David M. Jaspan, DO

In the upcoming issue of Annals of Internal Medicine, there are two articles that highlight highly unprofessional and unethical behavior by physicians toward their female patients. I have read “Our Family Secrets” and “On Being a Doctor: Shining a Light in the Dark Side” multiple times and shared the stories with ob.gyn. residents, faculty, and medical students (Ann Intern Med. 2015 doi: 10.7326/M14-2168; doi: 10.7326/M15-1144). Thus, you may say that the mission of opening a dialogue on professionalism was accomplished.

My initial reactions remain unchanged. I am offended that the authors chose the pathway of shock value to illicit a visceral response. Though there is merit in the conversation, publishing two stories from the field of obstetrics and gynecology is irresponsible and inflammatory. I am certain that the editors could have taken additional time to identify similar stories from other fields that would have led to the same response.

Further, I would have expected the article to include the fact that those in women’s health are caring, compassionate, and empathic providers, and these examples represent extreme actions. No one in the field of women’s health would find these behaviors acceptable. To paint the field of obstetrics and gynecology with a broad stroke breaks down the relationship that we seek to foster with our internal medicine colleagues. Publishing such stories in Annals without seeking comment from the ob.gyn. community feels as if someone is talking behind my back.

I cannot stare at my pen and maintain my silence. I feel the need to take on the role of the ”anesthesiologist” portrayed in “Our Family Secrets” and respectfully request that we collaborate as professionals to create a culture of mutual respect, accountability, and understanding. The understanding that doctors are human, and that sometimes the stress of the responsibility provokes behavior that we would like to be forgiven for.

We should continue to work toward creating a medical community where such behaviors are never tolerated and medical students, nurses, residents, and colleagues feel safe to immediately put an end to all disrespectful actions.

I applaud Annals for addressing professionalism, respect, and personal accountability. Certainly, we should all strive to be better.

Dr. Jaspan is chairman of the department of obstetrics and gynecology, chief of gynecology, director of minimally invasive and pelvic surgery, and associate residency program director at the Einstein Medical Center in Philadelphia. He is an associate professor of obstetrics and gynecology at the Thomas Jefferson University, also in Philadelphia.

In the upcoming issue of Annals of Internal Medicine, there are two articles that highlight highly unprofessional and unethical behavior by physicians toward their female patients. I have read “Our Family Secrets” and “On Being a Doctor: Shining a Light in the Dark Side” multiple times and shared the stories with ob.gyn. residents, faculty, and medical students (Ann Intern Med. 2015 doi: 10.7326/M14-2168; doi: 10.7326/M15-1144). Thus, you may say that the mission of opening a dialogue on professionalism was accomplished.

My initial reactions remain unchanged. I am offended that the authors chose the pathway of shock value to illicit a visceral response. Though there is merit in the conversation, publishing two stories from the field of obstetrics and gynecology is irresponsible and inflammatory. I am certain that the editors could have taken additional time to identify similar stories from other fields that would have led to the same response.

Further, I would have expected the article to include the fact that those in women’s health are caring, compassionate, and empathic providers, and these examples represent extreme actions. No one in the field of women’s health would find these behaviors acceptable. To paint the field of obstetrics and gynecology with a broad stroke breaks down the relationship that we seek to foster with our internal medicine colleagues. Publishing such stories in Annals without seeking comment from the ob.gyn. community feels as if someone is talking behind my back.

I cannot stare at my pen and maintain my silence. I feel the need to take on the role of the ”anesthesiologist” portrayed in “Our Family Secrets” and respectfully request that we collaborate as professionals to create a culture of mutual respect, accountability, and understanding. The understanding that doctors are human, and that sometimes the stress of the responsibility provokes behavior that we would like to be forgiven for.

We should continue to work toward creating a medical community where such behaviors are never tolerated and medical students, nurses, residents, and colleagues feel safe to immediately put an end to all disrespectful actions.

I applaud Annals for addressing professionalism, respect, and personal accountability. Certainly, we should all strive to be better.

Dr. Jaspan is chairman of the department of obstetrics and gynecology, chief of gynecology, director of minimally invasive and pelvic surgery, and associate residency program director at the Einstein Medical Center in Philadelphia. He is an associate professor of obstetrics and gynecology at the Thomas Jefferson University, also in Philadelphia.

