The American College of Obstetricians The American College of Obstetricians and Gynecologists and Gynecologists

MEDICAL-LEGAL ISSUES IN MEDICAL-LEGAL ISSUES IN OBSTETRIC PRACTICEOBSTETRIC PRACTICE

Douglas H. Kirkpatrick, MD, FACOGDouglas H. Kirkpatrick, MD, FACOGImmediate Past President, ACOImmediate Past President, ACOGG

WHAT IS THE ROLE OF ACOG IN WHAT IS THE ROLE OF ACOG IN

EDUCATION REGARDING EDUCATION REGARDING

CURRENT PRACTICE?CURRENT PRACTICE?

What is the Role of ACOG in Education What is the Role of ACOG in Education Regarding Current Practice?Regarding Current Practice?

ConclusionConclusion::

RoleRole: Huge!: Huge!

ImpactImpact: ACOG widely respected nationally and : ACOG widely respected nationally and

internationally for its informational contentinternationally for its informational content

Brief History of ACOGBrief History of ACOG

1951 – American Academy of Ob-Gyn 1951 – American Academy of Ob-Gyn

Incorporated in ChicagoIncorporated in Chicago

Restricted membershipRestricted membership

1956 – American College of Ob-Gyn1956 – American College of Ob-Gyn

Open membershipOpen membership

1981 – ACOG moved to Washington, DC1981 – ACOG moved to Washington, DC

2010 – 53,000 members2010 – 53,000 members

50% male / 50% female50% male / 50% female

ACOG’s Educational CommitteesACOG’s Educational Committees

25 committees ranging from Adolescent Health Care to 25 committees ranging from Adolescent Health Care to

Health Care for Underserved Women to Ethics to Health Care for Underserved Women to Ethics to

Obstetrical Practice to Patient SafetyObstetrical Practice to Patient Safety

Meet face to face twice a yearMeet face to face twice a year

Produce new documents and review older ones Produce new documents and review older ones

(every 5 to 6 years)(every 5 to 6 years)

Practice BulletinsPractice Bulletins

Represent highest level of evidence-based medicineRepresent highest level of evidence-based medicine

CurrentlyCurrently – 44 OB Practice Bulletins – 44 OB Practice Bulletins

– 34 GYN Practice Bulletins– 34 GYN Practice Bulletins

OB examplesOB examples: :

Intrapartum Fetal Heart Rate Monitoring Intrapartum Fetal Heart Rate Monitoring

Management of Preterm Labor Management of Preterm Labor

Perinatal Care at the Threshold of ViabilityPerinatal Care at the Threshold of Viability

Committee OpinionsCommittee Opinions

Give timely info on clinical management issuesGive timely info on clinical management issues

Represent views of sponsoring committee based on Represent views of sponsoring committee based on interpretation of published data in peer-reviewed journalsinterpretation of published data in peer-reviewed journals

CurrentlyCurrently: 43 Committee Opinions in OB: 43 Committee Opinions in OB

ExamplesExamples: :

Cesarean Section Delivery on Maternal RequestCesarean Section Delivery on Maternal Request

Prevention of Early Onset Group B Strep Disease in Prevention of Early Onset Group B Strep Disease in NewbornNewborn

Scheduled Cesarean Section and Prevention of Vertical Scheduled Cesarean Section and Prevention of Vertical Transmission of HIVTransmission of HIV

ACOG’s Journal: “ACOG’s Journal: “Obstetrics and Gynecology” Obstetrics and Gynecology” (The Green Journal)(The Green Journal)

Most widely read journal in our specialty in the worldMost widely read journal in our specialty in the world

Testimony of strength of ACOG’s educational materialTestimony of strength of ACOG’s educational material

Many Latin American countries join ACOG for Many Latin American countries join ACOG for educational benefiteducational benefit

Central America/South America/Dominican Republic Central America/South America/Dominican Republic

ACOG provides translation into SpanishACOG provides translation into Spanish

Important ACOG Documents Important ACOG Documents Over Past DecadeOver Past Decade

Best PracticeBest Practice: : Neonatal Encephalopathy and Cerebral Neonatal Encephalopathy and Cerebral PalsyPalsy (ACOG/AAP – 2003) (ACOG/AAP – 2003)

Vaginal Birth After Cesarean SectionVaginal Birth After Cesarean Section (July 1999)(July 1999)

Induction of LaborInduction of Labor (August 2009)(August 2009)

