49 Clinical outcomes of aCTG in primary midwife-led care with situations in pregnancy that pose an increased risk, including fetal movements, after external cephalic version in primary care and postdate pregnancy (from 41 +0 weeks). A trained midwife performed the external cephalic version in primary care according to a national standard [18]. The pregnant women were offered the option of an MLC-aCTG or OLC-aCTG. If they opted for MLC, the aCTG was autonomously performed and assessed by a primary care midwife. Another primary care midwife performed a real-time second assessment. Midwives are authorised to perform aCTG provided they are competent in training and experience [19,20]. All primary care midwives who participated in this innovation project followed training on aCTGassessment completed with an exam. In addition, mandatory attendance of at least four peer-training sessions, where midwives interpret and evaluate aCTGs with each other, together with a consulting obstetrician, was required. A portable CTG system (Sense4baby®) was used for carrying out aCTGs at women’s homes, midwifery practices, or community-based ultrasound centres. ACTG traces with a duration of at least 30 up to 45 min with a paper speed of 2 cm/min were assessed by using a classification system based on the International Federation of Gynecology and Obstetrics (FIGO) guidelines (Fig. 1) [21]. Although the FIGO classification is developed for intrapartum CTG, the Dutch Federation of Obstetrics and Gynaecology recommends using it for aCTG as well [22]. ACTGs could be classified as either reassuring or non-reassuring [11, 22–24] or as ‘insufficient quality (technical or registration quality)’. In the case of a reassuring aCTG in MLC, within 24 h, an ultrasound scan was performed in primary care to assess fetal growth, amniotic fluid, and presentation of the fetus. Blood pressure was measured as well. If all findings of aCTG, ultrasound, and blood pressure were normal, antenatal care was continued in MLC. If an aCTG was classified as non-reassuring or of insufficient quality, the woman was immediately referred to OLC for follow-up. Depending on the level of seriousness and the distance to the nearest hospital, this was by own transport or by ambulance. In each region, a quality committee monitors the quality of aCTG-assessments performed by primary care midwives by structurally evaluating randomly selected aCTG assessments plus all aCTGs where a serious perinatal outcome such as perinatal death or severe perinatal morbidity with admission to neonatal intensive care unit (NICU), subsequently occurred. 3
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