In the upcoming issue of Annals of Internal Medicine, there are two articles that highlight highly unprofessional and unethical behavior by physicians toward their female patients. I have read “Our Family Secrets” and “On Being a Doctor: Shining a Light in the Dark Side” multiple times and shared the stories with ob.gyn. residents, faculty, and medical students (Ann Intern Med. 2015 doi: 10.7326/M14-2168; doi: 10.7326/M15-1144). Thus, you may say that the mission of opening a dialogue on professionalism was accomplished.

My initial reactions remain unchanged. I am offended that the authors chose the pathway of shock value to illicit a visceral response. Though there is merit in the conversation, publishing two stories from the field of obstetrics and gynecology is irresponsible and inflammatory. I am certain that the editors could have taken additional time to identify similar stories from other fields that would have led to the same response.

Further, I would have expected the article to include the fact that those in women’s health are caring, compassionate, and empathic providers, and these examples represent extreme actions. No one in the field of women’s health would find these behaviors acceptable. To paint the field of obstetrics and gynecology with a broad stroke breaks down the relationship that we seek to foster with our internal medicine colleagues. Publishing such stories in Annals without seeking comment from the ob.gyn. community feels as if someone is talking behind my back.

I cannot stare at my pen and maintain my silence. I feel the need to take on the role of the ”anesthesiologist” portrayed in “Our Family Secrets” and respectfully request that we collaborate as professionals to create a culture of mutual respect, accountability, and understanding. The understanding that doctors are human, and that sometimes the stress of the responsibility provokes behavior that we would like to be forgiven for.

We should continue to work toward creating a medical community where such behaviors are never tolerated and medical students, nurses, residents, and colleagues feel safe to immediately put an end to all disrespectful actions.

I applaud Annals for addressing professionalism, respect, and personal accountability. Certainly, we should all strive to be better.

Dr. Jaspan is chairman of the department of obstetrics and gynecology, chief of gynecology, director of minimally invasive and pelvic surgery, and associate residency program director at the Einstein Medical Center in Philadelphia. He is an associate professor of obstetrics and gynecology at the Thomas Jefferson University, also in Philadelphia.

You open the chart, and you read the chief complaint. Like so many other charts, you see the words, "annual exam," but something catches your eye; her date of birth – "that can’t be right"– but before you can do the math, the number stares back at you – 14 years old. The last name may or may not look familiar – she could be the daughter of one your patients – nonetheless you are about to come to face to face with a 14-year-old patient. How you handle this interaction will forever be remembered by this young girl.

At this moment, I make a calculated decision on how I will proceed. Will I stand? Should I sit? What if she is so nervous she is standing, not sitting in the chair or on the table? I refocus on what is required for an adolescent visit? Does she need an exam? Will her mother or family member be in the room?

I have found that by asking questions and expecting a one-word answer, I am prepared to move the visit along. "What can I do for you today?" This is usually met with an expressionless face and a shoulder shrug. I generally follow that with, "Did someone tell you to come here today?" If you’re lucky, you may get a verbal response, but commonly, you will get the affirmative head nod. I view this as a breakthrough. Now I try to pry, "Are you having a problem?" Again a head nod is success. Once I understand that she is there for a problem, I find that leading questions that use the "embarrassing words" make it easier for the patient to communicate. She may not want to say the word vagina or sex, so take the opportunity to say it for her.

If she is there for an "annual exam," imagine her relief when you tell her she does not need to be examined. In fact, she will not need a Pap smear until she is 21 (soon to be changed to 25). With the ice now broken and a relieved patient before you, this is the golden moment. This is the moment that I use to educate. A speculum is no longer threatening. She is now relaxed that this thing will not be used on her, and she can now listen. While holding the small narrow speculum, I say, "This is not a clamp because clamps close and a speculum is used to open." I hold the speculum in my right hand and then make a loose fist with my left hand. I place the lower lip of the speculum against my left thumb, and say, "This is what your cervix looks like, and this is as far as the speculum must be opened." I then ask her to make a fist. I hold the speculum again her hand, and I use the cytobrush and cotton swab inside her hand Then I ask, "Did that hurt?" Of course, the response is no. I will say that there are many more pain sensors on your hand than in the vagina, but the vaginal exam is embarrassing.

Once I have done this, I use a module or pictures to show her the vagina, cervix, uterus, and ovaries. This pictorial provides a visual of what the pelvic exam is intended to do.

I then show her the stirrups and say, "You can put your heels here, and then slide your bottom to the end of the table, and then we will then use the speculum. When the speculum is placed, you will feel pressure toward your bottom. If you allow your knees to fall out to the side, the exam can be over very quickly. Once we are finished with the speculum, one finger is placed inside the vagina to check your cervix, uterus, and ovaries. That’s it."

