Douglas H. Kirkpatrick, MD, FACOG Immediate Past President, ACO G

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

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? • 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

17. Elective Inductions (Magee – Womens) • Lessons in change of physician behavior Magee – Women’s, 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

18. Elective 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 MD’s 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”)

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, ACOG