Obstetric litigation is asphyxiating our maternity services

Forensic Analysis of Umbilical and Newborn Blood Gas Values for Infants at Risk of Cerebral Palsy

Cerebral palsy litigation cases account for the highest claims involving obstetricians/gynecologists, a specialty that ranks among the highest liability medical professions. Although epidemiologic studies indicate that only a small proportion of cerebral palsy (10-20%) is due to birth asphyxia, negligent obstetrical care is often alleged to be the etiologic factor, resulting in contentious medical-legal conflicts. Defense and plaintiff expert opinions regarding the etiology and timing of injury are often polarized, as there is a lack of established methodology for analysis. The objective results provided by umbilical cord and newborn acid/base and blood gas values and the established association with the incidence of cerebral palsy provide a basis for the forensic assessment of both the mechanism and timing of fetal neurologic injury. Using established physiologic and biochemical principles, a series of case examples demonstrates how an unbiased expert assessment can aid in both conflict resolution and opportunities for clinical education.

Effect of Implementing a Standardized Shoulder Dystocia Documentation Form on Quality of Delivery Notes

OBJECTIVES

Complete and accurate documentation by the delivering provider in cases of shoulder dystocia is critical for providing clinical information and care to the patient and protecting providers from litigation risks. Standardized forms improve inclusion of certain data elements in the medical record, but the impact on subsequent narrative notes is unknown. We aimed to determine if implementation of a standardized shoulder dystocia documentation form improves obstetric provider written narrative delivery notes.

METHODS

In February 2005, our institution introduced a mandatory, standardized shoulder dystocia form containing 29 discrete data points relevant to shoulder dystocia documentation. We identified all deliveries complicated by shoulder dystocia from 1 year before and 4 years after implementation of this form and analyzed medical records for inclusion of delivery information in both the required form and the narrative delivery notes.

RESULTS

We identified 52 cases before and 100 cases after implementation of the standardized form. Inclusion of elements from the form in narrative delivery notes increased significantly after implementation (P = 0.01). Elements present at higher rates included prepregnancy maternal weight (13% before vs 28% after, P = 0.043), total maternal weight gain (19% vs 36%, P = 0.03), estimated fetal weight (60% vs 77%, P = 0.03), duration of active labor (40% vs 65%, P < 0.01), duration of second stage (27% vs 52%, P < 0.01), and time of delivery from head to body (4% vs 30%, P < 0.01).

CONCLUSIONS

Use of a mandatory shoulder dystocia documentation form is associated with significant improvement in the comprehensiveness of delivering provider narrative notes and may encourage more complete and accurate charting. Such improvements can allow for more complete and accurate explanation of events to patients and better demonstrate adherence to standards of care in the management of shoulder dystocia and may improve litigation defensibility.

The effects of time and temperature on umbilical cord gas analysis

OBJECTIVE

Our objective was to evaluate the effects of time and temperature on umbilical-cord blood analysis.

METHODS

This prospective study included the term spontaneous vaginal deliveries. One venous and seven arterial samples were drawn from each umbilical cord within 5 min from delivery. Three samples were immediately refrigerated (3 °C), while all other samples were stored at room temperature (23-26 °C). Samples were analyzed in pairs (refrigerated and room-temperature samples) at 0, 20, 40, and 60 min after delivery for pH and lactate levels. Repeated-measures analysis using a generalized linear model was used to compare the change in pH and lactate values over time.

RESULTS

518 samples from 74 women were analyzed. The mean gestational age was 39.1 ± 1.1 weeks. All neonates had an Apgar score of ≥9 in the 1st and 5th minutes. Mean arterial pH and lactate levels at delivery (time 0) were 7.32 ± 0.07 and 4.00 ± 1.36 mmol/L, respectively. Over time, a statistically significant decrease in pH and a reciprocal increase in lactate levels were observed. The mean change in arterial pH following 60 min was 0.021 ± 0.028 (room-temperature) and 0.016 ± 0.023 (refrigerated); p < 0.001. Compared to pH, a greater change was demonstrated in lactate levels over time; the mean change in lactate following 60 min was -0.896 ± 0.535 (room temperature) and -0.512 ± 0.450 mmol/L (refrigerated). Temperature significantly altered both pH and lactate levels, but lactate levels were altered at earlier time points.