"My promise to you is that if you are ever uncomfortable, you just say stop and the exam will stop. It is much more important to me that you feel safe here in this office. It took a great deal of courage to even walk in the door today, you can always reschedule."

The new American College of Obstetricians and Gynecologists (ACOG) guidelines do not recommend a pelvic exam until the age of 21, at the time of the first PAP smear. However, the more knowledge we can provide to our adolescent patients, the less fear they may have when the time does arrive for their first exam.

 

ACOG recommends that a young woman’s first visit to an ob.gyn. occur between the ages of 13 and 15 years old. This first visit should address health guidance, screening, and preventative health services. It is important to tell your patient that your discussions and exam will remain confidential. An internal exam is not necessary unless the patient is having a specific complaint. More importantly, this visit serves to establish rapport and trust between patient and doctor. This patient will be more likely to disclose important information about her health on future visits.

Initial and subsequent annual exams should include the following, according the recommendations:

• Vital signs including evaluation of menstrual cycle. This emphasizes the role of menstrual cycles in overall health status.

• Body mass index, which allows the opportunity to discuss dietary management.

• A discussion of normal adolescent development.

• A general physical exam should be performed at least once during early adolescence (12-14 years), middle adolescence (15-17 years), and late adolescence (18-21 years), but is not required at every visit.

• A pelvic exam is not required unless the patient is symptomatic.

• An evaluation of breast development.

• A training session about the external genitalia exam.

• An annual screen for sexually transmitted infections (STIs) (gonorrhea [GC], chlamydia [CT], and HIV) if the patient is sexually active. You can use urine specimens for GC/CT to avoid a pelvic exam.

• Discuss responsible sexual behavior: contraception, STIs, and emergency contraception.

• Discuss the importance of diet and physical activity. It also is important to screen for eating disorders.

• Discuss prevention of injuries: avoidance of alcohol/drugs, drinking and driving, weapons, seatbelts and helmets, and safe tattooing and piercing.

• Screen for sexual activity, depression, abuse, school performance, and tobacco, alcohol, and drug use. This can be done using a questionnaire that the patient fills out in the waiting room. It is important to go over this questionnaire during the visit.

• Check that immunizations are up to date.

In addition to your visit with the patient, it is important to address the parent or caregiver. It is recommended that this be done once during the patient’s early adolescence, mid-adolescence, and late adolescence. This can be done with the patient and the caregiver in the same room, or with the caregiver separately. Topics to discuss include:

• Discuss normal development.

• Describe signs and symptoms of depression, anxiety, and abuse.

• Discuss the benefits of maintaining normal body weight through physical exercise and a healthy diet.

• Describe parenting behaviors that promote healthy adolescent adjustment.

• Outline ways to minimize potentially harmful behaviors.

A successful first visit is the initial step toward lifelong health maintenance.

Dr. Jaspan is the chairman of obstetrics and gynecology for the Einstein Health Care Network in Philadelphia. Dr. Bohnert is a PGY3 resident in obstetrics and gynecology at the Einstein Medical Center in Philadelphia.

This column, "Adviser’s Viewpoint," appears regularly in Ob.Gyn. News.

You open the chart, and you read the chief complaint. Like so many other charts, you see the words, "annual exam," but something catches your eye; her date of birth – "that can’t be right"– but before you can do the math, the number stares back at you – 14 years old. The last name may or may not look familiar – she could be the daughter of one your patients – nonetheless you are about to come to face to face with a 14-year-old patient. How you handle this interaction will forever be remembered by this young girl.

At this moment, I make a calculated decision on how I will proceed. Will I stand? Should I sit? What if she is so nervous she is standing, not sitting in the chair or on the table? I refocus on what is required for an adolescent visit? Does she need an exam? Will her mother or family member be in the room?

I have found that by asking questions and expecting a one-word answer, I am prepared to move the visit along. "What can I do for you today?" This is usually met with an expressionless face and a shoulder shrug. I generally follow that with, "Did someone tell you to come here today?" If you’re lucky, you may get a verbal response, but commonly, you will get the affirmative head nod. I view this as a breakthrough. Now I try to pry, "Are you having a problem?" Again a head nod is success. Once I understand that she is there for a problem, I find that leading questions that use the "embarrassing words" make it easier for the patient to communicate. She may not want to say the word vagina or sex, so take the opportunity to say it for her.

