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PubMed2005

Cause and effect analysis of closed claims in obstetrics and gynecology.

BACKGROUND: Identifying the etiologies of real or perceived adverse clinical events and undesired outcomes is an important step in improving patient safety and reducing malpractice risks. Systematic analysis of obstetrics and gynecology-related risk management files allows a more complete examination of ways that human and systems factors may contribute to adverse events. OBJECTIVE: To learn the medical complaints of patients who experienced apparent adverse events, the general causes of those adverse events, and the significant specific causal factors involved in obstetrics and gynecology-related risk management cases. METHODS: This was a retrospective analysis of 90 consecutive obstetrics and gynecology-related internal review files opened by a medical center's risk managers between 1995 and 2001. Each file was analyzed to identify factors that may have contributed to or caused unanticipated adverse events. The main outcome was the pattern of contributing factors when they were aggregated into categories. RESULTS: Fifty percent of cases were associated with inpatient obstetrics. Factors that may have contributed to adverse events were identified in 78% of cases, and most had more than one contributing factor. Thirty-one percent of adverse events were associated with apparent communication problems. Clinical performance issues were identified in 31% of cases, diagnostic issues in 18% of cases, and patient behavior contributed to 14% of adverse events. CONCLUSION: Diagnostic, therapeutic, and communication issues were the most common factors identified. Although the generalizability of these data are unknown, all obstetrics and gynecology departments face multiple challenges in assuring consistent quality care. Analysis of claims files may help identify opportunities for improvement.

Cohort Studies↗

PubMed1995

Obstetric and neonatal competence of medical students.

During 1991-1992 a confidential questionnaire was administered to a sample of United Kingdom medical students to determine if undergraduate education improved students' perceived competence at eight practical procedures. Of 2521 students given questionnaires, 1483 (58.8%) replied; 948 (65.5%) had had some obstetric and 866 (60.8%) some neonatal education. Such education did improve students' perceived competence (P < 0.001) on self-assessed Likert scales, but most still believe themselves not to be competent when they have completed their obstetric and neonatal education. Regression models were able to explain much (38.7-65.1%) of the variability in perceived competence at obstetric procedures: obstetric education, performing practical procedures, and witnessing deliveries in a general practitioner unit were all associated with higher competence; but less (4.8-20.8%) of the variability in perceived neonatal competence. It is suggested that undergraduate experience should be congruent with the aims and objectives of obstetric and neonatal education, and that these need to be reviewed in the light of the recent General Medical Council proposed changes to medical education.

Attitude↗

PubMed1996

Anal and urinary incontinence in women with obstetric anal sphincter rupture.

OBJECTIVE: To assess the long term impact of obstetric anal sphincter rupture on the frequency of anal and urinary incontinence and to identify factors to predict women at risk. DESIGN: An observational study. SETTINGS: Departments of Obstetrics and Gynaecology and of Surgery D, Glostrup County University Hospital, Denmark. PARTICIPANTS: Ninety-four consecutive women who had sustained an obstetric anal sphincter rupture. INTERVENTIONS: Assessment of history, anal manometry, anal sphincter electromyography and pudendal nerve terminal motor latency at three months postpartum A questionnaire regarding anal and urinary incontinence was sent two to four years postpartum. MAIN OUTCOME MEASURES: The frequency of anal and urinary incontinence and risk factors for the development of incontinence. RESULTS: Thirty of 72 women (42%) who responded had anal incontinence two to four years postpartum; 23 (32%) had urinary incontinence and 13 (18%) had both urinary and anal incontinence. Overall, 40 of 72 women (56%) had incontinence symptoms. The occurrence of anal incontinence was associated with pudendal nerve terminal motor latencies of more than 2.0 ms, and the occurrence of urinary incontinence was associated with the degree of rupture, the use of vacuum extraction and previous presence of urinary incontinence. Seventeen women had subsequently undergone a vaginal delivery in relation to which four (24%) had aggravation of anal incontinence, and three (18%) had aggravation of urinary incontinence. Of the women with incontinence, 38% wanted treatment but only a few had sought medical advice. CONCLUSIONS: Obstetric anal sphincter rupture is associated with a risk of approximately 50% for developing either anal or urinary incontinence or both. The prediction of women at risk is difficult. Information and routine follow up of all women with obstetric anal sphincter rupture is mandatory.

Adolescent↗

PubMed1989

The impact of obstetrical liability on access to perinatal care in the rural United States.

