Serious maternal morbidity after childbirth: prolonged hospital stays and readmissions.

OBJECTIVE: To determine the frequency of and risk factors for serious morbidity resulting in a prolonged hospital stay or readmission among women enrolled in Tennessee's Medicaid program who delivered live or dead infants in 1991. METHODS: This retrospective cohort study included 33,251 women of white or black ethnicity. Main outcome measures included childbirth-related medical conditions serious enough to result in death, prolonged delivery hospitalization, or readmission within 60 days of delivery. RESULTS: Among 25,810 women with vaginal (78%) and 7441 (22%) women with cesarean deliveries, 2.6% and 8.9%, respectively, had at least one childbirth-related medical condition requiring prolonged delivery hospitalization or readmission, including infection (1.8% and 7.9%), hypertension-related complications (0.7% and 2.0%), or hemorrhage (0.5% and 2.4%). After controlling for other risk factors, maternal age over 32 years was independently associated with increased rate of serious morbidity among women who had vaginal (relative risk [RR] 1.9, 95% confidence interval [CI] 1.4, 2.7) or cesarean deliveries (RR 1.6, 95% CI 1.1, 2.2). Black women had approximately twice the rate of maternal morbidity with vaginal (RR 1.9, 95% CI 1.5, 2.4) or cesarean deliveries (RR 2.3, 95% CI 1.9, 2.9). Primiparous women who had vaginal or cesarean deliveries had a 60% (RR 1.6, 95% CI 1.3, 2.0) and 70% (RR 1.7, 95% CI 1.4, 2.0), respectively, greater risk of serious maternal morbidity than women with 1-3 prior births. CONCLUSION: Predictors of serious maternal morbidity included age over 32 years, black ethnicity, and primiparity.

Compensation for birth-related injury: no-fault programs compared with tort system.

OBJECTIVE: To compare compensation systems for birth-related injuries. DESIGN: Retrospective cohort study. SETTING: Florida. PARTICIPANTS: Parents of children with birth-related injuries who filed claims that closed before August 1, 1995, with Florida's no-fault program (Neurological Injury Compensation Act [NICA]) or who filed tort claims that closed from January 1, 1986, to August 1, 1995. MAIN OUTCOME MEASURES: Compensation for medical and income losses due to birth-related injuries. RESULTS: Families who received tort settlements were overcompensated for the injury, considering all sources of compensation. By contrast, NICA recipients broke even. Those who did not receive tort or NICA compensation lost nearly $75000 in the first 5 years following the birth. In the subsample of families of children with cerebral palsy, overcompensation by tort claim was even greater, whereas NICA recipients were undercompensated. The cost of care for cerebral palsy in both groups was the same. The difference between tort and NICA compensation levels was attributable to payment for income loss. Overall, NICA recipients were satisfied with compensation received. CONCLUSIONS: Medical expenses were adequately covered under NICA, but not income loss. A universal health insurance program for children would not cover income losses. Similar costs incurred in NICA and tort systems suggests no rationing of care by NICA. Finally, absent some sort of targeted compensation, the losses experienced by families of children with birth-related injuries were substantial.

Postdelivery mortality in Tennessee, 1989-1991.

OBJECTIVE: To describe postdelivery mortality rates among residents of Tennessee from 1989 through 1991 and to compare these rates with those of women who had not delivered a live or stillborn infant in the previous year. METHODS: Postdelivery deaths (those occurring within a year of delivery of a live or stillborn infant) were identified using a computerized linkage of birth and fetal death certificates to death certificates of female decedents aged 15-44 years. Each identified postdelivery death was reviewed and categorized as either pregnancy-related (temporally and causally related to pregnancy) or pregnancy-associated-but-not-related (temporally but not causally related to pregnancy). Cause-specific mortality rates were compared for women who died postdelivery with women who died but had not delivered in the previous year. RESULTS: We identified 129 postdelivery deaths, one quarter of which were classified as pregnancy-related. The rates of postdelivery pregnancy-related and of pregnancy-associated-but-not-related death were 14.6 and 58.7, respectively, per 100,000 women who had delivered. Nonwhite women were 6.9 times more likely to experience postdelivery pregnancy-related death and 2.0 times more likely to experience postdelivery pregnancy-associated-but-not-related death than were white women. The leading cause of death among both women who had delivered and women who had not delivered a live or stillborn infant in the previous year was injury, although the risk of death the year after delivery was lower than for women who had delivered. CONCLUSION: Women were less likely to die in the year after delivery than were women who had not delivered a live or stillborn infant in the previous year. However, regardless of their delivery status, injuries were the leading cause of death among women. Postdelivery mortality was statistically significantly higher in nonwhite than white women, especially for pregnancy-related deaths.