If she is there for an "annual exam," imagine her relief when you tell her she does not need to be examined. In fact, she will not need a Pap smear until she is 21 (soon to be changed to 25). With the ice now broken and a relieved patient before you, this is the golden moment. This is the moment that I use to educate. A speculum is no longer threatening. She is now relaxed that this thing will not be used on her, and she can now listen. While holding the small narrow speculum, I say, "This is not a clamp because clamps close and a speculum is used to open." I hold the speculum in my right hand and then make a loose fist with my left hand. I place the lower lip of the speculum against my left thumb, and say, "This is what your cervix looks like, and this is as far as the speculum must be opened." I then ask her to make a fist. I hold the speculum again her hand, and I use the cytobrush and cotton swab inside her hand Then I ask, "Did that hurt?" Of course, the response is no. I will say that there are many more pain sensors on your hand than in the vagina, but the vaginal exam is embarrassing.

Once I have done this, I use a module or pictures to show her the vagina, cervix, uterus, and ovaries. This pictorial provides a visual of what the pelvic exam is intended to do.

I then show her the stirrups and say, "You can put your heels here, and then slide your bottom to the end of the table, and then we will then use the speculum. When the speculum is placed, you will feel pressure toward your bottom. If you allow your knees to fall out to the side, the exam can be over very quickly. Once we are finished with the speculum, one finger is placed inside the vagina to check your cervix, uterus, and ovaries. That’s it."

"My promise to you is that if you are ever uncomfortable, you just say stop and the exam will stop. It is much more important to me that you feel safe here in this office. It took a great deal of courage to even walk in the door today, you can always reschedule."

The new American College of Obstetricians and Gynecologists (ACOG) guidelines do not recommend a pelvic exam until the age of 21, at the time of the first PAP smear. However, the more knowledge we can provide to our adolescent patients, the less fear they may have when the time does arrive for their first exam.

 

ACOG recommends that a young woman’s first visit to an ob.gyn. occur between the ages of 13 and 15 years old. This first visit should address health guidance, screening, and preventative health services. It is important to tell your patient that your discussions and exam will remain confidential. An internal exam is not necessary unless the patient is having a specific complaint. More importantly, this visit serves to establish rapport and trust between patient and doctor. This patient will be more likely to disclose important information about her health on future visits.

Initial and subsequent annual exams should include the following, according the recommendations:

• Vital signs including evaluation of menstrual cycle. This emphasizes the role of menstrual cycles in overall health status.

• Body mass index, which allows the opportunity to discuss dietary management.

• A discussion of normal adolescent development.

• A general physical exam should be performed at least once during early adolescence (12-14 years), middle adolescence (15-17 years), and late adolescence (18-21 years), but is not required at every visit.

• A pelvic exam is not required unless the patient is symptomatic.

• An evaluation of breast development.

• A training session about the external genitalia exam.

• An annual screen for sexually transmitted infections (STIs) (gonorrhea [GC], chlamydia [CT], and HIV) if the patient is sexually active. You can use urine specimens for GC/CT to avoid a pelvic exam.

• Discuss responsible sexual behavior: contraception, STIs, and emergency contraception.

• Discuss the importance of diet and physical activity. It also is important to screen for eating disorders.

• Discuss prevention of injuries: avoidance of alcohol/drugs, drinking and driving, weapons, seatbelts and helmets, and safe tattooing and piercing.

• Screen for sexual activity, depression, abuse, school performance, and tobacco, alcohol, and drug use. This can be done using a questionnaire that the patient fills out in the waiting room. It is important to go over this questionnaire during the visit.

• Check that immunizations are up to date.

In addition to your visit with the patient, it is important to address the parent or caregiver. It is recommended that this be done once during the patient’s early adolescence, mid-adolescence, and late adolescence. This can be done with the patient and the caregiver in the same room, or with the caregiver separately. Topics to discuss include:

• Discuss normal development.

• Describe signs and symptoms of depression, anxiety, and abuse.

• Discuss the benefits of maintaining normal body weight through physical exercise and a healthy diet.

• Describe parenting behaviors that promote healthy adolescent adjustment.

• Outline ways to minimize potentially harmful behaviors.

A successful first visit is the initial step toward lifelong health maintenance.

Dr. Jaspan is the chairman of obstetrics and gynecology for the Einstein Health Care Network in Philadelphia. Dr. Bohnert is a PGY3 resident in obstetrics and gynecology at the Einstein Medical Center in Philadelphia.

This column, "Adviser’s Viewpoint," appears regularly in Ob.Gyn. News.

