January 5, 2009

OB/GYNs Talk about Litigation and Risk Reduction

The December issue of the journal Obstetrics and Gynecology has an article, “Reducing Obstetric Litigation Through Alterations in Practice Patterns,” which summarizes material the authors presented at an annual meeting of the Society for Maternal–Fetal Medicine. In it, they look at 189 closed obstetric liability claims from 2000-2005, classifying whether each incident was associated with what they considered substandard care.

The authors attributed 23% of cases and 14% of costs to incidents that were deemed avoidable had an obstetrician been available continuously in-house (something that is not possible in all facilities). They attributed a chunk of the costs to failures to follow protocols, explaining:

“Forty-five percent of cases involving fetal monitoring in non-VBAC patients (27% of total costs) and 16% of maternal injury cases (3% of total costs) were deemed avoidable had the health care providers followed published, checklist-driven protocols for administration of oxytocin, misoprostol, and magnesium sulfate.”

The authors also address whether VBAC occurrences were appropriate (such as whether labor was spontaneous and non-augmented) and poor documentation and care in cases of shoulder dystocia.

Among their conclusions, the authors state, “First, even when judged by treating providers or defense consultants, most money currently paid in conjunction with obstetric malpractice cases is a result of actual substandard care resulting in preventable injury.” The authors also suggest a more conservative approach (with which many would disagree) to allowing VBAC, although they acknowledge that this would be for litigation reduction purposes and would reduce the number of women successfully having VBACs.

Authors from the same health care corporation wrote in the August issue of the American Journal of Obstetrics and Gynecology of the protocols within their large, multi-hospital system for misoprostol, magnesium sulfate, and management of shoulder dystocia. Although they did not assess their VBAC rates under the institutionally restrictive policy, they did find a somewhat reduced primary c-section rate in 2006, and guess that it “appears to be attributable to fewer cesareans for oxytocin-induced fetal heart rate abnormalities associated with the universal implementation in 2006 of a uniform, checklist-based system for oxytocin administration.”

Although these two papers are not as fully detailed as I would like, they’re an interesting read on which issues are being discussed by healthcare providers and institutions when it comes to birth choices and practices and litigation concerns.


7 Responses to “OB/GYNs Talk about Litigation and Risk Reduction”

  1. Jill Says:

    Interesting. The most common reason typically cited for the ridiculously high c-section rate in the U.S. is physician fear of being sued. The blame is often shifted back onto women for suing doctors for permanent birth injuries that were supposedly out of the doctor’s control. But according to this, even treating providers and defense consultants are acknowledging that most payouts on obstetric malpractice cases are the result of actual substandard care and injuries that could have been prevented?

    Wow.

  2. mrs spock Says:

    In my opinion, as a nurse, a lot of this substandard care is a result of jam-packed schedules and overbooked physician practices, and hospitals that are more interested in squeezing blood from stones in order to build The Next Big Thing instead of ensuring adequate RN to patient ratios. If you want to improve birth outcomes in hospitals, ask for those hospitals to provide 1:1 nursing care throughout an entire labor- and for docs with the time to wait on a labor to progress naturally because they don’t have 2 hysterectomies, 2 scheduled c-sections, 4 laboring patients, and office hours to cram into a day.

  3. labornurse@nursingjobs.org Says:

    ditto, mrs spock.

    I also have heard quite a bit of talk about how many lawsuits are for cases in which a c-section wasn’t done “quickly enough” that then resulted in injury to the fetus.

  4. MomTFH Says:

    Absolutely, mrs. spock.

    I need to go read the articles. I am assuming their protocols are evidence based. I would have hoped that the report would specifically push for more evidence based medicine, which usually ends up advocating for less interventions.

  5. Rachel Says:

    MomTFH, just a note that they didn’t republish them in the December article, but the August one includes checklists for mag sulfate, misoprostol and shoulder dystocia as figures, so you’ll need to get that one for review. Let me know if you have trouble finding a copy.

  6. Jackie Says:

    Time passes, and brings further accrual of proof that much of maternity care is practiced defensively and without regard to best evidence, and that fear of litigation drives practice. A Medscape article dated May 15 and entitled “ACOG 2009: Liability Fears May Be Linked to Rise in Cesarean Rates”, makes the tacit admission that the rise in c-sections corresponds to “changes in obstetrical and gynecological practice behavior that were thought to affect the rate of cesarean delivery.” It goes on: “It has been suggested that medical-legal pressures are a factor in the rise of cesarean deliveries. A number of studies have borne this out (studies cited) [which] found an association between professional liability premiums and rate of cesarean delivery”. When did “do no harm” and the principle of beneficence get replaced by the self-interest of the caregiver, his/her safety, convenience, greed? If you can say there’s a problem and then treat for it, with a c-section let’s say, and there is no problem after all, everyone is happy. Would that be the case if every OB was mandated to tell ALL the consequences of cesarean..especially those done for the oft-stated “your baby is too big”? I have heard OBs say that an 8lb baby, measured by the nototiously inaccurate 38-week ultrasound, was “too big”! I hope ACOG keeps talking to itself this way. Perhap truth will out!
    And in that vein.. what a treat I had. I saw Judy Norsigian speak this past week, and shook that famous hand!

  7. MomTFH Says:

    I think the link between fear of litigation and cesareans needs to be examined more closely. First of all, it seems pretty clear based on the articles in this OP that litigation usually happens because something went wrong. I suppose a preemptive cesarean can prevent a non reassuring strip on a non VBAC patient. I need to go back and look over the original article, but I think that means intermittent monitoring is recommended, which I think is fantastic.

    As for the litigation and cesareans thing, I was born in and live near Miami. We now have a more than 50% cesarean rate. We also have the worst malpractice rates and payouts in the country. What is the connection here? I can’t prove causality, but I can say it is unlikely that the excessive cesareans are decreasing malpractice rates and payouts.

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