CONCLUSION

Both time and temperature have significant effects on cord blood analysis. Yet, these changes are minor and may not have any clinical significance unless in extreme cases in which medicolegal aspects emerge.

Factors influencing utilisation of ‘free-standing’ and ‘alongside’ midwifery units for low-risk births in England: a mixed-methods study

Background

Midwifery-led units (MUs) are recommended for ‘low-risk’ births by the National Institute for Health and Care Excellence but according to the National Audit Office were not available in one-quarter of trusts in England in 2013 and, when available, were used by only a minority of the low-risk women for whom they should be suitable. This study explores why.

Objectives

To map the provision of MUs in England and explore barriers to and facilitators of their development and use; and to ascertain stakeholder views of interventions to address these barriers and facilitators.

Design

Mixed methods – first, MU access and utilisation across England was mapped; second, local media coverage of the closure of free-standing midwifery units (FMUs) were analysed; third, case studies were undertaken in six sites to explore the barriers and facilitators that have an impact on the development of MUs; and, fourth, by convening a stakeholder workshop, interventions to address the barriers and facilitators were discussed.

Setting

English NHS maternity services.

Participants

All trusts with maternity services.

Interventions

Establishing MUs.

Main outcome measures

Numbers and types of MUs and utilisation of MUs.

Results

Births in MUs across England have nearly tripled since 2011, to 15% of all births. However, this increase has occurred almost exclusively in alongside units, numbers of which have doubled. Births in FMUs have stayed the same and these units are more susceptible to closure. One-quarter of trusts in England have no MUs; in those that do, nearly all MUs are underutilised. The study findings indicate that most trust managers, senior midwifery managers and obstetricians do not regard their MU provision as being as important as their obstetric-led unit provision and therefore it does not get embedded as an equal and parallel component in the trust’s overall maternity package of care. The analysis illuminates how provision and utilisation are influenced by a complex range of factors, including the medicalisation of childbirth, financial constraints and institutional norms protecting the status quo.

Limitations

When undertaking the case studies, we were unable to achieve representativeness across social class in the women’s focus groups and struggled to recruit finance directors for individual interviews. This may affect the transferability of our findings.

Conclusions

Although there has been an increase in the numbers and utilisation of MUs since 2011, significant obstacles remain to MUs reaching their full potential, especially FMUs. This includes the capacity and willingness of providers to address women’s information needs. If these remain unaddressed at commissioner and provider level, childbearing women’s access to MUs will continue to be restricted.

Future work

Work is needed on optimum approaches to improve decision-makers’ understanding and use of clinical and economic evidence in service design. Increasing women’s access to information about MUs requires further studies of professionals’ understanding and communication of evidence. The role of FMUs in the context of rural populations needs further evaluation to take into account user and community impact.

Funding

This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 8, No. 12. See the NIHR Journals Library website for further project information.

From "apparent death" to "birth asphyxia": a history of blame

Since the sixteenth century, competition between midwives and surgeons has created a culture of blame around the difficult delivery. In the late seventeenth century, 100 years before oxygen was discovered, researchers associated "apparent death of the newborn" with impaired respiratory function of the placenta. The diagnosis "birth asphyxia" replaced the term "apparent death of the newborn" during the mass phobia of being buried alive in the eighteenth century. This shifted the interpretation from unavoidable fate to a preventable condition. Although the semantic inaccuracy ("pulselessness") was debated, "asphyxia" was not scientifically defined until 1992. From 1792 the diagnosis was based on a lack of oxygen. "Blue" and "white" asphyxia were perceived as different disorders in the eighteenth, and as different grades of the same disorder in the nineteenth century. In 1862, William Little linked birth asphyxia with cerebral palsy, and although never confirmed, his hypothesis was accepted by scientists and the public. Fetal well-being was assessed by auscultating heart beats since 1822, and continuous electronic fetal monitoring was introduced in the 1960s without scientific assessment. It neither diminished the incidence of birth asphyxia nor of cerebral palsy, but rather raised the rate of cesarean sections and litigation against obstetricians and midwives.