No-fault system of compensation for obstetric injury: winners and losers.

OBJECTIVE: To determine whether Florida's implementation of a no-fault system for birth-related neurologic injuries reduced lawsuits and total spending associated with such injuries, and whether no-fault was more efficient than tort in distributing compensation. METHODS: We compared claims and payments before and after implementation of a no-fault system in 1989. Data came from the Department of Insurance's medical malpractice closed claim files and no-fault records. Descriptive statistics were compiled for tort claims before 1989 and for tort and no-fault claims for 1989-1991. We developed two projection approaches to estimate claims and payments after 1989, with and without no-fault. We assessed the program's performance on the basis of comparisons of actual and projected values for 1989-1991. RESULTS: The number of tort claims for permanent labor-delivery injury and death fell 16-32%. However, when no-fault claims were added to tort claims, total claims frequency rose by 11-38%. Annually, an estimated 479 children suffered birth-related injuries; however, only 13 were compensated under no-fault. Total combined payments to patients and all lawyers did not decrease, but of the total, a much larger portion went to patients. Compensation of patients after plaintiff lawyers' fees rose 4% or 44%, depending on the projection method used. Less than 3% of total payments went to lawyers under no-fault versus 39% under tort. CONCLUSION: Some claimants with birth-related injuries were winners, taking home a larger percentage of their awards than their tort counterparts. Lawyers clearly lost under no-fault. Because of the narrow statutory definition, many children with birth-related neurologic injuries did not qualify for coverage.

Satisfaction with obstetric care: relation to neonatal intensive care.

OBJECTIVE: To examine the relationship between admitting children to a neonatal intensive care unit (NICU) and mothers' satisfaction with obstetric care. METHODS: Mothers of live-born infants who are now normal were interviewed about their perceptions of the interpersonal, organizational, and technical care they and their babies received during pregnancy, delivery, and the neonatal period, and their and their infants' health. Comparisons between the responses of mothers whose babies were admitted to the normal nursery (n = 595) and those whose babies were sent to an NICU (n = 72) were made by chi2 analysis (1 df) and Wilcoxon rank sum tests. RESULTS: Mothers whose babies were admitted to an NICU were more likely to complain that their obstetricians did not explain things in terms they could understand (P < .05); did not give them the right amount of information about what to expect during pregnancy (P < .05); hid something from them before delivery (P < .001); did not explain the reasons for tests performed during delivery (P < .05); misled them about their child's prognosis (P < .001); failed to treat properly a problem during delivery (P < .05); and did not know the latest medical developments (P < .05). CONCLUSION: Even when children do well, admission of newborns to an NICU is associated with greater maternal dissatisfaction with obstetric care.

Pelvic organ prolapse and stress urinary incontinence.

Pelvic organ prolapse presents a wide array of distressing symptoms to the female patient. Stress urinary incontinence is often considered a normal phenomenon of aging and tolerated for years before seeking medical attention. A detailed history outlining specific complaints and a targeted pelvic examination can usually elucidate the anatomic problems responsible for producing symptoms. Nonsurgical therapy can be initiated, often with great improvement in symptoms. If the results are not satisfactory, the patient can be referred for further evaluation and possible surgical intervention.

Effects of the threat of medical malpractice litigation and other factors on birth outcomes.

