was given by activating a link in the mail to the Delphi questionnaire. The study was evaluated by the Regional Ethical Committee of the Capital Region of Denmark, and ethical approval was not required according to Danish regulations (Protocol number: H-1-2012FSP).
Delphi panel members (number of maternity units)
Delphi rounds
42 (21) 21 midwives 21 obstetricians
The research group • stated six topics important when using CTG founded on national and international guidelines • E-mailed panel members the first Delphi round questionnaire
The research group • Condensed data based on a directed approach to content analysis • Developed objectives based on Bloom’s taxonomy • E-mailed panel members the objectives
The research group • Revised the objectives • Assessed the ratings of the objectives by means and distribution of ratings in percent for each objective • E-mailed panel members the revised objectives, including the ratings • The research group developed a prioritized list of objectives based on mean values
31 (20) 15 midwives 16 obstetricians
29 (19) 14 midwives 15 obstetricians
26 (18) 13 midwives 13 obstetricians
1. Panel members listed one to five learning objectives within each predefined topic
2. Panel members rated the relevance of each objective on a five-point scale, suggested new objectives and commented on existing ones.
3. Panel members re-rated the relevance of each objective. Comments were not encouraged.
Figure 1. Description of the three Delphi rounds, number of respondents, and analyses.
ª 2015 Nordic Federation of Societies of Obstetrics and Gynecology, Acta Obstetricia et Gynecologica Scandinavica 94 (2015) 869–877
871
Objectives for a CTG education program
Data analyses A directed approach to content analysis was applied in processing the data (26). The structure and phrasing of the objectives were based on Bloom’s taxonomy to secure meaningful and consistent use of verbs (27). Supplementary details are outlined in Appendix S1. The rating of the objectives was assessed by means, and the variances of responses were presented as the distribution of ratings in percent for each objective. Data were compiled and assessed in EXCEL 2010 (Microsoft Corp., Redmond, WA, USA).
Results Figure 1 depicts an overview of the study. Joint management occurred in six of the 24 maternity units, which meant that in three cases, two units had common obstetric management. A total of 21 units were therefore included. The inclusion criteria of CTG teaching experience could not be sufficiently honored at three of the maternity units (two midwives and two obstetricians) due to small size of maternity unit and/or lack of coordinated local CTG courses. All participants had more than 5 years of clinical experience. Of the 42 invited participants 33 responded in the first round, representing 20 maternity units. Two participants did not write any text in the questionnaire and were therefore excluded, so the total number of first round participants equaled 31. A total of 29 participants responded in the second round, and 26 participants in the third round, representing 19 and 18 maternity units, respectively. The overall participant response rate was 62% (26 of 42). The distribution of midwives and obstetricians who responded was equal in the three rounds, and all five regions of Denmark were represented. Six maternity units function as highly specialized units in Denmark and manage approximately half of all Danish births. All six were represented in the first two Delphi rounds and five were represented in the third round. A total of 536 responses were collected after the first Delphi round. The responses varied from well-constructed learning objectives, to cues, long descriptive sentences, questions, and reflective remarks. The responses were condensed to 41 learning objectives during the content analysis. No new objectives were suggested. Of the 29 respondents in the second round, only four obstetricians and two midwives from the Delphi panel commented on the objectives. The comments emphasized the cognitive level of knowledge, and objectives concerning ST analysis of fetal electrocardiography and fetal scalp-blood sampling. The research group evaluated the comments and made
872
L. Thellesen et al.
minor revisions. A list of comments and modifications is available from the authors on request. Ratings of relevance over two Delphi rounds resulted in a prioritized list of objectives presented in Table 1. There were no missing values within respondents. One objective was excluded due to a mean rating value
