Obstetric Malpractice Research Articles

Obstetric hemorrhage and surgical emergencies training workshops on fresh cadavers and simulators result in high application in daily practices and decreased patient referral.

Objective:In this study, we aimed to evaluate the effects of obstetric emergencies workshops combining theoretical lectures, simulation trainers and fresh cadaver models on daily practices and referrals of obstetrics and gynecology specialists.Materials and Methods:This is a prospective observational study involving obstetrics and gynecology specialists attending the Turkish Society of Obstetrics and Gynecology endorsed obstetrics hemorrhage management courses held in 2018 and 2019. The training course is an annually organized two-day course, one day allotted to theoretical lectures and the other day to practical training on both simulators and fresh cadavers. Trainees participating in the course was surveyed with an anonymous questionnaire on their motivation to attend the course and their juridical history of obstetric patient management. Attendees were asked to disclose whether they had ever independently performed the procedures stated in the questionnaire or not, before commencing the course and 1 year after attending the course.Results:Among the attendees 22% (n=32) had at least one obstetrical malpractice lawsuit and 36.1% (n=52) were accused of Health Care Complaints Comission. The main motivation of the attendees for taking this course was Professional development followed by reducing maternal mortality and morbidity and avoiding malpractice. One year after the course, attendees applying uterine devascularization surgery increased by 36.1% (52/144), uterine compression sutures increased by 52.7% (76/144), and ability to apply uterine balloon tamponade increased by 59.7% (86/144). Besides improvement in other obstetric surgical skills an indirect effect seen that the attandees operated on high-risk cases increased in placenta previa (15.3%), placenta acreata spectrum (30.5%), operative deliveries (27.7%), peripartum hysterectomy (24.9%) and relaparotomy for postpartum hemorrhage (34.7%).Conclusion:Opportunities of attending well organized fresh cadaveric workshops on managing postpartum hemorrhage and other obstetric surgeries, can quickly adapt to daily practice, restore the professional confidence of obstetric and gynecology specialists, and eventually decrease patient referral.

Effectiveness of the Educational Program Concerning Nurse- Midwives SBAR Tool Communication on Maternal Health Documentation at Maternal wards in Baghdad Maternity Hospitals

Background: Obstetrics is one of the most common specialties to encounter malpractice claims. Some of the obstetric malpractice claims are related to poor nurse –midwives obstetric communications. The Situation, Background, Assessment and Recommendation (SBAR) model has been suggested as a channel to facilitate effective communication between healthcare professionals, developed for health care. Objective: To assess the effect of SBAR (Situation, Background, Assessment, and Recommendation) on maternal health report documentation accuracy. To determine the effect of adopting SBAR practice and communication tool in emergency and delivery settings. To find out the differences in the practice and communication of nurse –midwives before and after SBAR implementation. To develop a script paper based on SBAR tool for nurse –midwives. To assess the relationship between of self-assessment and researcher evaluation of maternal scenario application competency of nurse-midwives using SBAR tool. Method: A quasi-experimental design was carried out with the application of pre- posttest for nurses-midwives’ knowledge regarding SBAR communication tool. The study is held in Al-Elwia maternity teaching hospital, Al –Karkh maternity hospital and Al-Yarmouk general teaching Hospital from 26/3/2017-to- 30/4/2018. The study aims to assess the Educational Program concerning Nurse- Midwives SBAR Tool Communication on Maternal Health Documentation at Maternal wards in Baghdad Maternity Hospitals and to assess the relationship between self-assessment and researcher evaluation of maternal scenario application competency of nurse-midwives using SBAR tool applying during fit time. The study sample consist of Non-probability (purposive) sample consisted of (84) nurse- midwives. The questionnaire comprised of demographic data, nurses- midwives knowledge of SBAR using (3) level Likert scale for assessment, with Cut –off point (2). Content validity was determined through (21) experts. ...............