VBAC DocumentVBAC Document

19891989 – ACOG recommended VBAC enthusiastically – ACOG recommended VBAC enthusiastically

19991999 – Physician immediately available due to published – Physician immediately available due to published uterine rupture rate of 1% with patient in laboruterine rupture rate of 1% with patient in labor

Resulted in huge pendulum shiftResulted in huge pendulum shift

VBAC StatisticsVBAC Statistics

70% success of vaginal delivery with VBAC 70% success of vaginal delivery with VBAC

ProblemProblem: 20% failed & subsequent C/S result in : 20% failed & subsequent C/S result in complications with mom and baby complications with mom and baby

Problem with ruptureProblem with rupture: 10% – 25% catastrophic with : 10% – 25% catastrophic with fetal loss or neurologic impairmentfetal loss or neurologic impairment

1/5001/500 risk newborn catastrophe with VBAC labor risk newborn catastrophe with VBAC labor

VBACVBAC (cont.)(cont.)

20022002 – ACOG extensive Informed Consent for patient – ACOG extensive Informed Consent for patient decision of VBAC including “death or brain damage to decision of VBAC including “death or brain damage to baby” with uterine rupturebaby” with uterine rupture

1999 to present1999 to present – biggest barrier – OB on L & D 24/7 – biggest barrier – OB on L & D 24/7

In community hospitals, economics do not workIn community hospitals, economics do not work

Pendulum swings to almost no VBACS in community Pendulum swings to almost no VBACS in community hospitalshospitals

Problem huge in western US with large rural statesProblem huge in western US with large rural states

VBACs now done in worse case scenario – at home VBACs now done in worse case scenario – at home with untrained lay midwifewith untrained lay midwife

VBACVBAC (cont.)(cont.)

20092009 – new generation of physicians – new generation of physicians – lifestyle over practice – lifestyle over practice

New job: laborist / hospitalist / nocturalistNew job: laborist / hospitalist / nocturalist

Community hospitals with large OB volume employ Community hospitals with large OB volume employ laborist – “shift work”laborist – “shift work”

Suspect pendulum for VBAC deliveries will returnSuspect pendulum for VBAC deliveries will return

With 24/7 coverage can offer VBACWith 24/7 coverage can offer VBAC

Decision time to delivery time yields consistently good Decision time to delivery time yields consistently good outcomes for mom and babyoutcomes for mom and baby

VBACVBAC (cont.)(cont.)

Above reflects how single ACOG Above reflects how single ACOG document in 1999 markedly changed document in 1999 markedly changed physician practice behavior physician practice behavior

Induction of LaborInduction of Labor 20092009 – 25% of women with medical or elective induction – 25% of women with medical or elective induction

of labor of labor 10% elective inductions10% elective inductions oxytocin discovered and used in 1948oxytocin discovered and used in 1948

19901990 – 12% inductions – medical & elective – 12% inductions – medical & elective Medical inductionsMedical inductions: for health of mom or baby: for health of mom or baby

High blood pressureHigh blood pressure Uterine infection (chorioamnionitis)Uterine infection (chorioamnionitis) Premature rupture of membranePremature rupture of membrane

ElectiveElective: patient preference/physician practice style: patient preference/physician practice style History of rapid laborsHistory of rapid labors Long distance from hospitalLong distance from hospital

Elective InductionsElective Inductions Why the fussWhy the fuss??

1.1. For every week before 39 weeks – increase For every week before 39 weeks – increase Admission to NICU (breathing disorders)Admission to NICU (breathing disorders) 37 weeks – 8/100037 weeks – 8/1000 38 weeks – 5/100038 weeks – 5/1000 39 weeks – 3/100039 weeks – 3/1000

2.2. Newspapers, including Newspapers, including Denver Post (Denver Post (October 2009)October 2009) ““Preemies inducing tighten delivery rules” Preemies inducing tighten delivery rules” ““Avoid delivering late preemies”Avoid delivering late preemies”

3.3. 20092009 – ACOG emphasized following induction guidelines – ACOG emphasized following induction guidelines including including NONO elective inductions before 39 weeks elective inductions before 39 weeks

Elective Inductions Elective Inductions (Magee – Womens)(Magee – Womens)

Lessons in change of physician behavior Lessons in change of physician behavior Magee – Women’s, PittsburghMagee – Women’s, Pittsburgh (9,300 (9,300 del/yr with 140 practicing physicians)del/yr with 140 practicing physicians)

