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.

Different labour outcomes in primiparous women that have been subjected to childhood sexual abuse or rape in adulthood: a case-control study in a clinical cohort

OBJECTIVE

To compare the duration and outcome of the first labour in women who have been subjected to childhood sexual abuse (CSA) and women who have been raped in adulthood (RA).

DESIGN

Case-control study in a clinical cohort.

SETTING

University Hospital of North Norway.

SAMPLE

In all, 373 primiparas: 185 subjected to CSA, 47 to RA and 141 controls without a history of abuse.

METHODS

Data on birth outcomes were retrieved from the patient files. Information on sexual abuse was reported in consultation with specialised midwives in the mental health team. Birth outcomes were analysed by multinominal regression analysis.

MAIN OUTCOME MEASURES

Vaginal births, delivery by caesarean section, operative vaginal delivery and duration of labour.

RESULTS

As compared with controls, the RA group showed a significantly higher risk for caesarean section (adjusted OR 9.9, 95% CI 3.4-29.4) and operative vaginal delivery (adjusted OR 12.2, 95% CI 4.4-33.7). There were no significant differences between the CSA and the control group. The RA group displayed significantly longer duration of labour in all phases as compared with the control and CSA groups.

CONCLUSIONS

There were major differences in the duration of labour and birth outcomes in the two abuse groups. Despite a higher proportion of obstetric risk factors at onset of labour in the CSA group, women subjected to CSA had shorter labours and less risk for caesarean section and operative vaginal deliveries than women subjected to RA. The best care for birthing women subjected to sexual abuse needs to be explored in further studies.

Episiotomy characteristics and risks for obstetric anal sphincter injuries: a case-control study

Objectives

To investigate the association between the geometrical properties of episiotomy and obstetric anal sphincter injuries (OASIS) because episiotomies angled at 40–60° are associated with fewer OASIS than episiotomies with more acute angles.

Design

Case–control study.

Setting

University Hospital of North Norway, Tromsø and Nordland Hospital, Bodø, Norway.

Sample

Seventy-four women who had one vaginal birth and episiotomy. Cases (n = 37) have sustained OASIS at birth, while controls (n = 37) had not. The groups were matched for instrumental delivery.

Methods

Two groups of women with history of only one vaginal birth were compared. Episiotomy scar was identified and photographed and relevant measures were taken. Data were analysed using conditional logistic analysis.

Main outcome measures

Mean episiotomy angle, length, depth, incision point.

Results

The risk of sustaining OASIS decreased by 70% (odds ratio [OR] 0.30; 95% CI 0.14–0.66) for each 5.5-mm increase in episiotomy depth, decreased by 56% (OR 0.44; 95% CI 0.23–0.86) for each 4.5-mm increase in the distance from the midline to the incision point of the episiotomy, and decreased by 75% (OR 0.25; 95% CI 0.10–0.61) for each 5.5-mm increase in episiotomy length. Lastly, there was no difference in mean angle between groups but there was a “U-shaped” association between angle and OASIS (OR 2.09; 95% CI 1.02–4.28) with an increased risk (OR 9.00; 95% CI 1.1–71.0) of OASIS when the angle was either smaller than 15°or >60°.

Conclusion

The present study showed that scarred episiotomies with depth > 16 mm, length > 17 mm, incision point > 9 mm lateral of midpoint and angle range 30–60° are significantly associated with less risk of OASIS. Shrinkage of tissue must be considered.

Is the operative delivery rate in low-risk women dependent on the level of birth care? A randomised controlled trial

Objective

To investigate possible differences in operative delivery rate among low-risk women, randomised to an alongside midwifery-led unit or to standard obstetric units within the same hospital.

Design

Randomised controlled trial.

Setting

Department of Obstetrics and Gynaecology, Østfold Hospital Trust, Tromsø, Norway.

Population

A total of 1111 women assessed to be at low risk at onset of spontaneous labour.

