{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,19]],"date-time":"2026-09-19T07:20:24Z","timestamp":1789802424062,"version":"4.0.1"},"reference-count":33,"publisher":"Wiley","issue":"3","license":[{"start":{"date-parts":[[2026,3,20]],"date-time":"2026-03-20T00:00:00Z","timestamp":1773964800000},"content-version":"vor","delay-in-days":0,"URL":"http:\/\/onlinelibrary.wiley.com\/termsAndConditions#vor"},{"start":{"date-parts":[[2026,3,20]],"date-time":"2026-03-20T00:00:00Z","timestamp":1773964800000},"content-version":"tdm","delay-in-days":0,"URL":"http:\/\/doi.wiley.com\/10.1002\/tdm_license_1.1"}],"content-domain":{"domain":["obgyn.onlinelibrary.wiley.com"],"crossmark-restriction":true},"short-container-title":["Intl J Gynecology &amp;amp; Obste"],"published-print":{"date-parts":[[2026,9]]},"abstract":"<jats:title>Abstract<\/jats:title>\n                  <jats:sec>\n                    <jats:title>Objective<\/jats:title>\n                    <jats:p>Cesarean section (CS) rates are rising worldwide. Abnormal fetal heart rate patterns (aFHRp) are a leading indication for primary CS. We evaluated whether different monitoring policies and training approaches influence CS rate performed for suspected fetal distress and influence neonatal outcomes.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p>\n                      This multicenter retrospective study included 3408 nulliparous and multiparous low\u2010risk, term, singleton, cephalic pregnancies in spontaneous labor during 2017 at Hospital A (\n                      <jats:italic>n<\/jats:italic>\n                      \u2009=\u20091428), Hospital B (\n                      <jats:italic>n<\/jats:italic>\n                      \u2009=\u20091113), and Hospital C (\n                      <jats:italic>n<\/jats:italic>\n                      \u2009=\u2009867). Monitoring policies were: (i) intermittent auscultation (IA) with cardiotocography (CTG) reserved for high risk pregnancies or in case of evolving concerns combined with structured team training; (ii) universal CTG with structured training; and (iii) universal CTG without structured training. Primary outcomes were intrapartum CS for aFHRp and neonatal outcomes.\n                    <\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>\n                      Overall intrapartum CS rates were 3.7% (Hospital A), 2.8% (Hospital B), and 11.4% (Hospital C). CS rate for aFHRp was lower in Hospital B (0.8%) and A (1.5%) and significantly higher in Hospital C (4.5%,\n                      <jats:italic>P<\/jats:italic>\n                      \u2009&lt;\u20090.001). Neonatal indicators such as Apgar &lt;7 at 5\u2009min, umbilical pH &lt;7.0, and neonatal intensive care unit (NICU) admission were comparable across hospitals. However, neonatal resuscitation was more frequent in Hospital C (12.1%) compared to Hospital A (0%,\n                      <jats:italic>P<\/jats:italic>\n                      \u2009=\u20090.008).\n                    <\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusion<\/jats:title>\n                    <jats:p>Continuous CTG combined with structured team training was strongly associated with the lowest rates of CS performed for suspected fetal distress, without compromising neonatal safety. In contrast, universal continuous CTG without training led to higher intervention rates. Human factors, particularly training and organizational culture, appear to be more influential than monitoring technology alone in determining cesarean delivery rates for suspected fetal compromise.