1.1. 20032003 – induction rate – 28% – induction rate – 28%

2.2. 20042004 – – physician education physician education on ACOG Practice Bulletin on ACOG Practice Bulletin No inductions before 39 weeks & cervix had to be No inductions before 39 weeks & cervix had to be

favorable favorable Education repetitive with one-on-one physician Education repetitive with one-on-one physician

communicationcommunication

3.3. 20062006 – No change in physician practice – No change in physician practice

NOWNOW: Above criteria strictly enforced: Above criteria strictly enforced

Elective Inductions Elective Inductions (Magee – Womens)(Magee – Womens)

4.4. Reduced number Reduced number of available induction slots on L & Dof available induction slots on L & D

Monthly reviewMonthly review – if MD did not adhere – individual – if MD did not adhere – individual education education

22ndnd non-adherence non-adherence – peer-review letter sent to MD and VP – peer-review letter sent to MD and VP Medical Affairs/ + part of MD’s re-credentialing fileMedical Affairs/ + part of MD’s re-credentialing file

5.5. ResultResults: s:

Induction rate decreased from 28% to 16%Induction rate decreased from 28% to 16%

C/S rate for electively-induced nullips – 35% (2004)C/S rate for electively-induced nullips – 35% (2004)

C/S rate for electively-induced nullips – 13.8% (2006) C/S rate for electively-induced nullips – 13.8% (2006) (Identical to C/S rate for “laboring nullips”)(Identical to C/S rate for “laboring nullips”)

Great Study on Physician BehaviorGreat Study on Physician Behavior

First ConclusionFirst Conclusion::

Relatively long time to effect changeRelatively long time to effect change

Once incentives or disincentives developed Once incentives or disincentives developed behavior change occurred behavior change occurred

ACOG’s Practice Bulletin ACOG’s Practice Bulletin on Induction of Laboron Induction of Labor

Second ConclusionSecond Conclusion::

With adoption of Induction of Labor With adoption of Induction of Labor Guidelines – improved clinical outcomesGuidelines – improved clinical outcomes

Future Practice of MedicineFuture Practice of Medicine

Evidence-Based Clinical Practice GuidelinesEvidence-Based Clinical Practice Guidelines

ChallengesChallenges: :

Accessible to MDs Accessible to MDs

Clear and applicable Clear and applicable

Involve all stakeholdersInvolve all stakeholders

Ultimate improvement in health careUltimate improvement in health care

Presidential Initiative – 2009 Presidential Initiative – 2009 Example of Practice GuidelinesExample of Practice Guidelines

Task Force “Patient Safety in Office Setting”Task Force “Patient Safety in Office Setting”

Focused on increasing number of operative procedures Focused on increasing number of operative procedures imported from outpatient OR to officeimported from outpatient OR to office

Institute Institute Check Lists Check Lists (like FAA) before operative (like FAA) before operative procedureprocedure

Periodic Periodic Mock Drills Mock Drills responding to simulated emergenciesresponding to simulated emergencies

Already doing on L & D – Emergency C/S and Already doing on L & D – Emergency C/S and Shoulder Dystocia DrillsShoulder Dystocia Drills

Presidential Initiative Presidential Initiative (cont.)(cont.)

Primary barrierPrimary barrier:: Convincing physicians that patient safety supercedes Convincing physicians that patient safety supercedes

all other priorities in practiceall other priorities in practice With patient safety # 1, culture of change will deliver With patient safety # 1, culture of change will deliver

the highest quality of medical carethe highest quality of medical care Secondary barrierSecondary barrier::

Ability to report errors in blameless culture (like FAA)Ability to report errors in blameless culture (like FAA) Need to learn from one another so history is not Need to learn from one another so history is not

repeatedrepeated 2005 Legislation “Patient Safety and Quality 2005 Legislation “Patient Safety and Quality

Improvement Act” was passed. Developing rules & Improvement Act” was passed. Developing rules & regulations for implementation.regulations for implementation.

The American College of Obstetricians The American College of Obstetricians and Gynecologists and Gynecologists

MEDICAL-LEGAL ISSUES IN MEDICAL-LEGAL ISSUES IN OBSTETRIC PRACTICEOBSTETRIC PRACTICE

Douglas H. Kirkpatrick, MD, FACOGDouglas H. Kirkpatrick, MD, FACOGImmediate Past President, ACOImmediate Past President, ACOGG