In their commentary on page 935, Amer-Wahlin and Dekker rightly draw attention to the question of why outcome might be poor instead of simply blaming technology or the human involved, without ‘digging deeper in order to understand why’.1 From medical legal cases published in the 1990s we know that obstetrical caregivers regularly acknowledged the presence of fetal heart rate (FHR) abnormalities during labour, but failed to act accordingly.2 A similar conclusion can be drawn from a paper in the February issue of the BJOG of this year.3 It is that kind of absence of response that should be further investigated. Inexperience and lack of training, busy labour ward, underestimation of the potential problem and previous experience with many false-positive abnormal FHR traces may all lie behind this. This definitely should be investigated seriously.
At the same time, it remains important to draw attention to the limitations of a new technique in clinical practice. This illustrates where labour-ward personnel take inappropriate action or where guidelines are incomplete. One may hardly expect that all aspects concerning a new technique are completely understood and properly described from its introduction. The cases published by us and by Ingemarsson and Westgren,4 have resulted in a consensus meeting among STAN(STAN®, Neoventa Medical, Güteborg, Sweden) users and in adjustment of the guidelines.5
Finally, Ingemarsson and Westgren4 pointed out that the management of STAN guidelines are primarily based on interpretation of the FHR pattern and will therefore not be of assistance if interpretation of these patterns is poor. That is correct and prompts for a better—numerical?—analysis of FHR patterns. We have recently confirmed the large inter- and intra-observer variation regarding interpretation of FHR patterns. Using the FIGO (STAN) criteria, however, we also found that the addition of information on STAN events resulted in a considerably better agreement and more consistent management (submitted for publication). So there seems some hope for the future.