Do perinatal guidelines have an impact on obstetric practices?

BACKGROUND: The publication of several sets of French guidelines was unfortunately not accompanied by planned assessment of their impact on practices. The goal of this study was to assess the impact of eight French perinatal guidelines on actual obstetric practices. METHODS: Historical cohort setting in France: the Audipog database of 299,412 pregnancies from 1994 to 2006, from which we extracted a sub-sample by randomLy selecting from each participating maternity ward all births occurring during a single month of each year (n=107,450 pregnancies). The main outcome measure was the incidence of pertinent perinatal indicators related to these guidelines. These included site of delivery for low-birth-weight infants (1998), caesarean delivery (2000), preterm delivery (2002), breastfeeding (2002), smoking and pregnancy (2004), immediate postpartum hemorrhages (2004), early discharge after delivery (2004) and episiotomies (2005). Standardised rates, before and after the year of each guideline, were compared using a Chi(2) test. RESULTS: The percentage of children weighing less than 1500 g at birth born in Level III hospitals increased through 1999 but dropped subsequently, without ever returning to the 1994 level (P<0.0001). The overall caesarean rate climbed slowly but regularly from 1994 through 2006 (P<0.0001). Use of antenatal corticosteroids for women hospitalised for threatened preterm labour and in children born before 33 weeks has fluctuated since the release of the guideline (P>0.05). Exclusive breastfeeding at discharge from the maternity ward has increased slowly (P<0.0001). The percentage of deliveries with active management of the third stage of labour rose notably from 1999 to 2006 (P<0.0001), and smoking cessation during pregnancy rose slightly in 2006 (P<0.0001). Since 1994, early discharges have become slowly, slightly, but regularly more frequent for all women (P<0.0001). The guideline on episiotomies has had a slight positive effect in the short term (P<0.0001). CONCLUSIONS: Globally, the impact on actual practices of clinical practice guidelines, except the guideline concerning the active management of the third stage of labour, was low. Most of the changes observed in practices began before the pertinent guideline was published.

Limit of viability in Japan: ethical consideration.

Viability means "the quality or state of being able to live, grow and develop." Limit of viability has been changed along with the advancement of perinatal and neonatal medicine. The viability limit defined in the Japanese Motherhood Protection Act was amended from 24 to 22 completed weeks of gestation in 1991 based on the survival rate of extremely preterm infants. Survival rates of infants at 22 and 23 weeks' gestation born between 2002 and 2004 in Japan were 31% and 56%, respectively. Though medical data are the most important means to define viability, socio-economical and ethical factors should be also considered, especially when we discuss the group of marginally viable infants. We think there are two different categories of viability limits, one from biological survival limit and another from social agreement of providing active medical intervention. Currently in Japan, the former viability definition based on purely medical data is 22 completed weeks and the latter definition is the social consensus of about 24-28 weeks' gestation.

Medical legal issues in prenatal diagnosis.

The capacity to diagnose fetal disease or abnormality continues to grow, especially in the genetic definition of the fetus. With this growth have come claims of medical malpractice that have mostly centered on a failure of informed consent. Failure may occur by omission or failed communication of pertinent information to the parents or by alleged error in the interpretation of diagnostic information. The usual claim against a physician or other provider is not that of causing damage or disease in the fetus but of causing a loss of opportunity to prevent conception or live birth of an infant who has an abnormality. Successful suits for "wrongful birth," brought by parents of an abnormal child, are common in many United States jurisdictions, but suits for "wrongful life," brought on behalf of the child, have usually been denied.

Communication-related allegations against physicians caring for premature infants.

OBJECTIVE: Maternal-fetal medicine physicians (MFMp) and neonatal-perinatal medicine physicians (NPMp) caring for premature infants and their families are exposed to significant risk for malpractice actions. Effective communication practices have been implicated to decrease litigious intentions but the extent of miscommunication as a cause of legal action is essentially unknown in this population. Analysis of communication-related allegations (CRAs) may help toward improving patient care and physician-patient relationships as well as decrease litigation risks. STUDY DESIGN: We retrospectively reviewed the Westlaw database, a primary online legal research resource used by United States lawyers and legal professionals, for malpractice cases against physicians involving premature infants. Inclusion criteria were: 22 to 36 weeks gestational age, cases related to peripartum events through infant discharge and follow-up, and legal records with detailed factual narratives. RESULTS: The search yielded 736 legal records, of which 167 met full inclusion criteria. A CRA was identified in 29% (49/167) of included cases. MFMp and/or NPMp were named in 104 and 54 cases, respectively. CRAs were identified in 26% (27/104) and 35% (19/54) of MFMp- and NPMp-named cases, respectively, with a majority involving physician-family for both specialties (81% and 74%, respectively). Physician-family CRAs for MFMp and NPMp most often regarded lack of informed consent (50% and 57%, respectively), lack of full disclosure (41% and 29%, respectively) and lack of anticipatory guidance (36% and 21%, respectively). CONCLUSIONS: This study of a major legal database identifies CRAs as significant causes of legal action against MFMp and NPMp involved in the care of high-risk women and infants delivered preterm. Physicians should be especially vigilant with obtaining genuine informed consent and maintaining open communication with families.