Most major health reform proposals include reform of medical malpractice. A major objective of the current medical malpractice system is to improve quality of care. The authors examine the effect of variations in the threat of medical malpractice, measured by claims frequency and payments per exposure year, on various indicators of birth outcomes, fetal deaths, low Apgar score, death within 5 days of birth, infant death, and death or permanent impairment at 5 years of age. Data came from 2 sources: a Survey of Obstetrical Care of 963 women in Florida in 1992 who delivered 5 years previously; and a fetal death and a linked birth-death file obtained from Florida Vital Statistics for 1987. Among the outcomes considered, only fetal deaths decreased in response to an increased threat of being sued, and this relationship was only obtained from one of the data sets. Overall, no systematic improvement in birth outcomes in response to an increased threat of medical malpractice litigation was obtained.

Monitoring maternal mortality using vital records linkage.

We developed a method to identify maternal deaths (deaths to women within 365 days of delivery) by linking Tennessee vital records. A computerized algorithm compared personal identifiers from the death certificates of reproductive-aged women to maternal identifiers on birth and fetal death certificates. For each decedent record which met the study criteria, the algorithm calculated a "match score" by comparing common elements in both files. The algorithm awarded full credit for data elements that agree exactly, partial credit for elements in partial agreement, and subtracted credit for information that mismatched. Match scores ranged from 0 to 35 for the 9,009 deaths in women 10-55 years of age during the three study years, with the majority of scores (96.3%) being 0 for "no match." Match scores of 1 to 8 were obtained by 153 (1.7%) of decedent records, while scores greater than 9 were obtained by 184 (2.0%) of decedent records. We used nurse-abstracted hospital, autopsy, and coroner records as our standard to verify the linkages. Manual review of personal identifiers showed that scores of 12 or less were not a match while scores of 13 or more indicated "true" matches. Based on this cutoff, the linkage algorithm yielded 130 maternal deaths. Of these, 32 (25%) were classified as truly pregnancy-related upon medical record review by an obstetrician. The remaining 98 deaths were associated only temporally with pregnancy. During the same time period, 16 individuals were identified to the State Health Department on their death certificates as dying from pregnancy-related causes, including one not identified by the linkage process.(ABSTRACT TRUNCATED AT 250 WORDS)

Universal screening for group B streptococcus: recommendations and obstetricians' practice decisions.

OBJECTIVE: To determine how obstetricians' opinions regarding universal screening of pregnant women for group B streptococcus (GBS) and their responses to positive culture results vary from American Academy of Pediatrics recommendations, and to determine the physician characteristics that predict divergent opinions. METHODS: One hundred ninety-four practicing obstetricians in the middle Tennessee region were queried by a mail survey. They were asked if they agreed with universal screening for GBS and to indicate whether they would prescribe antibiotics for women in labor, represented by six scenarios that differed with respect to presence or absence of preterm labor, premature rupture of membranes (ROM), prolonged ROM, and a positive GBS cervical culture. They were also asked to describe their practice and personality characteristics. RESULTS: Completed surveys were returned by 135 of 194 obstetricians (70%). Although only 28% of the respondents agreed with routine prenatal screening for GBS, most (74%) said they would treat a patient on the basis of a positive culture alone. Other risk factors, when added to a positive culture, slightly increased the decision to treat (from 74 to 88%). Multiple logistic regression, used to assess the relative effect of clinical and physician characteristics on treatment decisions, revealed that chemoprophylaxis for GBS was predicted most strongly by a positive culture at 28 weeks' gestation followed by prolonged ROM and preterm labor. Practicing in an urban location and seeing fewer than 20 patients per day also influenced the decision to treat. CONCLUSION: Although most obstetricians in the middle Tennessee region do not believe in universal screening, most will prescribe intrapartum antibiotics on the basis of a positive screening culture. However, other clinical risk factors and physician characteristics significantly and independently affect the decision to treat as well.

Obstetricians' prior malpractice experience and patients' satisfaction with care.