<\/jats:p>\n                    <jats:p>\n                      <jats:boxed-text content-type=\"graphic\" position=\"anchor\">\n                        <jats:graphic xmlns:xlink=\"http:\/\/www.w3.org\/1999\/xlink\" mimetype=\"image\/png\" position=\"anchor\" specific-use=\"enlarged-web-image\" xlink:href=\"graphic\/ijgo70967-gra-0001-m.png\">\n                          <jats:alt-text>image<\/jats:alt-text>\n                        <\/jats:graphic>\n                      <\/jats:boxed-text>\n                    <\/jats:p>\n                  <\/jats:sec>","DOI":"10.1002\/ijgo.70967","type":"journal-article","created":{"date-parts":[[2026,3,20]],"date-time":"2026-03-20T11:10:52Z","timestamp":1774005052000},"page":"1451-1457","update-policy":"https:\/\/doi.org\/10.1002\/crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["Tools or culture? Human factors, not technology, drive cesarean section rates for suspected fetal distress"],"prefix":"10.1002","volume":"174","author":[{"given":"Antonio","family":"Ragusa","sequence":"first","affiliation":[{"name":"Department of Gynecology and Obstetrics Ospedale Civile Sassuolo SpA  Sassuolo Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Alessandra","family":"Meloni","sequence":"additional","affiliation":[{"name":"SSD Emergenze Ostetriche e Ginecologiche\u2014AOU Cagliari P.O. D. Casula  Cagliari Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Isabella","family":"Maini","sequence":"additional","affiliation":[{"name":"Unit of Obstetrics Foundation IRCCS San Gerardo Dei Tintori  Monza Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Antonino","family":"Lo Re","sequence":"additional","affiliation":[{"name":"Department of Obstetrics and Gynecology Social Security Institute  San Marino Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-0623-1729","authenticated-orcid":false,"given":"Caterina","family":"De Luca","sequence":"additional","affiliation":[{"name":"Department of Gynecology and Obstetrics University Hospital Renato Dulbecco  Catanzaro Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Sara","family":"D'Avino","sequence":"additional","affiliation":[{"name":"Department of Gynecology and Obstetrics Gemelli Isola Hospital  Rome Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-4713-9539","authenticated-orcid":false,"given":"Alessandro","family":"Svelato","sequence":"additional","affiliation":[{"name":"Department of Experimental and Clinical Medicine \u201cMagna Graecia\u201d University of Catanzaro  Catanzaro Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Emanuele","family":"Soncini","sequence":"additional","affiliation":[{"name":"Department of Gynecology and Obstetrics Ospedale Civile Sassuolo SpA  Sassuolo Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Fernando","family":"Ficarola","sequence":"additional","affiliation":[{"name":"Department of Gynecology and Obstetrics San Camillo Hospital  Rome Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Maria","family":"Matta","sequence":"additional","affiliation":[{"name":"Hopital Civil Marie Curie, ULB  Charleroi Belgium"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Denise","family":"Rinaldo","sequence":"additional","affiliation":[{"name":"Department of Obstetrics ASST Grande Ospedale Metropolitano Niguarda  Milan Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"311","published-online":{"date-parts":[[2026,3,20]]},"reference":[{"key":"e_1_2_10_2_1","doi-asserted-by":"publisher","DOI":"10.1136\/bmjgh-2021-005671"},{"key":"e_1_2_10_3_1","doi-asserted-by":"publisher","DOI":"10.1097\/AOG.0b013e31821e5f65"},{"key":"e_1_2_10_4_1","doi-asserted-by":"publisher","DOI":"10.1186\/s12884-020-02945-5"},{"key":"e_1_2_10_5_1","doi-asserted-by":"publisher","DOI":"10.1111\/aogs.12962"},{"key":"e_1_2_10_6_1","doi-asserted-by":"publisher","DOI":"10.1186\/s12884-022-04440-5"},{"key":"e_1_2_10_7_1","doi-asserted-by":"publisher","DOI":"10.1097\/AOG.0b013e3181aef106"},{"key":"e_1_2_10_8_1","doi-asserted-by":"publisher","DOI":"10.1016\/0002-9378(95)91320-3"},{"key":"e_1_2_10_9_1","article-title":"Cardiotocography versus intermittent auscultation of fetal heart on admission to labour ward for assessment of fetal wellbeing","volume":"1","author":"Devane D","year":"2017","journal-title":"Cochrane Database Syst Rev"},{"key":"e_1_2_10_10_1","article-title":"Continuous electronic heart rate monitoring for fetal assessment during labor","volume":"2","author":"Thacker SB","year":"2001","journal-title":"Cochrane Database Syst Rev"},{"key":"e_1_2_10_11_1","unstructured":"National Institute for Health and Care Excellence (NICE).Intrapartum Care for Healthy Women and Babies. 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