Defensive medicine among obstetricians and gynaecologists in Turkey

In recent years, there has been a remarkable increase in medical malpractice litigations against OB/GYNs in Turkey and globally. This high litigation atmosphere may have changed attitudes, behaviour and practice of OB/GYNs. In the current study, opinions and attitudes of OB/GYNs regarding defensive medicine and to what extent they practice it were investigated. One hundred and eight OB/GYNs participated in the study. All participants found obstetrics and gynaecology riskier when compared with other medical branches and reported that they were increasingly practising defensive medicine. The majority of the OB/GYNs stated that they abstained from many risky interventions and expressed their belief that the high caesarean section (C-section) rate was associated with medico-legal concerns. The majority of the participants supported enacting of a specific medical malpractice law and supported the establishment of medically specialised courts. These regulations demanded by OB/GYNs should be taken into account by health authorities. Impact statement What is already known on this subject: In recent years, there has been a remarkable increase in medical malpractice litigations against OB/GYNs in Turkey and globally. Turkey has serious problems with the high C-section rate, which has been suggested to be related to medicolegal issues in a previous research. Fifty-one percent of babies, namely most of them, are delivered via C-section. There is no specific medical malpractice law and medically specialised court in Turkey. What the results of this study add: It seems like there is a professional liability crisis among OB/GYNs in Turkey. OB/GYNs reported that they were increasingly practising defensive medicine, and stated that they abstained from many risky interventions. A high C-section rate was found to be related to medicolegal concerns in OB/GYNs' perspective in the current study. OB/GYNs demanded some reasonable regulations. What the implications are of these findings for clinical practice and/or further research: Regulations demanded by OB/GYNs, which were probed in the current study, such as enacting a specific medical malpractice law and establishment of a medically specialised court, should be taken into account by health authorities in Turkey. The findings of the current study is believed to produce important results for the success of Health transformation programme put into practice in Turkey, which was not able to stop increasing C-section rates. Studies evaluating the direct or indirect costs related to defensive medicine practices of OB/GYNs in Turkey should be performed in subsequent research.

Implementation of a multicenter shoulder dystocia injury prevention program

Although the evidence for supporting the effectiveness of many patient safety practices has increased in recent years, the ability to implement programs to positively impact clinical outcomes across multiple institutions is lagging. Shoulder dystocia simulation has been shown to reduce avoidable patient harm. Neonatal injury from shoulder dystocia contributes to a significant percentage of liability claims. We describe the development and the process of implementation of a shoulder dystocia simulation program across five academic medical centers and their affiliated hospitals united by a common insurance carrier. Key factors in successful roll out of this program included the following: involvement of physician and nursing leadership from each academic medical center; administrative and logistic support from the insurer; development of consensus on curriculum components of the program; conduct of gap and barrier analysis; financial support from insurer to close necessary gaps and mitigate barriers; and creation of dashboards and tracking performance of the program.

Obstetric and gynecologic malpractice claims in Saudi Arabia: Incidence and cause

INTRODUCTION

The occurrence of a bad outcome, injury or death of a patient during treatment increases the chance of malpractice litigation, increases legal responsibility and leads to increased fees for malpractice insurance. Physicians practicing obstetrics and gynecology face among the highest risks of malpractice litigation, and such litigation has led to an increase in the practice of defensive medicine and has made this specialty less appealing. Previous clinical data from Saudi Arabia have shown that more malpractice litigation concerns claims in obstetrics and gynecology than claims in any other field of medicine.

OBJECTIVE

To identify the main causes of obstetrics and gynecology (OBGYN) professional liability claims in Saudi Arabia to have a better understanding and management of risks.

METHODS

All OBGYN claims opened in Saudi Arabia between 2008 and 2013 were analyzed to identify the most common causes of claims. The results of these claims and the times until a final judgment made were also analyzed.