Malpractice litigation, quality improvement, and the University Hospitals Obstetric Quality Network

Objective A healthcare organization’s medical malpractice data can help identify patient safety risks and drive improvement. In most organizations, obstetric malpractice losses are assumed to be part of the risk of delivering obstetric care. We describe a systematic approach to mitigating risks for obstetric patients and their newborns while simultaneously improving patient outcomes and reducing obstetric litigation costs at University Hospitals, a northeast Ohio-based health system of 18 hospitals, including seven hospitals providing obstetric services and delivering approximately 8000 women per year. Methods From multiple data sources, including malpractice claims data, the team identified four key drivers of risk on the obstetric service: hypoxic ischemic encephalopathy, obstetric hemorrhage, hypertensive disorders of pregnancy, and shoulder dystocia. Collectively, these contributed to multiple adverse maternal and neonatal outcomes and accounted for 71% of obstetric litigation costs from 2009 to 2015. In response, the team built a regional obstetric quality network and implemented interventions to mitigate the four major risk areas. Results We achieved a substantial reduction in serious safety events from 2010 to 2018, defined as any event where the standard of care was not met and the level of harm to mother or baby was one (death) or two (severe permanent or temporary harm). We also achieved a reduction in obstetric litigation costs between 2009–2012 and 2015–2018. Discussion This multifaceted intervention was associated with decreased patient harm and reduced obstetric litigation costs. Application of this approach to other hospitals could result in improvements in obstetric patient safety and reduced obstetric litigation costs.

Episiotomy: an informed consent proposal

Purpose Since every obstetric surgical procedure requires gaining informed consent from patient, we have set out to evaluate whether such requirement also applies to episiotomy. Material and methods To that end, we have conducted a thorough search of relevant scientific literature on multidisciplinary databases (Scopus, PubMed, PubMed, Central, Research Gate, Google Scholar) and articles that were published from 1989 to March 2019. The search keys used were: “episiotomy,” “informed consent,” “complications,” “malpractice.” Results The sources that we have ultimately drawn upon, whilst acknowledging the need for a targeted informed consent for episiotomy, do not deal with the specifics of what such consent should include, in terms of information provided and related aspects. Therefore, the authors have laid out an episiotomy-targeted consent form, drawing upon opinions and indications from scientific societies and institutions, in order to properly reflect and document the patient’s acceptance or refusal of the procedure. Conclusions Valid consent documentation may well prove instrumental in staving off or reducing complications, malpractice and liability, and in order to safeguard health care operators from obstetric malpractice allegations.

Obstetric and gynecologic malpractice claims in Saudi Arabia: Incidence and cause

IntroductionThe occurrence of a bad outcome, injury or death of a patient during treatment increases the chance of malpractice litigation, increases legal responsibility and leads to increased fees for malpractice insurance. Physicians practicing obstetrics and gynecology face among the highest risks of malpractice litigation, and such litigation has led to an increase in the practice of defensive medicine and has made this specialty less appealing. Previous clinical data from Saudi Arabia have shown that more malpractice litigation concerns claims in obstetrics and gynecology than claims in any other field of medicine. ObjectiveTo identify the main causes of obstetrics and gynecology (OBGYN) professional liability claims in Saudi Arabia to have a better understanding and management of risks. MethodsAll OBGYN claims opened in Saudi Arabia between 2008 and 2013 were analyzed to identify the most common causes of claims. The results of these claims and the times until a final judgment made were also analyzed. ResultsOut of a total of 463 malpractice claims that were closed during the study period, 114 (24.6%) claims were in obstetrics and gynecology, and 92 (80.7%) of these claims concerned complications related to delivery room events. The most common causes of obstetric malpractice litigation were shoulder dystocia (brachial plexus injury) and fetal distress (hypoxic ischemic encephalopathy). Urinary system injury was the most common cause of gynecology cases. Most cases were decided in favor of the defendants with the exception of cases for which maternal and/or fetal death was the cause of litigation; nearly all of those cases were decided against the defendants. ConclusionObstetricians face a high risk of malpractice claims in Saudi Arabia, although most claims do not end in payments to plaintiffs. However, the effects of such claims on obstetric care should not be underestimated. Adherence to standards of care and careful documentation may decrease litigation and the number of indefensible malpractice claims.