OBJECTIVE: To examine the relationship between prior physician malpractice experience and patients' satisfaction with care. DESIGN: Women were interviewed using a questionnaire that contained structured and open-ended questions. PARTICIPANTS: Mothers of all stillborn infants, infant deaths, and a random sampling of viable infants drawn from 1987 Florida Vital Statistics were sorted into four groups based on the malpractice claims experience of their obstetricians between 1983 and 1986. Interviews were completed with 963 of 1536 women, most by telephone, 53 by in-person interview. MAIN OUTCOME MEASURES: Mothers' responses to closed-ended and open-ended questions about their perceptions of the care they received during their pregnancy, labor, and delivery. RESULTS: Even though none of the women actually filed a claim, a consistent pattern of differences emerged when comparing women's perceptions of care received. Patients seeing physicians with the most frequent numbers of claims but without high payments were significantly more likely to complain that they felt rushed, never received explanations for tests, and were ignored. In response to the open-ended question, "What part of your care were you least satisfied with?" women seeing physicians in the High Frequency malpractice risk group offered twice as many complaints as those seeing physicians who had never been sued. Problems with physician-patient communication were the most commonly offered complaints. CONCLUSION: Physicians who have been sued frequently are more often the objects of complaints about the interpersonal care they provide even by their patients who do not sue.

The relationship between malpractice claims history and subsequent obstetric care.

OBJECTIVE: To determine the relationship between prior malpractice claims experience and the quality of clinical obstetric care. DESIGN: Historical cohort study of obstetricians, classified by their prior malpractice claims experience, with blinded review of medical records from their practices 5 to 10 years later. SETTING: Florida obstetricians who lost, settled, or defended malpractice claims between 1977 and 1983 and who were still practicing obstetrics in 1987. MAIN OUTCOME MEASURES: Objective and subjective assessment of quality of clinical care of patients attended by obstetricians with different histories of malpractice claims. RESULTS: No differences were found in any of the objective or subjective measures of the quality of clinical care provided to patients of obstetricians who were classified into one of four groups according to their prior claims history. CONCLUSIONS: No relationship was found between prior malpractice claims experience and the technical quality of practice by Florida obstetricians. Strategies that attempt to identify physicians at risk for future clinical errors by using data on prior malpractice claims (such as the National Practitioner Data Bank) may be misjudging the likelihood that substandard clinical care will be provided by physicians with prior claims.

Antenatal care and intrapartum management.

Cost-effective care is an increasingly important issue in medicine. This will necessitate re-evaluating many aspects of antenatal and intrapartum care, including health-care delivery systems and routine surveillance techniques for uncommon events such as Down syndrome. It will demand justification for broadening indications for cesarean section by including fetal macrosomia and intensify the search for the causes of preterm labor. As new techniques are developed for intrapartum monitoring, such as fetal electrocardiography, fetal lactic acid levels, and near-infrared spectroscopy, they, too, will have to be determined to be cost-effective before attaining a role in clinical management.

Maternal recall and medical records: an examination of events during pregnancy, childbirth, and early infancy.

It is not currently known whether sufficiently precise data on a previous pregnancy, labor and delivery, and early infancy can be obtained retrospectively. We conducted a telephone survey in 1991 of women who delivered babies between 1984 and 1986 at two teaching hospitals in Nashville, Tennessee, to assess how well mothers recall information on factors predictive of an adverse birth outcome. The survey yielded 102 usable responses that were compared with hospital records for mothers and infants. Overall, 89 percent agreement was found between women's responses and their charts. Respondents were not reluctant to answer potentially sensitive questions, and their technical knowledge was typically better for their own health than about some prenatal diagnostic procedures and their infants' health. We found no difference in recall accuracy according to whether mothers experienced some adversity with the index pregnancy. Accurate perinatal information can generally be obtained with a recall period as high as four to six years.

A multicenter study of preterm birth weight and gestational age-specific neonatal mortality.

OBJECTIVE: This analysis was performed to present updated neonatal mortality data by age and birth weight for preterm newborns and to demonstrate the influence of plurality, ethnicity, and infant sex on mortality. STUDY DESIGN: Preterm birth weight and gestational age-specific mortality rates were compiled from the five centers that participated in the March of Dimes Multicenter Preterm Birth Prevention Project. In each center gestational age was assessed by standardized methods. A birth weight and gestational age-specific mortality chart for preterm births was created with live-birth data. RESULTS: In each birth weight group mortality decreased as the gestational age advanced; for each gestational age group heavier infants had less mortality. Female infants < 29 weeks survived better than male infants, and singletons < 29 weeks survived better than twins. Survival for black preterm newborns was better than that of whites but differences were not significant. Mortality for black term infants was significantly higher. The largest improvement in survival occurred between 25 and 26 weeks. At 30 weeks survival was > 90% and improved < 1% per week thereafter. CONCLUSIONS: When compared with rates in previous reports, mortality rates appear to have improved, especially at gestational ages < 29 weeks. These data may be useful in decision-making and in counseling patients at risk for preterm delivery.