RESULTS

Out of a total of 463 malpractice claims that were closed during the study period, 114 (24.6%) claims were in obstetrics and gynecology, and 92 (80.7%) of these claims concerned complications related to delivery room events. The most common causes of obstetric malpractice litigation were shoulder dystocia (brachial plexus injury) and fetal distress (hypoxic ischemic encephalopathy). Urinary system injury was the most common cause of gynecology cases. Most cases were decided in favor of the defendants with the exception of cases for which maternal and/or fetal death was the cause of litigation; nearly all of those cases were decided against the defendants.

CONCLUSION

Obstetricians face a high risk of malpractice claims in Saudi Arabia, although most claims do not end in payments to plaintiffs. However, the effects of such claims on obstetric care should not be underestimated. Adherence to standards of care and careful documentation may decrease litigation and the number of indefensible malpractice claims.

Intra- and interobserver agreement among obstetric experts in court regarding the review of abnormal fetal heart rate tracings and obstetrical management

OBJECTIVE

The objective of the study was to evaluate the intra- and interobserver agreement among obstetric experts in court regarding the retrospective review of abnormal fetal heart rate tracings and obstetrical management of patients with abnormal fetal heart rate during labor.

STUDY DESIGN

A total of 22 French obstetric experts in court reviewed 30 cases of term deliveries of singleton pregnancies diagnosed with at least 1 hour of abnormal fetal heart rate, including 10 cases with adverse neonatal outcome. The experts reviewed all cases twice within a 3-month interval, with the first review being blinded to neonatal outcome. For each case reviewed, the experts were provided with the obstetric data and copies of the complete fetal heart rate recording and the partogram. The experts were asked to classify the abnormal fetal heart rate tracing and to express whether they agreed with the obstetrical management performed. When they disagreed, the experts were asked whether they concluded that an error had been made and whether they considered the obstetrical management as the cause of cerebral palsy in children if any.

RESULTS

Compared with blinded review, the experts were significantly more likely to agree with the obstetric management performed (P < .001) and with the mode of delivery (P < .001) when informed about the neonatal outcome and were less likely to conclude that an error had been made (P < .001) or to establish a link with potential cerebral palsy (P = .003). The experts' intraobserver agreement for the review of abnormal fetal heart rate tracing and obstetrical management were both mediocre (kappa = 0.46-0.51 and kappa = 0.48-0.53, respectively). The interobserver agreement for the review of abnormal fetal heart rate tracing was low and was not improved by knowledge of the neonatal outcome (kappa = 0.11-0.18). The interobserver agreement for the interpretation of obstetrical management was also low (kappa = 0.08-0.19) but appeared to be improved by knowledge of the neonatal outcome (kappa = 0.15-0.32).

CONCLUSION

The intra- and interobserver agreement among obstetric experts in court for the review of abnormal fetal heart rate tracing and the appropriateness of obstetrical care is poor, suggesting a lack of objectivity of obstetrical expertise as currently performed in court.

Examination of the placenta: medico-legal implications

Formal examination of the placenta may provide valuable information to the clinicians, family, and court of law in cases of adverse pregnancy outcome when litigation is initiated. Placental examination contributes towards the identification of specific intrinsic or secondary placental lesions, and understanding the nature of the intrauterine environment. This article provides an update of important placental pathologies that may contribute towards neurologic injury of the newborn child, and describes the role of placental findings in the adjudication of cases of adverse neonatal outcome.

The consistency of experts' evaluation of obstetric claims for compensation

OBJECTIVE

The aim of this study was to investigate the consistency of experts' evaluation of different types of obstetric claims for compensation.

DESIGN

Inter-rater reliability study of obstetric claims for compensation.

SETTING

Medical experts' evaluation in The Norwegian System of Compensation to Patients, a no-blame system.

SAMPLE

The 15 most frequently used medical experts were asked to evaluate 12 obstetric claims applied for compensation.

METHODS

Inter-rater agreement was assessed by absolute agreement, Fleiss' kappa statistic and Gwet's AC1.

MAIN OUTCOME MEASURES

Consistency in the evaluation of negligence (carelessness without intention to harm) and causality (relation between care and injury) between negligence and patient injury.