Supreme Court Brief of Amici Curiae on Petition for Writ of Certiorari in Support of Petitioner, Ortiz v. U.S. ex rel. Evans Army Community Hospital, No. 15-488 (Nov. 17, 2015)

This is an amicus brief urging the Supreme Court to hear the case of U.S. Air Force Major Heather Ortiz and her baby, who were denied legal remedies for obstetric malpractice by military doctors that left the baby with severe brain damage. The case is No. 15-488, Ortiz v. U.S. ex rel. Evans Army Community Hospital. Professors Fox and Stein urge the Court to overturn the Tenth Circuit’s holding that the federal government’s immunity against liability for intramilitary torts extends to wrongful injuries like those sustained by Major Ortiz’s baby. They argue that this holding misinterprets the immunity, misapplies the Federal Tort Claims Act (FTCA), and constitutes no less than unconstitutional sex discrimination. Fox and Stein explain:"When a civilian spouse of a serviceman receives negligent prenatal care from military doctors and delivers an injured baby as a result of that malpractice, there is no question that Feres immunity does not apply and that the baby can sue the United States under the FTCA. When military medical malpractice injures the baby of a servicewoman, this baby should be equally able to obtain redress under the FTCA. A system that would single out the civilian children of servicewomen for adverse treatment discriminates against women who serve in the armed forces.... To interpret the FTCA as the Tenth Circuit did permits discrimination between these two classes of similarly situated victims of military malpractice and violates fundamental principles of equal protection."

The causes and implications of obstetric malpractice

<p>Obstetrics and Gynaecology (O & G) are among the specialties at high risk of malpractice claims. In particular, obstetric malpractice attracts high incidence of claims as birth injuries are usually serious and devastating. The resulting disabilities and malformation from the injuries tend to be life-long and victims are deprived of years of enjoyment in life, independence and productivity. As these injuries occur on the victims early in life, the costs of medical care are usually enormous. As this imposes stressful and heavy burden on the family members, they tend to resort to litigation as means of procuring monetary compensation. The highest numbers of medical negligence cases in Malaysia involve obstetric injuries and six to seven-figure court awards are now becoming the trend for compensating obstetric malpractice victims. However, proving obstetric malpractice is not an easy task with years of litigation, which eventually may not provide victims with monetary compensation if unsuccessful. Further, the increase in obstetric litigation has triggered higher premium for medical indemnity insurance causing many doctors to leave the subspecialty. Even though the doctor at the end may not be found guilty but the trauma of being sued caused them to suffer difficulties in returning to their work.</p>

Tribute to a great obstetrician: in memory of Ingemar Ingemarsson.

Ingemar Ingemarsson, grew up in a rural area in Smaland in the southern part of Sweden. He studied and graduated at the Medical Faculty at Lund University and started his career in obstetrics and gynecology in 1972 at the University Hospital in Lund. He defended his PhD thesis in 1975, was appointed consultant and later became Head of the Department and Professor in Obstetrics at Lund University. In 1997 the Royal College of Obstetricians and Gynaecologists acknowledged Ingemar Ingemarsson's contributions to our speciality and honored him by the "Fellow ad eundum" award; one of seven Swedish obstetricians and gynecologists to be given that honor. This article is protected by copyright. All rights reserved.

Litigation in obstetrics: does defensive medicine contribute to increases in cesarean delivery?