You open the chart, and you read the chief complaint. Like so many other charts, you see the words, "annual exam," but something catches your eye; her date of birth – "that can’t be right"– but before you can do the math, the number stares back at you – 14 years old. The last name may or may not look familiar – she could be the daughter of one your patients – nonetheless you are about to come to face to face with a 14-year-old patient. How you handle this interaction will forever be remembered by this young girl.

At this moment, I make a calculated decision on how I will proceed. Will I stand? Should I sit? What if she is so nervous she is standing, not sitting in the chair or on the table? I refocus on what is required for an adolescent visit? Does she need an exam? Will her mother or family member be in the room?

I have found that by asking questions and expecting a one-word answer, I am prepared to move the visit along. "What can I do for you today?" This is usually met with an expressionless face and a shoulder shrug. I generally follow that with, "Did someone tell you to come here today?" If you’re lucky, you may get a verbal response, but commonly, you will get the affirmative head nod. I view this as a breakthrough. Now I try to pry, "Are you having a problem?" Again a head nod is success. Once I understand that she is there for a problem, I find that leading questions that use the "embarrassing words" make it easier for the patient to communicate. She may not want to say the word vagina or sex, so take the opportunity to say it for her.

If she is there for an "annual exam," imagine her relief when you tell her she does not need to be examined. In fact, she will not need a Pap smear until she is 21 (soon to be changed to 25). With the ice now broken and a relieved patient before you, this is the golden moment. This is the moment that I use to educate. A speculum is no longer threatening. She is now relaxed that this thing will not be used on her, and she can now listen. While holding the small narrow speculum, I say, "This is not a clamp because clamps close and a speculum is used to open." I hold the speculum in my right hand and then make a loose fist with my left hand. I place the lower lip of the speculum against my left thumb, and say, "This is what your cervix looks like, and this is as far as the speculum must be opened." I then ask her to make a fist. I hold the speculum again her hand, and I use the cytobrush and cotton swab inside her hand Then I ask, "Did that hurt?" Of course, the response is no. I will say that there are many more pain sensors on your hand than in the vagina, but the vaginal exam is embarrassing.

Once I have done this, I use a module or pictures to show her the vagina, cervix, uterus, and ovaries. This pictorial provides a visual of what the pelvic exam is intended to do.

I then show her the stirrups and say, "You can put your heels here, and then slide your bottom to the end of the table, and then we will then use the speculum. When the speculum is placed, you will feel pressure toward your bottom. If you allow your knees to fall out to the side, the exam can be over very quickly. Once we are finished with the speculum, one finger is placed inside the vagina to check your cervix, uterus, and ovaries. That’s it."

"My promise to you is that if you are ever uncomfortable, you just say stop and the exam will stop. It is much more important to me that you feel safe here in this office. It took a great deal of courage to even walk in the door today, you can always reschedule."

The new American College of Obstetricians and Gynecologists (ACOG) guidelines do not recommend a pelvic exam until the age of 21, at the time of the first PAP smear. However, the more knowledge we can provide to our adolescent patients, the less fear they may have when the time does arrive for their first exam.

 

ACOG recommends that a young woman’s first visit to an ob.gyn. occur between the ages of 13 and 15 years old. This first visit should address health guidance, screening, and preventative health services. It is important to tell your patient that your discussions and exam will remain confidential. An internal exam is not necessary unless the patient is having a specific complaint. More importantly, this visit serves to establish rapport and trust between patient and doctor. This patient will be more likely to disclose important information about her health on future visits.

Initial and subsequent annual exams should include the following, according the recommendations:

• Vital signs including evaluation of menstrual cycle. This emphasizes the role of menstrual cycles in overall health status.

• Body mass index, which allows the opportunity to discuss dietary management.

• A discussion of normal adolescent development.

• A general physical exam should be performed at least once during early adolescence (12-14 years), middle adolescence (15-17 years), and late adolescence (18-21 years), but is not required at every visit.

• A pelvic exam is not required unless the patient is symptomatic.

• An evaluation of breast development.

• A training session about the external genitalia exam.

• An annual screen for sexually transmitted infections (STIs) (gonorrhea [GC], chlamydia [CT], and HIV) if the patient is sexually active. You can use urine specimens for GC/CT to avoid a pelvic exam.

• Discuss responsible sexual behavior: contraception, STIs, and emergency contraception.

• Discuss the importance of diet and physical activity. It also is important to screen for eating disorders.

• Discuss prevention of injuries: avoidance of alcohol/drugs, drinking and driving, weapons, seatbelts and helmets, and safe tattooing and piercing.