RESULTS

The experts demonstrated moderate consistency in their evaluation of negligence (Fleiss' kappa = 0.53/AC1 = 0.54) and causality (Fleiss' kappa = 0.41/AC1 = 0.54). There was a higher level of agreement in clinical scenarios with well-documented diagnostic criteria and guidelines, including shoulder dystocia and asphyxia with low Apgar score and metabolic acidosis.

CONCLUSION

We found a moderate level of agreement in experts' evaluation of negligence and causality between the injury and provided health care, the two most important questions to be answered in obstetric claims for compensation.

Fault and blame, insults to the perinatal brain may be remote from time of birth

There is a certainty in malpractice cases that neurodevelopmental deficits are caused by preventable events at birth when the onset, nature, and timing of the insult in the antenatal and natal period are unknown. The biggest problem is determining timing. Electronic fetal monitoring is given excessive importance in legal cases. Before assigning fault on events at birth, a better understanding of developmental neurobiology and limitations of the present clinical biomarkers is warranted. The issues of single versus repeated episodes, timing of antenatal insults, pros and cons of legal arguments, interaction of various etiologic and anatomic factors are discussed.

Being safe practitioners and safe mothers: a critical ethnography of continuity of care midwifery in Australia

OBJECTIVE

To examine how midwives and women within a continuity of care midwifery programme in Australia conceptualised childbirth risk and the influences of these conceptualisations on women's choices and midwives' practice.

DESIGN AND SETTING

A critical ethnography within a community-based continuity of midwifery care programme, including semi-structured interviews and the observation of sequential antenatal appointments.

PARTICIPANTS

Eight midwives, an obstetrician and 17 women.

FINDINGS

The midwives assumed a risk-negotiator role in order to mediate relationships between women and hospital-based maternity staff. The role of risk-negotiator relied profoundly on the trust engendered in their relationships with women. Trust within the mother-midwife relationship furthermore acted as a catalyst for complex processes of identity work which, in turn, allowed midwives to manipulate existing obstetric risk hierarchies and effectively re-order risk conceptualisations. In establishing and maintaining identities of 'safe practitioner' and 'safe mother', greater scope for the negotiation of normal within a context of obstetric risk was achieved.

KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

The effects of obstetric risk practices can be mitigated when trust within the mother-midwife relationship acts as a catalyst for identity work and supports the midwife's role as a risk-negotiator. The achievement of mutual identity-work through the midwives' role as risk-negotiator can contribute to improved outcomes for women receiving continuity of care. However, midwives needed to perform the role of risk-negotiator while simultaneously negotiating their professional credibility in a setting that construed their practice as risky.

Maternity care and liability: pressing problems, substantive solutions

BACKGROUND

This paper summarizes a new report presenting the best available research about the impact of the liability environment on maternity care, and policy options for improving this environment. Improved understanding of these matters can help to transcend polarized discourse and guide policy intervention.

METHODS

We used a best available evidence approach and drew on more recent empirical legal studies and health services research about maternity care and liability when available, and considered other studies when unavailable.

FINDINGS

The best available research does not support a series of widely held beliefs about maternity care and liability, including the economic impact of liability insurance premiums on maternity care clinicians, the existence of extensive defensive maternity care practice, and the impact of limiting the size of awards for non-economic damages in a malpractice lawsuit. In the practice of an average maternity caregiver, negligent injury of mothers and newborns seems to occur more frequently than any claim and far more frequently than a payout or trial. Many important gaps in knowledge relating to maternity care and liability remain. Some improvement strategies are likely to be more effective than others.

CONCLUSIONS

Empirical research does not support many widely held beliefs about maternity care and liability. The liability system does not currently serve well childbearing women and newborns, maternity care clinicians, or those who pay for maternity care. A number of promising strategies might lead to a higher functioning liability system, whereas others are unlikely to contribute to needed improvements.

Medical liability reform: a case study of Mississippi

Mississippi enacted medical negligence and other tort reform legislation that generally became effective for causes of action filed on or after January 1, 2003, and September 1, 2004. Data regarding lawsuits against physicians insured by the Medical Assurance Company of Mississippi (MACM), the largest medical liability insurer in the state, and MACM-insured Obstetrician-gynecologists (ob-gyns) in particular, were compared by year from 1986 to 2010. The data encompassed the periods before and after the implementation of Mississippi's tort reform legislation. In addition, MACM medical liability premiums were compared by year from 2000 to 2010. Mississippi's tort reform laws were associated with a steep drop in lawsuits against MACM-insured physicians, particularly MACM-insured ob-gyns, as well as medical liability premium reductions and refunds.