Objective: Obstetrics is one of the most sued subspecialties in the US. This study aimed to examine clinicians’ medical-legal experience and its association with recommending cesarean delivery.Design: Cross-sectional convenience survey.Population or sample: This is a survey study of clinicians in the US.Methods: Survey included eight common obstetric clinical vignettes and 27 questions regarding clinicians’ practice environment. Chi-square test, multivariable logistic regression models were used for statistical comparisons.Main outcome measures: Likelihood of recommending cesarean delivery.Results: There were 1486 clinicians who completed the survey. Clinicians were categorized based on answers to clinical vignettes. Having had lawsuits and daily worry of suits were associated with higher likelihood of recommending cesarean, compared to those without lawsuits (17.2 versus 11.3%, respectively; p = 0.008) as was frequent worry of lawsuits (every day, 20.3% more likely; every week/month, 12.3%; few times a year/never, 11.4%, p < 0.001).Conclusion: Obstetric malpractice lawsuit and frequent worry about lawsuit are associated with higher propensity of recommending cesarean delivery in common obstetric settings.

Is the term “obstetrical brachial plexus palsy” obsolete? An international survey to assess consensus among peripheral nerve surgeons

Brachial plexus injury diagnosed following delivery often causes lifelong disability and frequently results in litigation. While there is no universally accepted name for this condition, the term 'obstetrical brachial plexus palsy' (OBPP) is commonly used worldwide. The difficulty with the term 'OBPP' lies with the use of the word 'obstetrical', which some have construed to imply obstetrical malpractice even if none occurred. Many regions, especially in the United States, are suffering increasing obstetrician shortages, sometimes as a result of unsustainable liability insurance premiums. We wanted to determine whether surgeons felt that an alternative to the term 'OBPP' was more appropriate. We surveyed peripheral nerve surgeons worldwide to determine the appropriateness of the term 'OBPP' and alternative terms. The majority of US-based surgeons (94%) preferred alternative terms, such as 'neonatal brachial plexus palsy'. However, only 53% of surgeons from other regions preferred alternative terms. This difference was statistically significant (p < 0.0002). More precise and descriptive alternatives to the term 'OBPP' are available and acceptable to many surgeons. An alternative to 'OBPP' may improve communication between practitioners, families and the legal system, especially in the United States. Our peripheral nerve organisations may be able to provide further leadership on this matter.

Placenta: A silent witness: Clinical and forensic importance of placental examination

There is no doubt that obstetrics carries high medical liability risk. In many countries, gynecologists-obstetricians who attend childbirths and perform complex obstetric procedures are faced with increasing malpractice insurance premiums and litigation risk. The american College of Obstetricians and Gynecologists (aCOG) publishes its survey of Professional Liability since 1983, with the objective to analyze the effect that malpractice litigation has had on the practice of obstetrics and gynecology in the United states1. according to the 2003 aCOG survey, 76.3% of the members who answered the questionnaire have been involved in a lawsuit at least once in their professional career; gynecologists/obstetricians have been sued a total of 2.64 times per individual over the course of their careers1,2. In the 2006 aCOG survey, 89% of respondents indicated that they had been sued during their careers. The average number of claims per obstetrician was 2.6 (3). The aCOG’s 2009 survey on Professional Liability showed that nearly 91% of gynecologists/obstetricians had experienced at least one liability claim filed against them during their professional careers, with an average of 2.69 claims per physician. In 2009, 62% percent of the total reported claims were for obstetric care as opposed to gynecology, the same as in the 2006 survey3,4. In the 2003 aCOG survey, fetal monitoring, neurologically impaired children, neonatal death, shoulder dystocia, uterine rupture, and “decision-to-incision” time were identified as clinical factors frequently present in obstetric malpractice cases1. In both 2006 and 2009 surveys the reasons for claim were neurologically impaired infant (in 31% of cases in both surveys), stillbirth/neonatal death (with 16 % of cases in both surveys), and delay or failure in diagnosis (in 11% of cases in 2009 vs. 14% in 2006)3,4. In all the surveys, neurological impair is the leading cause of the reasons for liability claim, with the cerebral palsy being the most serious damage. The possible etiologies have been discussed for years, and although the damage to neural tissue is undebatable, there is still no agreement upon the timing of the damage. some authors think that 90% of the cases of cerebral palsy are not due to intrapartum events, while in the opinion of others most of the devastating events occurred in the perinatal period5,6. It is still impossible to firmly determine in each single case whether the hypoxic insult has developed during delivery, in the first few hours after birth, or was already present before the labor began, as a consequence of long lasting hypoxia during pregnancy. Careful gross and histopathological examination of the placenta in chosen cases can elucidate the events that occurred some time before labor, and help to connect and reconstruct the course of disease7,8.