Medical liability, risk management, and the quality of health care.

The medical malpractice situation in many countries is reaching epidemic proportions. This paper examines the concepts of medical liability and professional risk management, as well as the relationship they play in determining the quality of healthcare services. The role of documentation and accurate record keeping is also stressed. High-risk clinical situations and medication errors are also addressed.

Litigation.

The law in relation to clinical practice is specialised and complex. Most practitioners have a rudimentary understanding of the basic concepts. This chapter explores the principles of duty of care, breach and causation, and how-using case law-they are applied to neonatal care. It considers the roles and responsibilities of the practitioner and the organisation in providing standards of care that are supportable in the current clinical governance and medicolegal climate. The problems facing practitioners who find themselves involved in a case many years after the actual clinical events are also discussed, and some risk management suggestions are made. Detailed and good-quality published data on the extent and nature of neonatal cases is lacking in the UK but should be improved by the changes that have occurred following the establishment of the National Health Service Litigation Authority. Finally, consideration is given to the difficulties parents, practitioners and experts can face in dealing with information and expectations in adverse clinical outcomes when litigation is inevitable.

Good practice in consent.

Informed parental consent reminds the health professional to respect parent autonomy with respect to their infant's health care. It involves at least four elements: information, assessment of understanding, assessment of capacity, and freedom to choose. Critical issues are training of staff, timing of approach, and quality and presentation of information. In the newborn period, additional problems include parental distress and competence, consent for research into emergency treatments (exceptions to this are proposed below); screening for future disease, circumcision and withdrawing intensive care are considered as special cases. Variation in practice and policies in European neonatal units is described.

Ten years of maternal-fetal transport.

One maternal-fetal transport system and the public health policies that supported its development are presented. System development, the components necessary for successful two-way maternal-fetal transports, and growth between 1981 and 1991 are summarized.

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.

[Pregnancy and perinatality: biological follow-up]. / Grossesse et périnatalité: suivi biologique.

Blood and urinary tests which are necessary for pregnancy diagnosis and follow-up, for newborn and mother medical supervision, during the month following birthday, are today described in reglementary texts, laws, and recommendations such as advised medical references (RMO). These documents specify the nature of obligatory tests, the checking rhythm and the list of useless tests. hCG research remains necessary for pregnancy diagnosis, but hCG dosage is essential only in case of programmed medical assistance or pathological pregnancy (extrauterine pregnancy, hydatiform mole, choriocarcinoma). The obligatory follow-up of a pregnant woman includes determination of blood groups, research of infectious agents responsible for diseases (toxoplasmosis, rubeola, hepatitis B, syphilis), proteinuria and glycosuria research and blood count according to a given calendar. When the mother's condition is bad and reminiscent of a pathological pregnancy, when a genetic risk exists for the fetus or when fetal growth is abnormal as indicated by echographic control (intra-uterine growth retardation), laboratory tests are used to follow the maternal pathological course (arterial hypertension, diabetes mellitus, anemia, bacterial, viral or parasitic disease), to verify the existence of a genetic disease, to know about the fetal functional state (by amniocentesis or cordocentesis), to identify an erythrocyte fetomaternal incompatibility. Since last trimester pregnancy accidents are able to endanger mother's and fetus lives, the feto-maternal follow-up must be adjusted to pathological diagnosis types and requires a particular supervision of the delivery. Finally mother and child must undergo a post-natal follow-up during the four weeks after birthday (perinatality control).

Effect of revised IOM weight gain guidelines on perinatal outcomes.

OBJECTIVE: We sought to examine perinatal outcomes in women with a body mass index (BMI) of 25 kg/m(2) comparing those whose weight gain met 2009 IOM guidelines to women meeting 1990 IOM guidelines. METHODS: This is a retrospective cohort study utilizing birth records linked to hospital discharge data for all term, singleton infants born to overweight, Missouri residents (2000-2006) with a BMI of 25 kg/m(2). We excluded congenital anomalies, mothers with diabetes, hypertension, or previous cesarean delivery. RESULTS: Fourteen thousand nine hundred fifty-five women gained 25-35 lbs (1990 guidelines); 1.6% delivered low birth weight (LBW) infants and 1.1% delivered macrosomic infants. Eight thousand three hundred fifty women gained 15-25 lbs (2009 guidelines); 3.4% delivered LBW infants and 0.6% delivered macrosomic infants. Women who gained 15-25 lbs were 1.99 (95% CI 1.67, 2.38) times more likely to have a LBW infant and 0.59 (95% CI 0.40, 0.76) times less likely to deliver a macrosomic infant. CONCLUSION: Limiting weight gain in women with a BMI of 25 kg/m(2), per the 2009 guidelines, increases the risk of LBW deliveries and decreases the risk of macrosomia but does not reduce associated adverse perinatal outcomes. Further studies should explore the optimal weight gain to reduce these outcomes.