Title: The American College of Obstetricians and Gynecologists MEDICAL-LEGAL ISSUES IN OBSTETRIC PRACTICE
1The American College of Obstetricians and
Gynecologists MEDICAL-LEGAL ISSUES IN
OBSTETRIC PRACTICE
- Douglas H. Kirkpatrick, MD, FACOG
- Immediate Past President, ACOG
2WHAT IS THE ROLE OF ACOG IN EDUCATION REGARDING
CURRENT PRACTICE?
3What is the Role of ACOG in Education Regarding
Current Practice?
- Conclusion
- Role Huge!
- Impact ACOG widely respected nationally and
internationally for its informational content
4Brief History of ACOG
- 1951 American Academy of Ob-Gyn
- Incorporated in Chicago
- Restricted membership
- 1956 American College of Ob-Gyn
- Open membership
- 1981 ACOG moved to Washington, DC
- 2010 53,000 members
- 50 male / 50 female
5ACOGs Educational Committees
- 25 committees ranging from Adolescent Health Care
to Health Care for Underserved Women to Ethics to
Obstetrical Practice to Patient Safety - Meet face to face twice a year
- Produce new documents and review older ones
(every 5 to 6 years)
6Practice Bulletins
- Represent highest level of evidence-based
medicine - Currently 44 OB Practice Bulletins
34 GYN Practice Bulletins - OB examples
- Intrapartum Fetal Heart Rate Monitoring
- Management of Preterm Labor
- Perinatal Care at the Threshold of Viability
7Committee Opinions
- Give timely info on clinical management issues
- Represent views of sponsoring committee based on
interpretation of published data in peer-reviewed
journals - Currently 43 Committee Opinions in OB
- Examples
- Cesarean Section Delivery on Maternal Request
- Prevention of Early Onset Group B Strep Disease
in Newborn - Scheduled Cesarean Section and Prevention of
Vertical Transmission of HIV
8ACOGs Journal Obstetrics and Gynecology (The
Green Journal)
- Most widely read journal in our specialty in the
world - Testimony of strength of ACOGs educational
material - Many Latin American countries join ACOG for
educational benefit - Central America/South America/Dominican Republic
- ACOG provides translation into Spanish
9Important ACOG Documents Over Past
Decade
- Best Practice Neonatal Encephalopathy and
Cerebral Palsy (ACOG/AAP 2003) - Vaginal Birth After Cesarean Section (July 1999)
- Induction of Labor (August 2009)
10VBAC Document
- 1989 ACOG recommended VBAC enthusiastically
- 1999 Physician immediately available due to
published uterine rupture rate of 1 with patient
in labor - Resulted in huge pendulum shift
11VBAC Statistics
- 70 success of vaginal delivery with VBAC
- Problem 20 failed subsequent C/S result in
complications with mom and baby - Problem with rupture 10 25 catastrophic with
fetal loss or neurologic impairment - 1/500 risk newborn catastrophe with VBAC labor
12VBAC (cont.)
- 2002 ACOG extensive Informed Consent for
patient decision of VBAC including death or
brain damage to baby with uterine rupture - 1999 to present biggest barrier OB on L D
24/7 - In community hospitals, economics do not work
- Pendulum swings to almost no VBACS in community
hospitals - Problem huge in western US with large rural
states - VBACs now done in worse case scenario at home
with untrained lay midwife
13VBAC (cont.)
- 2009 new generation of physicians
lifestyle over practice - New job laborist / hospitalist / nocturalist
- Community hospitals with large OB volume employ
laborist shift work - Suspect pendulum for VBAC deliveries will return
- With 24/7 coverage can offer VBAC
- Decision time to delivery time yields
consistently good outcomes for mom and baby
14VBAC (cont.)
- Above reflects how single ACOG document in 1999
markedly changed physician practice behavior
15Induction of Labor
- 2009 25 of women with medical or elective
induction of labor - 10 elective inductions
- oxytocin discovered and used in 1948
- 1990 12 inductions medical elective
- Medical inductions for health of mom or baby
- High blood pressure
- Uterine infection (chorioamnionitis)
- Premature rupture of membrane
- Elective patient preference/physician practice
style - History of rapid labors
- Long distance from hospital
16Elective Inductions
- Why the fuss?
- For every week before 39 weeks increase
Admission to NICU (breathing disorders) - 37 weeks 8/1000
- 38 weeks 5/1000
- 39 weeks 3/1000
- Newspapers, including Denver Post (October 2009)
- Preemies inducing tighten delivery rules
- Avoid delivering late preemies
- 2009 ACOG emphasized following induction
guidelines including NO elective inductions
before 39 weeks
17Elective Inductions (Magee Womens)
- Lessons in change of physician behavior
Magee Womens, Pittsburgh
(9,300 del/yr with 140 practicing physicians) - 2003 induction rate 28
- 2004 physician education on ACOG Practice
Bulletin - No inductions before 39 weeks cervix had to be
favorable - Education repetitive with one-on-one physician
communication - 2006 No change in physician practice
- NOW Above criteria strictly enforced
18Elective Inductions (Magee Womens)
- Reduced number of available induction slots on L
D - Monthly review if MD did not adhere
individual education - 2nd non-adherence peer-review letter sent to
MD and VP Medical Affairs/ part of MDs
re-credentialing file - Results
- Induction rate decreased from 28 to 16
- C/S rate for electively-induced nullips 35
(2004) - C/S rate for electively-induced nullips 13.8
(2006) (Identical to C/S rate for laboring
nullips)
19Great Study on Physician Behavior
- First Conclusion
- Relatively long time to effect change
- Once incentives or disincentives developed
behavior change occurred
20ACOGs Practice Bulletin on Induction of Labor
- Second Conclusion
- With adoption of Induction of Labor Guidelines
improved clinical outcomes
21Future Practice of Medicine
- Evidence-Based Clinical Practice Guidelines
- Challenges
- Accessible to MDs
- Clear and applicable
- Involve all stakeholders
- Ultimate improvement in health care
22Presidential Initiative 2009 Example of
Practice Guidelines
- Task Force Patient Safety in Office Setting
- Focused on increasing number of operative
procedures imported from outpatient OR to office - Institute Check Lists (like FAA) before operative
procedure - Periodic Mock Drills responding to simulated
emergencies - Already doing on L D Emergency C/S and
Shoulder Dystocia Drills
23Presidential Initiative (cont.)
- Primary barrier
- Convincing physicians that patient safety
supercedes all other priorities in practice - With patient safety 1, culture of change will
deliver the highest quality of medical care - Secondary barrier
- Ability to report errors in blameless culture
(like FAA) - Need to learn from one another so history is not
repeated - 2005 Legislation Patient Safety and Quality
Improvement Act was passed. Developing rules
regulations for implementation.
24The American College of Obstetricians and
Gynecologists MEDICAL-LEGAL ISSUES IN
OBSTETRIC PRACTICE
- Douglas H. Kirkpatrick, MD, FACOG
- Immediate Past President, ACOG