1. The American College of Obstetricians and Gynecologists MEDICAL-LEGAL ISSUES IN OBSTETRIC PRACTICE Douglas H. Kirkpatrick, MD, FACOG Immediate Past President, ACO G

2. WHAT IS THE ROLE OF ACOG IN EDUCATION REGARDING CURRENT PRACTICE?

3. What is the Role of ACOG in Education Regarding Current Practice?  Conclusion:  Role: Huge!  Impact: ACOG widely respected nationally and internationally for its informational content

4. Brief 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

5. ACOG’s 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)

6. Practice 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

7. Committee 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

8. ACOG’s Journal: “Obstetrics and Gynecology” (The Green Journal)  Most widely read journal in our specialty in the world  Testimony of strength of ACOG’s educational material  Many Latin American countries join ACOG for educational benefit  Central America/South America/Dominican Republic  ACOG provides translation into Spanish

9. Important 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)

10. VBAC 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

11. VBAC 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

12. VBAC (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

13. VBAC (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

14. VBAC (cont.)  Above reflects how single ACOG document in 1999 markedly changed physician practice behavior

15. Induction 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

16. Elective Inductions  Why the fuss? 1. For every week before 39 weeks – increase Admission to NICU (breathing disorders)  37 weeks – 8/1000  38 weeks – 5/1000  39 weeks – 3/1000 2. Newspapers, including Denver Post (October 2009)  “ Preemies inducing tighten delivery rules”  “Avoid delivering late preemies” 3. 2009 – ACOG emphasized following induction guidelines including NO elective inductions before 39 weeks

17. Elective Inductions (Magee – Womens)  Lessons in change of physician behavior Magee – Women’s, Pittsburgh (9,300 del/yr with 140 practicing physicians) 1. 2003 – induction rate – 28% 2. 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 3. 2006 – No change in physician practice NOW: Above criteria strictly enforced

18. Elective Inductions (Magee – Womens) 4. Reduced number of available induction slots on L & D Monthly review – if MD did not adhere – individual education 2 nd non-adherence – peer-review letter sent to MD and VP Medical Affairs/ + part of MD’s re-credentialing file 2 nd non-adherence – peer-review letter sent to MD and VP Medical Affairs/ + part of MD’s re-credentialing file 5. 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”)

19. Great Study on Physician Behavior  First Conclusion:  Relatively long time to effect change  Once incentives or disincentives developed behavior change occurred

20. ACOG’s Practice Bulletin on Induction of Labor  Second Conclusion:  With adoption of Induction of Labor Guidelines – improved clinical outcomes

21. Future Practice of Medicine  Evidence-Based Clinical Practice Guidelines  Challenges:  Accessible to MDs  Clear and applicable  Involve all stakeholders  Ultimate improvement in health care

22. Presidential 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

23. Presidential 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.

24. The American College of Obstetricians and Gynecologists MEDICAL-LEGAL ISSUES IN OBSTETRIC PRACTICE Douglas H. Kirkpatrick, MD, FACOG Immediate Past President, ACO G