Liability issues have caused large numbers of obstetrical providers, particularly family and general practitioners, to discontinue offering perinatal care in rural areas. Losses of even small numbers of rural obstetrical providers can severely limit access to care for large geographic areas. A lack of access to local obstetrical care can result in less than adequate prenatal care and in potential delays in the diagnosis and care of acute perinatal complications. Women who live in these underserved rural communities suffer increased adverse birth outcomes, leading to significantly higher medical costs. Proposed solutions to the problem include risk management programs associated with reduced liability premiums; increased Medicaid reimbursement for obstetrical care; health department subsidies to offset insurance premiums for rural obstetrical care; and programs in predoctoral and residency training designed to identify, assess and address the health care needs of rural areas. Although some measure of success has resulted from these efforts, more systematic and comprehensive policy changes are needed to meet the challenge of this crisis.

Female↗

PubMed1989

Loss of a rural hospital obstetric unit: a case study.

As family and general practitioners who provide a substantial portion of the obstetric care in rural areas quit their obstetric practice, small rural hospital obstetric units are at risk of closing. Using a case study design, we examined the impact of the loss of obstetric services at a small rural hospital in Missouri. This unit was the site of delivery for less than one-half of the infants born to women living within its service area. However, it was the most likely source of care for women who were young, undereducated and unmarried (p less than 0.01). Evidence derived from birth certificates showed that women who delivered there had good perinatal outcomes compared with local women who delivered at larger hospitals. A gradual decline in the number of physicians providing obstetric care preceded the closing of the hospital unit. Women from the hospital service area who presented late for prenatal care were twice as likely to have had a low birthweight infant in the year after the local hospital unit closed (16.7% versus 7.4%), although this difference and other comparisons of outcomes were not statistically significant.

Evaluation Studies as Topic↗

PubMed1999

Impact of physicians' perceptions of malpractice and adaptive changes on intention to cease obstetrical practice.

Physicians who provide obstetrical care in rural areas face exposure to liability action and confront a critical decision--whether to continue to offer these services. This paper draws upon social-psychological and decision theories to investigate this decision. Ninety-four percent of all obstetricians and family and general physicians practicing in the 12 nonmetropolitan counties of one state responded to a mail survey that asked about their intention to continue or discontinue obstetrical practice, two dimensions of subjective risk (perceived likelihood of threats in the malpractice environment and perceived magnitude of negative consequences from being sued), and adaptive changes to protect against malpractice. The results suggest that (a) perceived extent of negative consequences (but not perceived likelihood of malpractice threats) drives intention to leave obstetrics, (b) the professional and reputational impacts of a suit--not the dollar amount of award or settlement--predicts intention to stop practicing obstetrics, and (c) physicians planning to continue providing obstetrical care in the future have made recent practice changes that may further exacerbate access problems.

Adult↗

PubMed1998

[Review, present and prospects of obstetrics].

During the last 25 years, the most impressive development in obstetrics has been the reduction of perinatal mortality from approximately 25 to below 6. Contrary to the expectations of those days, this has not been achieved by a decreased rate of premature births but by a better management of prematurely born babies, particularly by the induction of fetal organ maturity by corticosteroids and the antenatal transfer of high-risk pregnant women to a perinatal care centre. A more careful birth management and the corresponding ameliorations in neonatology (e.g. dosing of surfactants, less invasive methods of artificial respiration) have also contributed to the better results. The introduction of the prostaglandins to expel the fetus, the induction of delivery treatment of postpartal atonia were other milestones in the of obstetrics. Apart from these medical developments, sociological trends shaped obstetrics too, and these will influence it future: the increasing importance of the patient's will, paramedical factors in obstetrics and the heightened readiness to go to court in case of supposed damage. In obstetrics, the next few decades will show an uncheckable increase in the frequency of caesarean sections, due to - among other factors - the knowledge that vaginal deliveries cause injuries of the pelvic floor which have mostly been disregarded until now. Because of the expected decrease in birth rates, the increased number of doctors and midwives, the more and more demanding attitude of the population and the relentless readiness of supposedly injured patients to take legal action, the environment for obstetricians well become even more difficult in the future.

Austria↗

PubMed2001

Distribution of study designs in four major US journals of obstetrics and gynecology.