VBAC: a medicolegal perspective

History has always been a series of pendulum swings, and there is perhaps no better example in obstetrics than that of vaginal birth after cesarean. Vaginal birth after cesarean (VBAC) rates rose steadily in the early 1990s. However, VBAC rates have declined dramatically over recent years, while the cesarean delivery rate has continued to rise unabated. Many physicians and hospitals are no longer offering trial of labor after cesarean, largely because of medicolegal concerns. This article explores the medical and legal risks of trial of labor after cesarean.

[Cerebral palsy and perinatal asphyxia (II--Medicolegal implications and prevention)]

Obstetric litigation is a growing problem in developed countries and its escalating cost together with increasing medical insurance premiums is a major concern for maternity service providers, leading to obstetric practice cessation by many practitioners. Fifty-four to 74 % of claims are based on cardiotocographic (CTG) abnormalities and their interpretation followed by inappropriate or delayed reactions. A critical analysis is performed about the nine criteria identified by the American College of Obstetricians and Gynecologists and the American Academy of Pediatrics in their task force on Neonatal Encephalopathy and Cerebral Palsy: four essential criteria defining neonatal asphyxia and five other suggesting an acute intrapartum event sufficient to cause cerebral palsy in term newborns. The importance of placental histologic examination is emphasized in order to confirm sudden catastrophic events occurring before or during labor or to detect occult thrombotic processes affecting the fetal circulation, patterns of decreased placenta reserve and adaptative responses to chronic hypoxia. It may also exclude intrapartum hypoxia by revealing some histologic patterns typical of acute chorioamnionitis and fetal inflammatory response or compatible with metabolic diseases. Magnetic resonance imaging (MRI) of the infant's damaged brain is very contributive to elucidate the mechanism and timing of asphyxia in conjunction with the clinical picture, by locating cerebral injuries predominantly in white or grey matter. Intrapartum asphyxia is sometimes preventable by delivering weak fetuses by cesarean sections before birth, by avoiding some "sentinel" events, and essentially by responding appropriately to CTG anomalies and performing an efficient neonatal resuscitation. During litigation procedures, it is necessary to have access to a readable CTG, a well-documented partogram, a complete analysis of umbilical cord gases, a placental pathology and an extensive clinical work-up of the newborn infant including cerebral MRI. Malpractice litigation in obstetric care can be reduced by permanent CTG education, respect of national CTG guidelines, use of adjuncts such as fetal blood sampling for pH or lactates, regular review of adverse events in Clinical Risk Management (CRM) groups and periodic audits about low arterial cord pH in newborns, admission to neonatal unit, the need for assisted ventilation and the decision-to-delivery interval for emergency operative deliveries. Considering the fast occurrence of fetal cerebral hypoxic injuries, and thus despite an adequate management, many intrapartum asphyxias will not be preventable. Conversely, well-documented hypoxic-ischemic brain insults during the antenatal period do not automatically exclude intrapartum suboptimal obstetric care.

Recovery after caesarean birth: a qualitative study of women's accounts in Victoria, Australia

BACKGROUND

The caesarean section rate is increasing globally, especially in high income countries. The reasons for this continue to create wide debate. There is good epidemiological evidence on the maternal morbidity associated with caesarean section. Few studies have used women's personal accounts of their experiences of recovery after caesarean. The aim of this paper is to describe women's accounts of recovery after caesarean birth, from shortly after hospital discharge to between five months and seven years after surgery.

METHOD

Women who had at least one caesarean birth in a tertiary hospital in Victoria, Australia, participated in an interview study. Women were selected to ensure diversity in experiences (type of caesarean, recency), caesarean and vaginal birth, and maternal request caesarean section. Interviews were audiotaped and transcribed verbatim. A theoretical framework was developed (three Zones of clinical practice) and thematic analysis informed the findings.