• Screen for sexual activity, depression, abuse, school performance, and tobacco, alcohol, and drug use. This can be done using a questionnaire that the patient fills out in the waiting room. It is important to go over this questionnaire during the visit.

• Check that immunizations are up to date.

In addition to your visit with the patient, it is important to address the parent or caregiver. It is recommended that this be done once during the patient’s early adolescence, mid-adolescence, and late adolescence. This can be done with the patient and the caregiver in the same room, or with the caregiver separately. Topics to discuss include:

• Discuss normal development.

• Describe signs and symptoms of depression, anxiety, and abuse.

• Discuss the benefits of maintaining normal body weight through physical exercise and a healthy diet.

• Describe parenting behaviors that promote healthy adolescent adjustment.

• Outline ways to minimize potentially harmful behaviors.

A successful first visit is the initial step toward lifelong health maintenance.

Dr. Jaspan is the chairman of obstetrics and gynecology for the Einstein Health Care Network in Philadelphia. Dr. Bohnert is a PGY3 resident in obstetrics and gynecology at the Einstein Medical Center in Philadelphia.

This column, "Adviser’s Viewpoint," appears regularly in Ob.Gyn. News.

The authors report no financial relationships relevant to this article.

CASE: Primigravida with ruptured membranes

A 21-year-old patient was admitted to the labor and delivery suite in active labor. After a reassuring fetal tracing was documented, active management with oxytocin was initiated.

Five hours later, the nurse noted a prolonged deceleration.

Resuscitative efforts failed to alleviate the deceleration. The nurse notified the attending OB of the situation. An emergency cesarean section was called because:

1. of a nonreassuring fetal heart rate tracing and
   
2. delivery was not imminent.
   

Now, the attending leaves her home promptly to perform the cesarean section; the anesthesiologist, who is not in the hospital, is notified.

The team is assembled and the patient is moved to the operating room; 34 minutes have elapsed between the time the decision was made to perform the cesarean section and the time the incision is made on the abdomen.

Two minutes later, the baby is delivered. Apgar scores are as follows: 0 at 1 minute; 0 at 5 minutes; 0 at 10 minutes; and 1 at 15 minutes.

Subsequently, the baby is determined to be severely brain-damaged. The parents file a claim of malpractice.

ObGyns have come to depend on ACOG’s Committee Opinions, Educational Bulletins, Practice Bulletins, Policy Statements, and Technology Assessments to help us take the best care of our patients. To quote the College, each of these documents “is reviewed periodically and either reaffirmed, replaced, or withdrawn to ensure its continued appropriateness to practice.”¹

Sometimes, however, an ACOG bulletin, statement, or assessment may be misinterpreted and can actually contribute to some of the medicolegal problems that we face. The actual clinical situation just described, relating to ACOG’s statement on the so-called decision-to-incision gold standard, is a case in point.

The parties in the case go to trial

During the subsequent trial, the plaintiff alleges negligence by claiming that the defendant:

• did not anticipate or recognize developing fetal problems
  
• failed to perform a C-section within 30 minutes after the decision was made to do so.
  

The defendant counters:

• There was no fetal indication of hypoxia or cause for concern until the fetal bradycardia was noted
  
• Brain damage was caused by an unanticipated event that occurred more than 30 minutes before delivery
  
• The team responded as rapidly as it could given the circumstances of the hospital and staffing patterns.
  

No verdict was reached; instead, the parties agreed to a multimillion-dollar settlement that is based on 1) more than 30 minutes having elapsed from “decision to incision” and 2) the assertion that a 30-minute decision-to-incision time is the standard of care for an emergency C-section.

Are we held to a standard that can’t be met and has no basis in evidence?

To repeat, as reported in hospital records admitted into evidence at trial, the baby was delivered, with a low Apgar score, 34 minutes after the decision was called. The fact that the incision commenced after more than 30 minutes was a major factor contributing to the multimillion-dollar settlement.

That 30-minute mark is taken directly from the fifth edition of ACOG’s Guideline for Perinatal Care:

Any hospital providing obstetric service should have the capability of responding to an obstetric emergency. No data correlate the timing of intervention with outcome, and there is little likelihood that any will be obtained. However, in general, the consensus has been that hospitals should have the capability of beginning a cesarean section within 30 minutes of the decision to operate.²

The interpretation that all C-sections must be performed within 30 minutes of a decision is challenged by a recent study sponsored by The National Institute of Child Health and Human Development (NICHD) Maternal–Fetal Medicine Units Network.³ The design of that study was observational, because no ethical means exist to randomize women to less than or more than 30 minutes from the time of a decision to perform a C-section to the time of the incision.