Evaluation and impact of cardiotocography training programmes: a systematic review

The interpretation and management of cardiotocography (CTG) tracings are often criticised in obstetric malpractice cases. As a consequence, regular CTG training has been recommended, even though little is known about the effect of CTG training. To perform a systematic review of the existing literature on studies on CTG training in order to assess educational strategies, evaluation of training programmes, and impact of training programmes. The Medline database was searched to identify studies describing and/or evaluating CTG training programmes. The literature search resulted in 409 citations. Twenty studies describing and evaluating CTG training programmes were included. There was no restriction on study design. Data regarding study design, study quality, educational strategies used for training in CTG interpretation and decision making, target groups, number of participants, methods used for evaluation, quality of evaluation, level of evaluation and results of training was extracted from 20 articles, and analysed using Kirkpatrick's four-level model for the evaluation of education. Training was associated with improvements on all Kirkpatrick levels, resulting in increased CTG knowledge and interpretive skills, higher interobserver agreement, better management of intrapartum CTG, and improved quality of care. Computer-based training (CBT) might be less time-consuming than classroom teaching. Clinical skills seem to decrease faster than theoretical knowledge. Training can improve CTG competence and clinical practise. Further research on CBT, test-enhanced learning and long-term retention, evaluation of training and impact on clinical outcomes is recommended.

Editor’s Choice

Editor’s Choice

IMOC et justice. Les limites à ne pas dépasser (à propos des discussions sur l’imputation d’une IMOC à une hypoxie intrapartum)

If most of the Cerebral Palsy (CP) are bound to diverse antepartum pathologies, it appears nevertheless that a percentage, of the order of 20 %, is bound directly and exclusively to acute accidents (uterine rupture, placental abruption, cord accidents, etc.) or to medical faults (bad practices) committed by the obstetric team during childbirth. Furthermore, this “official” percentage concerns only the severe forms of the CP, pathology the spectrum of which we know better, now. In front of the inflation of obstetrical malpractice claims, a consensus was established around the criteria defined, in 1999, then in 2003, by the “International Task Force on Cerebral Palsy” clustering main American professionals’ syndicates. Literally applied, these criteria allow certain experts and/or certain insurances’ lawyers to eliminate any intrapartum cause of CP. The suggestion of a pathological antenatal cause becomes too often an automatic reflex of the defense. This unbearable situation for the victims launched a strong counter-attack of their defenders. Some recent court cases compel us to ring the alarm bell and to remind firmly that there are ethical limits not to be transgressed so that the financial component do not dominate the debates, to the detriment of the truth of the obstetrical facts and the just compensation of the victims.