RESULTS

Thirty-two women were interviewed who between them had 68 births; seven women had experienced both caesarean and vaginal births. Three zones of clinical practice were identified in women's descriptions of the reasons for their first caesareans. Twelve women described how, at the time of their first caesarean section, the operation was performed for potentially life-saving reasons (Central Zone), 11 described situations of clinical uncertainty (Grey Zone), and nine stated they actively sought surgical intervention (Peripheral Zone).Thirty of the 32 women described difficulties following the postoperative advice they received prior to hospital discharge and their physical recovery after caesarean was hindered by a range of health issues, including pain and reduced mobility, abdominal wound problems, infection, vaginal bleeding and urinary incontinence. These problems were experienced across the three zones of clinical practice, regardless of the reasons women gave for their caesarean.

CONCLUSION

The women in this study reported a range of unanticipated and unwanted negative physical health outcomes following caesarean birth. This qualitative study adds to the existing epidemiological evidence of significant maternal morbidity after caesarean section and underlines the need for caesarean section to be reserved for circumstances where the benefit is known to outweigh the harms.

Diagnosis, treatment, and prevention of cerebral palsy

Cerebral palsy is the most prevalent cause of persisting motor function impairment with a frequency of about 1/500 births. In developed countries, the prevalence rose after introduction of neonatal intensive care, but in the past decade, this trend has reversed. A recent international workshop defined cerebral palsy as "a group of permanent disorders of the development of movement and posture, causing activity limitation, that are attributed to non-progressive disturbances that occurred in the developing fetal or infant brain." In a majority of cases, the predominant motor abnormality is spasticity; other forms of cerebral palsy include dyskinetic (dystonia or choreo-athetosis) and ataxic cerebral palsy. In preterm infants, about one-half of the cases have neuroimaging abnormalities, such as echolucency in the periventricular white matter or ventricular enlargement on cranial ultrasound. Among children born at or near term, about two-thirds have neuroimaging abnormalities, including focal infarction, brain malformations, and periventricular leukomalacia. In addition to the motor impairment, individuals with cerebral palsy may have sensory impairments, cognitive impairment, and epilepsy. Ambulation status, intelligence quotient, quality of speech, and hand function together are predictive of employment status. Mortality risk increases incrementally with increasing number of impairments, including intellectual, limb function, hearing, and vision. The care of individuals with cerebral palsy should include the provision of a primary care medical home for care coordination and support; diagnostic evaluations to identify brain abnormalities, severity of neurologic and functional abnormalities, and associated impairments; management of spasticity; and care for associated problems such as nutritional deficiencies, pain, dental care, bowel and bladder continence, and orthopedic complications. Current strategies to decrease the risk of cerebral palsy include interventions to prolong pregnancy (eg, 17alpha-progesterone), limiting the number of multiple gestations related to assisted reproductive technology, antenatal steroids for mothers expected to deliver prematurely, caffeine for extremely low birth weight neonates, and induced hypothermia for a subgroup of neonates diagnosed with hypoxic-ischemic encephalopathy.

Reducing obstetric litigation through alterations in practice patterns

OBJECTIVE

To estimate the extent to which obstetric malpractice claims might be reduced by adherence to a limited number of specific practice patterns.

METHODS

We examined all 189 closed perinatal claims between 2000 and 2005 from a single, large, professional liability insurer. Each case was subjected to three separate analyses: 1) whether the adverse outcome was caused by substandard care, 2) what changes in practice likely would have avoided the adverse outcome, regardless of standard-of-care considerations, and 3) to what extent did substandard documentation lead to payment in cases in which there was no objective evidence of substandard care.

RESULTS

Seventy percent of claims involving obstetric practice (accounting for 79% of all costs) involved substandard care. Payments in 85% of cases involving non-vaginal birth after cesarean (VBAC) fetal monitoring, 16% of maternal injury cases, 80% of cases involving VBAC, and 54% of shoulder dystocia cases were avoidable had four specific practice and documentation patterns been followed.

