The paper by Berkowitz et al is very thought-provoking and invites a debate on a complex subject. Experts have achieved significant consensus about the need for standardization of terminology of electronic fetal monitoring (EFM). Consequently, periodic skills-retraining and even some local assessments of knowledge gained are already in place in some countries. Although a very painstaking, commendable and valuable endeavour ; the pros and cons of a progression to ‘pass/fail credentialing examinations’ could be debated by American nurses and obstetricians.

The need for an extremely elaborate statistical processing of questions and answers itself highlights the significant gaps and difference of opinions in assessment of EFM traces. Even this complex statistical modelling may not guarantee exactitude of the script. Judgement questions (termed ‘script concordance’ test) to assess contextual reasoning and progressive decision making are particularly prone to subjectivity and different interpretations. Is it justifiable to ‘fail’ practicing obstetricians and midwives using such examinations (sometimes funded by insurance companies)? What support mechanisms or supervision will be in place? The Royal College of Obstetricians and Gynaecologists (RCOG, London) in its online training module ‘eFM’ provided 100 test cases of EFM for progressive decision making with answers by 3 experts. Most often one expert (at random) disagreed with the other two. The fallible nature of judgement questions may be apparent in the very example provided for illustration. When additional information is provided, why should there not be good or strong impact (eg, corroboration) on ‘thinking’ about the management (as questioned) even though this information may not change the management itself?

Moreover, the interpretation of EFM traces is not absolute, given or clinically proven. The standardization of terminology, guidelines, and knowledge-based testing do have merit, but these should withstand basic scientific scrutiny. The author of a recent American study (Editors’ Choice) concluded that EFM interpretation remained unhelpful in practice particularly because of the peculiar nomenclature of fetal heart rate decelerations (not just academic considerations) leading to loss of meaning. Definitions of fetal heart rate decelerations were proposed as entirely theoretical constructs without any discernible correlation to etiology or fetal condition. Many questions about EFM remain unanswered by the experts. Hence, alternative models proposed may need some consideration rather than being summarily discarded as nonconcrete or unproven. ‘Pass/fail’ examinations may risk discouraging alternative thinking, challenges, and possibly innovation/improvements. The science of EFM is still too imperfect (even compared with many other scientific controversies) and evolving; and may not be ripe for ‘credentialing’ examinations comprising judgement questions.