Reducing Obstetric Litigation Through Alterations in Practice Patterns

OBJECTIVE: To estimate the extent to which obstetric malpractice claims might be reduced by adherence to a limited number of specific practice patterns. METHODS: We examined all 189 closed perinatal claims between 2000 and 2005 from a single, large, professional liability insurer. Each case was subjected to three separate analyses: 1) whether the adverse outcome was caused by substandard care, 2) what changes in practice likely would have avoided the adverse outcome, regardless of standard-of-care considerations, and 3) to what extent did substandard documentation lead to payment in cases in which there was no objective evidence of substandard care. RESULTS: Seventy percent of claims involving obstetric practice (accounting for 79% of all costs) involved substandard care. Payments in 85% of cases involving non-vaginal birth after cesarean (VBAC) fetal monitoring, 16% of maternal injury cases, 80% of cases involving VBAC, and 54% of shoulder dystocia cases were avoidable had four specific practice and documentation patterns been followed. CONCLUSION: Most money currently paid in conjunction with obstetric malpractice cases is a result of actual substandard care resulting in preventable injury. Well more than half of hospital litigation costs might be avoided if physician practice included: 1) delivery in a facility with 24-hour in-house obstetric coverage; 2) adherence to published high-risk medication protocols; 3) a more conservative approach to VBAC; and 4) use of a comprehensive, standardized procedure note in cases of shoulder dystocia.

Obstetricians' Rising Liability Insurance Premiums and Inductions at Late Preterm Gestations

To estimate the association between professional liability insurance premiums for obstetricians and late preterm induction (LPI) rates. Data from the National Center for Health Statistics were used to identify all Illinois women pregnant with singletons at 34 weeks' gestation from 1991 to 2003. The independent association between LPI (induction between 34 and 37 weeks' gestation) rates and the previous year's obstetric malpractice insurance premiums was evaluated using linear regression. The mean annual LPI rate (5.4/1000 in 1991 to 15.2/1000 in 2003, P < 0.001) nearly tripled, and obstetricians' professional liability insurance premiums ($55,480 to $110,613, P < 0.001) approximately doubled. After adjusting for race, previous cesarean delivery, marital status, and the presence of antepartum risk factors for indicated preterm delivery, LPI rates increased by 1/1000 births (P = 0.004) for each annual $10,000 increase in the county's obstetric malpractice insurance premium. Rising premiums are associated with increased frequency of LPI among women with singleton gestations.

Reducing Obstetric Litigation Through Alterations in Practice Patterns

To estimate the extent to which obstetric malpractice claims might be reduced by adherence to a limited number of specific practice patterns. We examined all 189 closed perinatal claims between 2000 and 2005 from a single, large, professional liability insurer. Each case was subjected to three separate analyses: 1) whether the adverse outcome was caused by substandard care, 2) what changes in practice likely would have avoided the adverse outcome, regardless of standard-of-care considerations, and 3) to what extent did substandard documentation lead to payment in cases in which there was no objective evidence of substandard care. Seventy percent of claims involving obstetric practice (accounting for 79% of all costs) involved substandard care. Payments in 85% of cases involving non-vaginal birth after cesarean (VBAC) fetal monitoring, 16% of maternal injury cases, 80% of cases involving VBAC, and 54% of shoulder dystocia cases were avoidable had four specific practice and documentation patterns been followed. Most money currently paid in conjunction with obstetric malpractice cases is a result of actual substandard care resulting in preventable injury. Well more than half of hospital litigation costs might be avoided if physician practice included: 1) delivery in a facility with 24-hour in-house obstetric coverage; 2) adherence to published high-risk medication protocols; 3) a more conservative approach to VBAC; and 4) use of a comprehensive, standardized procedure note in cases of shoulder dystocia. III.