CONCLUSION

Most money currently paid in conjunction with obstetric malpractice cases is a result of actual substandard care resulting in preventable injury. Well more than half of hospital litigation costs might be avoided if physician practice included: 1) delivery in a facility with 24-hour in-house obstetric coverage; 2) adherence to published high-risk medication protocols; 3) a more conservative approach to VBAC; and 4) use of a comprehensive, standardized procedure note in cases of shoulder dystocia.

LEVEL OF EVIDENCE

III.

Cesarean delivery on maternal request: the impact on mother and newborn

Mothers should be counseled that the most concerning risks related to maternal request cesarean delivery are neonatal respiratory morbidity and those that may affect the mother's future reproductive health, including life-threatening conditions, such as placenta accreta. The literature suggests that overall risks of maternal complications with cesarean delivery on maternal request are slightly lower than a trial of vaginal delivery and are primarily driven by the avoidance of unplanned or emergent cesarean deliveries and their associated increased rate of complications. When addressing risks and benefits with patients, there are three areas of importance. First, the risks for neonatal respiratory morbidity and abnormal placentation with future pregnancies should be emphasized. Secondly, there are many areas on which studies are lacking. Finally, numerous factors can alter the risks and benefits--such as culture, maternal obesity, and provider background--and should be acknowledged.

The emergence of high-tech birthing

The journey from "normal" to high-tech childbirth has taken place gradually over the past century. This article gives a historic review of maternity care and defines normal birth according to care practices adapted from the World Health Organization. The issues facing today's consumers, care providers, and caregivers that have led to the high-tech approach to birth are discussed. Recommendations for nursing practice are proposed to balance a normal approach to childbirth with a high-tech clinical environment.

Medical legal issues in fetal monitoring

Despite almost universal fetal monitoring during labor, debates over its role and benefits persist in the medical community and in obstetric negligence lawsuits. Irrespective, there is widespread agreement that improvement in perinatal outcome is possible and that the events of labor contribute significantly to perinatal hazards. Timely application and proper interpretation of the fetal heart rate pattern in concert with evaluations of the maternal condition and the feasibility of safe vaginal delivery permit an evaluation of the quality of care and the preventability of fetal injury whether in peer review or in malpractice cases.

The Vanishing Mother: Cesarean Section and ?Evidence-Based Obstetrics?

The philosophy of "evidence-based medicine"--basing medical decisions on evidence from randomized controlled trials and other forms of aggregate data rather than on clinical experience or expert opinion--has swept U.S. medical practice in recent years. Obstetricians justify recent increases in the use of cesarean section, and dramatic decreases in vaginal birth following previous cesarean, as evidence-based obstetrical practice. Analysis of pivotal "evidence" supporting cesarean demonstrates that the data are a product of its social milieu: The mother's body disappears from analytical view; images of fetal safety are marketing tools; technology magically wards off the unpredictability and danger of birth. These changes in practice have profound implications for maternal and child health. A feminist project within obstetrics is both feasible and urgently needed as one locus of resistance.

Birth outcomes associated with interventions in labour amongst low risk women: A population-based study

INTRODUCTION

Despite concern over high rates of operative birth in many countries, particularly amongst low risk healthy women, the obstetric antecedents of operative birth are poorly described. We aimed to determine the association between interventions introduced during labour with interventions in the birth process amongst women of low medical risk.

METHODS

We undertook a population-based descriptive study of all low risk women amongst the 753,895 women who gave birth in Australia during 2000-2002. Adjusted odds ratios (AOR) were calculated using multinomial logistic regression to describe the association between mode of birth and each of four labour intervention subgroups separately for primiparous and multiparous women.

RESULTS

We observed increased rates of operative birth in association with each of the interventions offered during the labour process. For first time mothers the association was particularly strong.

CONCLUSIONS

This study underlines the need for better clinical evidence of the effects of epidurals and pharmacological agents introduced in labour. At a population level it demonstrates the magnitude of the fall in rates of unassisted vaginal birth in association with a cascade of interventions in labour and interventions at birth particularly amongst women with no identified risk markers and having their first baby. This information may be useful for women wanting to explore other methods of influencing the course of labour and the management of pain in labour, especially in their endeavour to achieve a normal vaginal birth.