Gonococcal peritonitis after tubal ligation. A case report.

Gonococcal peritonitis occurred after a tubal ligation. Falk's postulated benefit of cornual resection as a preventive measure for recurrent infection does not extend to isthmic interruption. Pelvic inflammatory disease should be considered when a sterilized woman presents with an acute abdomen.

PIP: Presented is the first case report of intraperitoneal Neisseria gonorrhoea infection after tubal ligation. The patient, a 34-year-old women who underwent bilateral tubal ligation 10 years prior to presentation, complained of right lower quadrant pain, fever, chills, anorexia, and constipation. Prior to sterilization, she had been treated at least 3 times for pelvic inflammatory disease (PID). Laparotomy revealed 200 mL of free pus in the abdominal cavity, induration of the proximal stump of the right fallopian tube, and a tuboperitoneal fistula. the intraperitoneal culture was positive for N gonorrhoea and pathology demonstrated acute salpingitis. Treatment with ampicillin, gentamicin, and clindamycin eliminated the infection, although uterine and adnexal tenderness persisted at the 6-week follow-up. Falk's postulate that cornual resection prevents reinfection with PID of the upper genital tract apparently cannot be extended to isthmic interruption of the lower and upper tracts. Since this case demonstrates that there can be ascending gonococcal infection in women with prior tubal sterilization, PID should be part of the differential diagnosis of all sterilized women who present with acute pelvic pain.

Transvaginal scanning of the endometrium.

Transvaginal sonography (TVS) can accurately depict the anteroposterior, width, and long axis of the endometrium. This article describes and illustrates normal and abnormal endometria as depicted by TVS.

Transvaginal sonography (TVS) of the endometrium: current and potential clinical applications.

This review has discussed and illustrated the numerous applications of TVS for the sonographic detection of the endometrium. Its major applications are in early pregnancy evaluation and in evaluation of patients with endometrial carcinoma. As more clinical experience with this technique is gained, more extensive application of this technique will undoubtedly come about.

Sonographic evaluation of maternal disorders during pregnancy.

This article has reviewed and illustrated the sonographic features of the most common pelvic masses that can be encountered in pregnant patients. Sonographic evaluation allows delineation of the size, consistency, and location of pelvic masses occurring during pregnancy. It has an important role in establishing the enlargement or regression of pelvic masses that occur during pregnancy. Sonography also has an important role in the diagnosis of cholecystitis and upper urinary tract obstruction and/or infections in the pregnant patient.

Umbilical artery velocimetry as a predictor of adverse outcome in pregnancies complicated by oligohydramnios.

Oligohydramnios is associated with increased perinatal mortality and morbidity. Traditional methods of in utero fetal evaluation have been unsuccessful in reliably distinguishing oligohydramnios with normal outcome from that associated with increased perinatal morbidity. A prospective study was undertaken to establish the predictive value of Doppler velocimetry in identifying the fetus with oligohydramnios at increased risk of adverse perinatal outcome. Twenty-two gravid women with subjective oligohydramnios on ultrasound had continuous-wave umbilical artery velocimetry. Subjects were divided into two groups based on the results of Doppler analysis. Group 1 (N = 13) had normal umbilical Doppler waveforms. In this group, 12 of 13 patients had normal perinatal outcome, defined by the absence of intrapartum fetal distress or evidence of intrauterine growth retardation. Group 2 consisted of nine subjects with abnormal waveforms. Perinatal morbidity occurred in 100% in this group. We conclude that an abnormal umbilical artery waveform may provide confirmatory evidence of impending fetal compromise when the antenatal sonographic diagnosis of oligohydramnios is made.