The data collected came only from primagravid women in active labor who had an infant that had a birth weight of more than 2,500 g. Indications for C-section included: nonreassuring fetal heart rate, umbilical cord prolapse, placental abruption, placenta previa with hemorrhage, and uterine rupture. A total of 11,481 cases were analyzed over a 2-year period, with 2,808 C-sections performed for those indications (a 24.5% rate of C-section). Ninety-four per cent of the C-sections were undertaken because of a nonreassuring fetal heart rate.

 

In a university setting, where one would expect in-house OB coverage and anesthesia to be available, only 65% of emergency C-sections commenced within 30 minutes of a decision (17% in less than 10 minutes; 27% in less than 20 minutes). Investigators also found that, in cases in which a C-section was performed for a nonreassuring fetal heart rate, only 62% were performed in fewer than 30 minutes.

The data are clear: More than one third of all C-sections for these indications did not comply with the “30-minute rule.”

Notably, the study also found that:

• when the decision-to-incision time was less than 30 minutes, the rates of fetal acidemia and intubation in the delivery room were higher
  
• 95% of infants delivered in more than 31 minutes did not experience any of the adverse outcomes listed in the accompanying TABLE
  
• only one of eight neonatal deaths occurred in the group of infants delivered after 31 minutes (at 33 minutes).
  

The investigators also found that decision-to-incision time had no impact on maternal complications.

TABLE

Outcomes are no better when the decision-to-incision time is less than 30 minutes³

OUTCOME	INCIDENCE AT	INCIDENCE AT >30 MIN
Urine pH,	4.8%	1.6%*
Intubation in delivery	3.1%	1.3%*
Hypoxic–ischemic encephalopathy	0.7%	0.5%
Fetal death	0.2%	0%
Neonatal death	0.4%	0.2%
Apgar score at 5 min,	1.0%	0.9%
None of the above	92.6%	95.4%*
*P <.05>

30 minutes? It’s not a mandate

The study supported by NICHD shows that:

• the decision-to-incision interval appears to have no impact on maternal complications
  
• an infant delivered within 30 minutes for an emergency indication was more likely to be acidemic and to require intubation than an infant delivered in longer than 30 minutes for an emergency indication
  
• delivery within 30 minutes does not guarantee that there will be no adverse outcome
  
• 95% of infants delivered in more than 30 minutes did not have compromise.
  

Where did it originate? These facts make us wonder: How did the controversial, seemingly random time of 30 minutes crawl into the courtroom and become a benchmark? Why have attorneys and expert witnesses for the plaintiff taken this 30-minute rule to be fact?

The ACOG guideline is, as stated, clearly not a requirement. It does not mandate that all C-sections commence within 30 minutes from the time of the decision to perform one. Rather, the guideline clearly states that the hospital should be capable of performing the procedure within 30 minutes.

To be clear, we are not advocating a guideline or policy of waiting to perform a C-section! We believe rapid delivery is proper. But the optimal time, or even minimal time, to delivery has not been defined by data—and may never be.

What should it really mean? Thirty minutes, therefore, should be a goal, not a finite time. Data published by NICHD should now be used to temper notions that exceeding the so-called 30-minute rule necessarily 1) is an indicator of substandard care and 2) has adverse effects on outcome for the newborn.

Perhaps it’s time for ACOG to review these recent data and then reaffirm, replace, or withdraw the statement from the perinatal guidelines proposing that 30 minutes be the maximum time from decision to incision.¹

Here’s what you should do until the matter is clarified

If you must defend yourself against an accusation of not having performed a C-section in a timely fashion, data from the NICHD Perinatal Collaborative may offer a helpful defense. Because 38% of C-sections for a nonreassuring fetal heart rate tracing are not performed within 30 minutes of a decision to proceed, even in a university setting, this cannot be considered a standard and not meeting this arbitrary time should be looked on as a frequent occurrence.

Based on current data, therefore, any medicolegal case in which the plaintiff’s attorney implies that failure to conform to this putative standard resulted in a bad outcome should be defended vigorously—and should not be settled.

The authors report no financial relationships relevant to this article.

CASE: Primigravida with ruptured membranes

A 21-year-old patient was admitted to the labor and delivery suite in active labor. After a reassuring fetal tracing was documented, active management with oxytocin was initiated.

Five hours later, the nurse noted a prolonged deceleration.