OBJECTIVE: To classify and compare articles, based on the study design, in four leading US obstetrics and gynecology journals. METHODS: One year of each journal, American Journal of Obstetrics and Gynecology (AJOG), Obstetrics and Gynecology (O&G), Gynecologic Oncology (GO), and Fertility and Sterility (F&S), beginning May 1997, was reviewed. Supplementary issues were excluded from review. The percentage of articles devoted to observational versus experimental study design was determined, and the quality of evidence was assessed including how heavily randomized controlled trials were represented versus other study designs. RESULTS: 1,517 articles were reviewed. The average percentage of clinical research articles was 90.4. The percentage of animal studies were 10.7 (AJOG), 1.1 (O&G), 1.1 (GO) and 4.2 (F&S) (chi(2) p < 0.001). There were 5.3, 1.9, 6.5, and 7.5% basic science articles, respectively (chi(2) p = 0.007). The average percentage of observational articles was 68.2 and that of experimental articles was 14.1. The percentages of total articles classified as controlled experimental were 10.9 (AJOG), 14.6 (O&G), 5.1 (GO), and 15.2 (F&S) (chi(2) p = 0.01). There were 8.7, 11.1, 3.3 and 9.5% randomized controlled trials, respectively (chi(2) p = 0.008). CONCLUSIONS: The majority of research reviewed was clinical, and more than half of the articles were observational. Under the US Preventative Services Task Force rating system, the randomized control trial is given the highest rating - class I evidence. The drive toward evidence-based clinical practice may not be fully supported by researchers in obstetrics and gynecology, as reflected by submissions to and publications in the major obstetrics and gynecology journals.

Animals↗

PubMed1996

[Room with a view for the "daughters of pain": 1828 was the beginning of new obstetrics in Erlangen].

The roots of clinical obstetrics at the University of Erlangen go back as far as the end of the 18th century. In 1796, Christian Friedrich Deutsch (1768-1843) was appointed as the first university teacher solely responsible for obstetrics. At the same time, he was also vehemently committed to the creation of a clinical institution for the purpose of training in obstetrics. For several reasons, the opening of a maternity home in a converted private house on the outskirts of town did not take place until 1828 under the leadership of Anton Bayer (1791-1832). In 1854/55, it was possible to move into a new building situated directly next to the university hospital; this new building was planned by Eugen Rosshirt (1798-1872). The increasing number of births and students as well as the introduction of gynecology finally led to the establishment, in 1878, of the first gynecological hospital in the sense understood by us today. The hospital was designed by Karl Schröder (1838-1887) who was the first Erlangen teacher of obstetrics to complete his habilitation in this field and probably has to be considered as the founder of the science of obstetrics at the University of Erlangen.

Female↗

PubMed2005

Provision for major obstetric haemorrhage: an Australian and New Zealand survey and review.

Obstetric haemorrhage is a leading cause of maternal death and the most common contributor to serious obstetric morbidity. Maternal mortality audit data suggest that appropriate preparation and good emergency management leads to improved outcome. The aim of this study was to assess facilities relevant to major obstetric haemorrhage management in all units in Australia and New Zealand that offer operative obstetric services. The questionnaire was divided into ten sections: demographics, facilities, staffing, policies and guidelines, drugs, procedures, equipment, point of care testing, availability of O negative blood and free comments. Responses were received from 240 (76.4%) of the 314 hospitals surveyed (187 public and 53 private). One hundred and nine units (45%) had fewer than 500 deliveries per year Distances to referral facilities were frequently very large. Of the 90 hospitals (38.1%) without an onsite blood bank, 12 did not have a supply of blood for emergencies. Half of all units (n=121) had on-site intensive care or high dependency facilities and 72.9% (n=175) had an on-site cardiac arrest team. Only 58.8% of units (n=141) had a written haemorrhage protocol. Findings are presented in the context of other literature, including evidence-based guidelines. Haemorrhage responds well to appropriate treatment, although careful preparation and anticipation of problems is required. In our region geographical factors and different systems of healthcare complicate provision of obstetric services. Where facilities are limited, women should be offered antenatal transfer to a larger centre.

Anesthesia↗

PubMed2006

Exposure to obstetric complications and subsequent development of bipolar disorder: Systematic review.

BACKGROUND: Research has suggested an association between obstetric complications and bipolar disorder. However, no quantitative evaluation has been made of the pooled data from existing studies. AIMS: To systematically review studies comparing exposure to obstetric complications in cases of bipolar disorder v. non-psychiatric controls, and in cases of bipolar disorder v. cases of other mental disorders. METHOD: Publications were identified by computer searches of seven databases, by hand searches of reference lists and from raw data received from researchers. RESULTS: Forty-six studies were identified, of which 22 met the inclusion criteria. The pooled odds ratio for exposure to obstetric complications and subsequent development of bipolar disorder was 1.01 (95% CI 0.76-1.35) compared with healthy controls, 1.13 (95% CI 0.64-1.99) compared with cases of unipolar disorder and 0.61 (95% CI 0.39-0.95) compared with those who developed schizophrenia. CONCLUSIONS: There is no robust evidence that exposure to obstetric complications increases the risk of developing bipolar disorder. However, the range of events regarded as obstetric complications and methodological inadequacies make definitive conclusions difficult.