Methods

Randomisation into one of three birth units: the special unit; the normal unit; or the midwife-led unit.

Main outcome measures

Total operative delivery rate, augmentation, pain relief, postpartum haemorrhage, sphincter injuries and intrapartum transfer, Apgar score <7 at 5 minutes, metabolic acidosis and transfer to neonatal intensive care unit.

Results

There were no significant differences in total operative deliveries between the three units: 16.3% in the midwife-led unit; 18.0% in the normal unit; and 18.8% in the special unit. There were no significant differences in postpartum haemorrhage, sphincter injuries or in neonatal outcomes. There were statistically significant differences in augmentation (midwife-led unit versus normal unit RR 0.73, 95% CI 0.59–0.89; midwife-led unit versus special unit RR 0.69, 95% CI 0.56–0.86), in epidural analgesia (midwife-led unit versus normal unit RR 0.68, 95% CI 0.52–0.90; midwife-led unit versus special unit RR 0.64, 95% CI 0.47–0.86) and in acupuncture (midwife-led unit versus normal unit RR 1.45, 95% CI 1.25–1.69; midwife-led unit versus special unit RR 1.45, 95% CI 1.22–1.73).

Conclusions

The level of birth care does not significantly affect the rate of operative deliveries in low-risk women without any expressed preference for level of birth care.

Labor admission test: an assessment of the test's value as screening for fetal distress in labor

BACKGROUND

To determine if the labor admission test (LAT) can predict fetal distress in a population of laboring women, and in subgroups of low- or high-risk women, who delivered within six hours or between six and 24 hours after LAT.

METHODS

The data charts of all women who delivered at Hammerfest Hospital in 1996, 1997 and 1998 were retrospectively read. If the woman was admitted to the hospital because of onset of labor, was in the first stage of labor and delivered within 24 hours after admission, she was included. In the study period, 1639 gave birth and 932 were included in the study. A descriptive analysis of the population and assessment of LAT's sensitivity, positive predictive value, specificity and negative predictive value at different cut-off values was done.

RESULTS

In the study population 5.8% had fetal distress, and 5.3% had an operative delivery because of fetal distress. LAT's sensitivity in the whole population was 0.15 and positive predictive value was 0.16. Specificity was 0.95 and positive predictive value was 0.95. In the subgroups of low- and high-risk women, who delivered within six hours or between six and 24 hours after LAT, sensitivity varied between 0 and 0.36, and positive predictive value varied between 0 and 0.27. Specificity varied between 0.92 and 0.96, and negative predictive value varied between 0.89 and 0.97.

CONCLUSIONS

According to these results, LAT cannot be recommended as a screening test for fetal distress in labor in low-risk women. Sensitivity is too low, and there are too many false-positive tests. It is unclear if LAT has benefits among high-risk women.

[Modified midwife managed unit--an alternative for small birthing departments?]

BACKGROUND

The Norwegian Board of Health has proposed to divide the delivery units into three categories. For several of today's smaller consultant managed units this could lead to a reclassification into midwife managed units.

MATERIAL AND METHODS

During 1997 and 1998 the community hospital in Lofoten has tried out a modified type of midwife managed unit. By a continuous selection process a high risk and a low risk group of gravidas were identified. The high risk group was referred to the central hospital in Bodø, while the low risk group was offered to deliver locally.

RESULTS

Previously more than 90% delivered at the community hospital in Lofoten, while approximately 70% still delivered locally during the trial period. There were no deliveries during transport and no serious complications for mother or child caused by the new system. The community hospital had facilities for performing emergency caesarean sections. In 1997 nine caesarean sections out of 211 deliveries and in 1998 four out of 224 were performed. The caesarean section rate for the total population was lower during the trial period than over the previous five years.

INTERPRETATION

A modified midwife managed unit could be a good alternative for small consultant managed units if the Norwegian Board of Health's proposal is carried through.