Obstetric Simulation as a Risk Control Strategy

Patient safety initiatives aimed at reducing medical errors and adverse events are being implemented in Obstetrics. The Controlled Risk Insurance Company (CRICO), Risk Management Foundation (RMF) of the Harvard Medical Institutions pursued simulation as an anesthesia risk control strategy. Encouraged by their success, CRICO/RMF promoted simulation-based team training as a risk control strategy for obstetrical providers. We describe the development, implementation, and evaluation of an obstetric simulation-based team training course grounded in crisis resource management (CRM) principles. We pursued systematic design of course development, implementation, and evaluation in 3 phases, including a 1-year or more posttraining follow-up with self-assessment questionnaires. The course was highly rated overall by participants immediately after the course and 1-year or more after the course. Most survey responders reported having experienced a critical clinical event since the course and that various aspects of their teamwork had significantly or somewhat improved as a result of the course. Most (86%) reported CRM principles as useful for obstetric faculty and most (59%) recommended repeating the simulation course every 2 years. A simulation-based team-training course for obstetric clinicians was developed and is a central component of CRICO/RMF's obstetric risk management incentive program that provides a 10% reduction in annual obstetrical malpractice premiums. The course was highly regarded immediately and 1 year or more after completing the course. Most survey responders reported improved teamwork and communication in managing a critical obstetric event in the interval since taking the course. Simulation-based CRM training can serve as a strategy for mitigating adverse perinatal events.

Analysis of malpractice claims with a focus on oxytocin use in labour

The objective of this study was to analyse the motives behind disciplinary action in obstetric malpractice cases concerning delivery, and to evaluate the frequency of inappropriate oxytocin use in these cases. An analysis of all malpractice claims resulting in disciplinary action against physicians and midwives during the period 1996-2003. Investigations and decisions made by the Board of Medical Responsibility were reviewed with special focus on the use of oxytocin. Of 77 cases, 60 regarded patients in labour. In the majority, there had been a normal pregnancy and spontaneous start of labour (78%). At the beginning of labour, 87% showed a normal fetal heart rate (FHR) pattern, indicating fetal well-being. In 70%, there was adverse fetal outcome with brain damage or death. The most common reason for disciplinary action was improper interpretation of fetal monitor tracings and corresponding failure to recognise fetal distress (76%). Injudicious use of oxytocin was common (68.5%), and was the primary reason for disciplinary action in 33% of the cases. In a Swedish setting, a few common clinical problems pervade; interpretation of FHR patterns and the use of oxytocin account for the majority of rulings of negligence in malpractice cases regarding delivery. Analysis of the cases suggests that the adverse fetal outcomes could possibly have been prevented.

Reducing obstetric litigation through alterations in practice patterns - experience with 189 closed claims

PATTERNS EXPERIENCE WITH 189 CLOSED CLAIMS STEVEN CLARK, MICHAEL BELFORT, GARY DILDY, Hospital Corporation of America, Nashville, Tennessee OBJECTIVE: To determine to what extent obstetric malpractice claims might be reduced by adherence to a limited number of practice patterns. STUDY DESIGN: We examined all 189 closed perinatal claims between 20002005 in a large healthcare delivery system. Substandard care was defined as practice at odds with published ACOG guidelines, or judgment to this effect by a treating health care provider or defense consultant. RESULTS: 61% of obstetric cases (accounting for 79% of all costs) involved substandard care. 23% of cases involving non-VBAC fetal monitoring, (14% of total litigation costs) were avoidable had an obstetrician been continuously in-house. 45% of such cases (27% of total cost) and 16% of maternal injury cases (3% of total cost) were avoidable had the health care providers followed available, checklist-driven protocols for administration of oxytocin, misoprostol and MgSO4 An additional 17% of fetal monitoring cases (10% total costs) were avoidable with either of the above. 80% of cases involving VBAC (5% of total cost) were avoidable had this procedure been limited to spontaneous labors progressing without augmentation and absence of repetitive moderate/ severe variable decelerations. 54% of shoulder dystocia cases (4% of all costs) were avoidable had documentation been complete and consistent. CONCLUSION: Obstetric claims appear less likely to involve actual substandard care than general medical claims. Well over half of hospital litigation costs might be avoided if physician practice included: 1. Practice in a facility with 24 hour in house obstetric coverage, 2. Adherence to existing medication protocols. 3. A more conservative approach to VBAC. 4. Use of a comprehensive, standardized procedure note in cases of shoulder dystocia,. Malpractice insurance might be offered at a fraction of the current cost for most physicians who abide by these 4 practice patterns.