Bipolar Disorder↗

PubMed2003

Aspects of molecular diagnostics and therapy in obstetrics and gynecology.

Scientific progress and information relating to the theoretical and clinical work being carried out in the field of obstetrics and gynecology has dramatically increased due to recent developments in molecular biology. Molecular obstetrics and gynecology is therefore the link between the different sections in obstetrics and gynecology. At present, the molecular understanding of cellular pathways is much greater than that of the direct integration of molecular diagnostics and therapy in routine clinical practice. The use of molecular diagnostics, such as preimplantation diagnostics or predictive genetic testing, still has technical problems as well as novel, and to date unclear, social, ethical and legal implications. To date, the technical elements of molecular therapy have not yet fulfilled their expectations. In the broad spectrum of obstetrics and gynecology, new molecular discoveries are influenced not only by technical but also by socioeconomic and political considerations. These include, for example, free access to genetic testing, patents for genes and the financial monopoly over molecular medication. Society must propose rules for the potential integration of the knowledge of molecular obstetrics and gynecology into the daily care of those seeking aid or advice.

Ethics, Medical↗

PubMedDate not supplied

Obstetric analgesia. Clinical pharmacokinetic considerations.

All drugs used in obstetric analgesia are more or less lipophilic, their site of action is in the central nervous system, and they have good membrane penetrability in the fetomaternal unit. Thus the dose and method of administration as well as the duration of treatment are important clinical determinants of drug effects in the fetus and newborn. In the past, too much emphasis has been placed on fetomaternal blood concentration ratios of different agents; it is now appreciated that the extent of fetal tissue distribution and the neonatal elimination rate are pharmacokinetically much more important. Extensive fetal tissue distribution is reflected in a low fetomaternal drug concentration ratio, which may be followed by prolonged neonatal elimination of the drug. Currently, the most effective and safest method for obstetric analgesia is regional epidural administration of bupivacaine or lignocaine (lidocaine); only low doses are needed and the newborn is able to handle these agents efficiently. On the basis of pharmacokinetic and neurobehavioural assessments, inhalational anaesthetic agents appear to be more attractive than pethidine (meperidine) or benzodiazepines. Intermittent administration and fast pulmonary elimination of inhalational agents ensure that long-lasting residual effects are unlikely to occur. The kinetics of epidural and intrathecal opiates explain the problems associated with their use in obstetrics. Among the newer drugs used in obstetric analgesia, the properties of meptazinol and isoflurane appear interesting and these agents warrant further study. All drugs used in obstetric analgesia have a potentially detrimental effect on the neonate and, therefore, knowledge of fetal and neonatal pharmacokinetics is of importance to the clinician.

Anesthesia, Obstetrical↗

PubMed2002

Consultation-liaison psychiatry in obstetrics and gynecology.

Data documenting the activity of Modena and Reggio Emilia University Hospital Consultation-Liaison Psychiatry Psychosomatic Service (C-LPPS) to the 59 bed gynecological-obstetric unit are compared to the corresponding European Consultation Liaison Workgroup (ECLW) study results and discussed in the light of recent epidemiological studies suggesting a low rate of detection and psychiatric referral in obstetric and gynecological patients. All psychiatric consultations of gynecological-obstetric inpatients during a 3-year (1996-1998) period were included in this study and data were derived from valid and reliable consultation forms tested for reliability. Within the 3-year period 55 patients were referred to C-LPPS by the gynecological-obstetric unit for psychiatric consultation. Referral rate was 0.5% of the admitted patients in the unit. The gynecological-obstetric group represented 2.5% (vs. 4.5% ECLW study) of all psychiatric consultations requested in the study period. The most frequent reasons for referral were: current psychiatric symptoms (47.3% Modena study vs. 39% ECLW), psychiatric history (20% vs. 7.3%), unexplained physical symptoms (12.7% vs. 16.2%) and coping-compliance problems (3.6% vs. 16.6%). The most common ICD-10 psychiatric diagnoses were: neurotic, anxiety and adjustment disorders (41.8% vs. 31.2%), mood disorders (29% vs. 18.4%), personality disorders (7.3% vs. 6.1%), schizophrenic and other psychotic disorders (5.5% vs. 7%).

Adult↗

PubMedDate not supplied

Risk management in obstetric care for family physicians: results of a 10-year project.

