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Re: Book Review: Handbook of CTG Interpretation: From Patterns to

Physiology (by Mr Edwin Chandraharan), Cambridge University Press, 2017.
The Obstetrician & Gynaecologist, 2019; 2...

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DOI: 10.13140/RG.2.2.30671.30880

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Shashikant Sholapurkar
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Comment / Book Review
Submitted to
Re: Book Review: Handbook of CTG Interpretation: From Patterns to Physiology
(by Mr Edwin Chandraharan), Cambridge University Press, 2017. The Obstetrician &
Gynaecologist, 2019; 21: 152.
‘Usual polite etiquettes do not apply when confronting a possibility to pathological science’
This comment / book review presents the other
side of the coin to balance the recent highly
favourable book review1 of “Handbook of CTG
Interpretation: From Patterns to Physiology”, in the
interest of patient safety. The core and the
strikingly different message of this handbook2 is,
“Instead of morphological classification of fetal
heart rate (FHR) decelerations into
early/variable/late, the clinicians should classify
decelerations according to the main underlying
mechanisms. Baroreceptor decelerations
(occlusion of umbilical artery) are characterised by
rapid fall and recovery. Chemoreceptor
decelerations due to fetal hypoxia are
characterised by gradual and slow recovery2 (page
34)”. However, a recent study3 of the interpretation
of teaching illustrations from this handbook2 shows
the pathophysiology of decelerations taught and
practiced1,2 to be invalid and risky. The rapid vs
gradual shape ideology has been repeatedly
challenged.4 FHR decelerations are of course
centre-stage in CTG interpretation.3,4 Several cord-
compression animal experiments have proven that
the rapid FHR decelerations are primarily due to
chemoreceptor stimulation (hypoxia) and the
baroreceptor hypothesis seems fatally flawed.3 The
teaching illustration (Fig 5.2, page 35) of pure
baroreceptor ‘benign’ cord-compression
2
decelerations in this handbook was interpreted as
pathological (hypoxemic) by 88% of the study
participants.3 The detailed discussion on fetal
physiology2 does not seem to translate into
practically useful and safe algorithm for
1
cardiotocography (CTG) interpretation and
management.
The controversial doctrine of non-recognition
of pathological “late” FHR decelerations has led to
a recommendation in this handbook that “the fetus
is decompensated only when deepening
decelerations are combined with maximal rise in
baseline heart rate and absent baseline variability”
(page 176).2 This seems a very unsafe
recommendation.3 Despite this the perinatal
outcome in the index hospital2 may not be poor
because of the concurrent use of fetal ECG (STAN)
which does require classification of decelerations
into early/variable/late. More likely, the grassroots
clinicians most times may have been unable fully
follow the risky ideology prescribed in the
handbook.2
The RCOG and RCM should consider giving a
definitive guidance to their members regarding the
very forceful risky teaching in this handbook.1,2
Would the RCOG or RCM experts support a midwife
or obstetrician who persists in “not recognising late
/ variable-late decelerations as pathological”? Or
will they face disciplinary measures and retraining?
In summary, the risky ideology of ‘physiological
CTG interpretation’ presented in this handbook
seems ‘anti-physiological’. In contrast, it is very
important to continue categorising FHR
decelerations into different meaningful patterns
based on timing (early/variable/late)3,4 rather than
shape (rapid/gradual) as proposed in the
handbook.2
 Interest statement: The author has no conflict of
interest to declare.
Dr Shashikant L Sholapurkar, MD, MRCOG.
Bath, UK. 1st August 2019.
References
1. Book Review: Handbook of CTG Interpretation:
From Patterns to Physiology. TOG - The
Obstetrician & Gynaecologist 2019; 21: 152.
2. Chandraharan E. Applying fetal physiology to
interpret CTG traces. In: Chandraharan E.
editor. Handbook of CTG interpretation: From
patterns to physiology, 1st edition. Cambridge,
UK: Cambridge University Press. 2017; 32-44.
3. Sholapurkar SL. Study of interpretation of
Cardiotocography educational illustrations by
Afterword
To make up their minds, the readers need
access to a variety of opinions available on
electronic media. The “Handbook of CTG
interpretation: From patterns to physiology” by Mr
Edwin Chandraharan is a 200-page book which
repeats plenty of existing knowledge about CTG
and is bound to have some good contributions by
many authors. The chapter on “Intelligent IA”
makes flawed recommendations of looking for
‘post-deceleration overshoots’ and ‘cycling’. The
detailed pathophysiology is overdone. Most
importantly, the very central concept of this book
(CTG interpretation esp. decelerations) is “anti-
physiological” and fraught with danger.3 The same
unscientific doctrine with denial of ‘late
decelerations’ has also been taught by others at St
Georges Hospital for many years as (mistaken)
physiological approach.5 The author of the
Handbook2 does not work for St. Georges Hospital
NHS Trust London since March 2020.
View publication stats
experts discarding early/late/variable
deceleration categorization – Physiology or
unscientific ideology, myths and Road to
Perdition? Ann Obstet Gynecol 2019; 2: 1010-
1019. (open Access)
4. Sholapurkar SL. The conundrum of vanishing
early decelerations in British obstetrics, a step
backwards? Detailed appraisal of British and
American classifications of fetal heart rate
decelerations - Fallacies of emphasis on
waveform and putative aetiology. J Obstet
Gynaecol 2012; 32: 505-511.
All NHS hospitals need to abandon teaching
and practising the so-called ‘Physiological CTG
interpretation’.2 After highly recommending this
‘handbook’,2 the TOG (of RCOG) has so far declined
to publish the comment above (even as a letter to
the Editor) since 2019 without giving any reasons.
Repeated formal appeals have been made to
remind the TOG about its journalistic responsibility
to present a balanced debate challenging
‘pathological science’ in the interest of patient
safety.
References
5. Ugwumadu A. Are we (mis)guided by current
guidelines on intrapartum fetal heart rate
monitoring? Case for a more physiological
approach to interpretation. BJOG
2014;121:1063-70.