BACKGROUND: Malpractice issues within the United States remain a critical factor for family physicians providing obstetric care. Although tort reform is being widely discussed, little has been written regarding the malpractice crisis from a risk management perspective. METHODS: Between 1989 and 1998, a 10-year risk management study at the UC Davis Health System provided a unique collaboration between researchers, a mutual insurance carrier and family physicians practicing obstetrics. Physicians were asked to comply with standardized clinical guidelines, attend continuing medical education (CME) seminars, and submit obstetric medical records for review. Feedback analysis was provided to each physician on their records, and the insurance carrier tracked interim malpractice claims. RESULTS: One hundred and ninety-four physicians participated, attending to 32,831 births. Compliance with project guidelines was 91%. Five closed obstetric cases were reported with only one settlement reported to the National Provider Data Bank. Physicians believed the project was beneficial to their practices. CONCLUSIONS: Family physicians practicing obstetrics are willing to participate in a collaborative risk management program and are compliant with standardized clinical guidelines. The monetary award for successful malpractice claims was relatively low. This collaborative risk management model may offer a potential solution to the current malpractice crisis.

California↗

PubMed2000

The sometimes uncertain world of Canadian obstetrics, 1900-1950.

All specialties in medicine in the first half of the twentieth century partook of the prestige of medical science and their practitioners looked to the past as a gauge to how far their specialty had progressed. Obstetrics was no different. The introductions to most obstetric textbooks and articles contained almost mandatory praise for the advances made. The writers acknowledged the art of obstetrics and, at times, gave it equal rhetorical standing, but in emphasis, the "science" of obstetrics dominated. Yet underlying the bravado was an unease that not all was well with the field. Several issues contributed to the sense of anxiety-the deficiencies in obstetrical education, its status vis-à-vis other medical specialties, the reality of practice, including the remuneration received, and the perception of competition from "unqualified" individuals. Such concerns are important for historians of childbirth to recognize.

Canada↗

PubMed1998

[De-professionalization or 'para-professionalization'?. The professional development of the midwife and her place in the obstetrics of the 19th century].

The present article deals with the standing and the tasks of midwives in 19th century Württemberg. After outlining the legal framework of obstetrics, special emphasis was given to the education and activities of contemporary midwives, and to their numbers. At the beginning of the 18th century, obstetrics was almost exclusively in the hands of women. After 1800, a growing number of barber-surgeons and physicians began to practise obstetrics. At the same time, vocational training and qualification of women-obstetricians increased considerably. Schools for midwives and lying-in hospitals were founded. In these schools a limited number of midwives were trained by physicians. Finally a hierarchy of different groups of obstetricians developed: first physicians, then barber-surgeons, midwives and folk healers. Although midwives were more or less excluded from operative obstetrics and high-risk-pregnancies, care and supervision of uncomplicated pregnancies, and of women in childbed remained their responsibility. It could be shown that in 19th century Württemberg more than 90 percent of pregnancies ran a safe course, and neither physicians nor barber-surgeons took a special interest in the care of normal births. Thus there was no dramatic transfer of obstetric care from the hands of the midwives to those of academically trained men. The high social status of the university-bred physicians separated them from most of the patients, as did the doctors' high fees. A certain indolence, and a remarkable sense of shame on the part of the pregnant women prevented much demand for academic obstetricians.

Female↗

PubMed1999

Satisfaction with obstetric care. Patient survey in a family practice shared-call group.

OBJECTIVE: To examine patients' satisfaction with their obstetric care in a family medicine shared-call group. DESIGN: A survey was given to a convenience sample of patients who came to see their doctors over a 6-week period. SETTING: Brameast Family Practice in Brampton, Ont, where eight doctors participate in a shared obstetrics call group with 16 other physicians, each taking call 1 day in 23 days. PARTICIPANTS: Mothers in the practice who had delivered in the previous 8 months. MAIN OUTCOME MEASURES: Demographic data, interventions during delivery, and satisfaction ratings. RESULTS: Of the 70% of women who responded, 96% were delivered by a doctor other than their own. Eighty-eight percent of these women were satisfied with their medical care at delivery and 96% were satisfied with their prenatal care. Nearly 79% said they would choose this shared-call group again. CONCLUSIONS: This pilot study demonstrated a high level of patient satisfaction with obstetric care, despite the fact that most patients were delivered by a doctor other than their own. Family practice groups sharing obstetric call offer a feasible alternative for physicians who wish to avoid the interference with lifestyle and office appointments that practising obstetrics usually entails.

Adult↗