Resuscitative efforts failed to alleviate the deceleration. The nurse notified the attending OB of the situation. An emergency cesarean section was called because:

1. of a nonreassuring fetal heart rate tracing and
   
2. delivery was not imminent.
   

Now, the attending leaves her home promptly to perform the cesarean section; the anesthesiologist, who is not in the hospital, is notified.

The team is assembled and the patient is moved to the operating room; 34 minutes have elapsed between the time the decision was made to perform the cesarean section and the time the incision is made on the abdomen.

Two minutes later, the baby is delivered. Apgar scores are as follows: 0 at 1 minute; 0 at 5 minutes; 0 at 10 minutes; and 1 at 15 minutes.

Subsequently, the baby is determined to be severely brain-damaged. The parents file a claim of malpractice.

ObGyns have come to depend on ACOG’s Committee Opinions, Educational Bulletins, Practice Bulletins, Policy Statements, and Technology Assessments to help us take the best care of our patients. To quote the College, each of these documents “is reviewed periodically and either reaffirmed, replaced, or withdrawn to ensure its continued appropriateness to practice.”¹

Sometimes, however, an ACOG bulletin, statement, or assessment may be misinterpreted and can actually contribute to some of the medicolegal problems that we face. The actual clinical situation just described, relating to ACOG’s statement on the so-called decision-to-incision gold standard, is a case in point.

The parties in the case go to trial

During the subsequent trial, the plaintiff alleges negligence by claiming that the defendant:

• did not anticipate or recognize developing fetal problems
  
• failed to perform a C-section within 30 minutes after the decision was made to do so.
  

The defendant counters:

• There was no fetal indication of hypoxia or cause for concern until the fetal bradycardia was noted
  
• Brain damage was caused by an unanticipated event that occurred more than 30 minutes before delivery
  
• The team responded as rapidly as it could given the circumstances of the hospital and staffing patterns.
  

No verdict was reached; instead, the parties agreed to a multimillion-dollar settlement that is based on 1) more than 30 minutes having elapsed from “decision to incision” and 2) the assertion that a 30-minute decision-to-incision time is the standard of care for an emergency C-section.

Are we held to a standard that can’t be met and has no basis in evidence?

To repeat, as reported in hospital records admitted into evidence at trial, the baby was delivered, with a low Apgar score, 34 minutes after the decision was called. The fact that the incision commenced after more than 30 minutes was a major factor contributing to the multimillion-dollar settlement.

That 30-minute mark is taken directly from the fifth edition of ACOG’s Guideline for Perinatal Care:

Any hospital providing obstetric service should have the capability of responding to an obstetric emergency. No data correlate the timing of intervention with outcome, and there is little likelihood that any will be obtained. However, in general, the consensus has been that hospitals should have the capability of beginning a cesarean section within 30 minutes of the decision to operate.²

The interpretation that all C-sections must be performed within 30 minutes of a decision is challenged by a recent study sponsored by The National Institute of Child Health and Human Development (NICHD) Maternal–Fetal Medicine Units Network.³ The design of that study was observational, because no ethical means exist to randomize women to less than or more than 30 minutes from the time of a decision to perform a C-section to the time of the incision.

The data collected came only from primagravid women in active labor who had an infant that had a birth weight of more than 2,500 g. Indications for C-section included: nonreassuring fetal heart rate, umbilical cord prolapse, placental abruption, placenta previa with hemorrhage, and uterine rupture. A total of 11,481 cases were analyzed over a 2-year period, with 2,808 C-sections performed for those indications (a 24.5% rate of C-section). Ninety-four per cent of the C-sections were undertaken because of a nonreassuring fetal heart rate.

 

In a university setting, where one would expect in-house OB coverage and anesthesia to be available, only 65% of emergency C-sections commenced within 30 minutes of a decision (17% in less than 10 minutes; 27% in less than 20 minutes). Investigators also found that, in cases in which a C-section was performed for a nonreassuring fetal heart rate, only 62% were performed in fewer than 30 minutes.

The data are clear: More than one third of all C-sections for these indications did not comply with the “30-minute rule.”

Notably, the study also found that:

• when the decision-to-incision time was less than 30 minutes, the rates of fetal acidemia and intubation in the delivery room were higher
  
• 95% of infants delivered in more than 31 minutes did not experience any of the adverse outcomes listed in the accompanying TABLE
  
• only one of eight neonatal deaths occurred in the group of infants delivered after 31 minutes (at 33 minutes).
  

The investigators also found that decision-to-incision time had no impact on maternal complications.

TABLE

Outcomes are no better when the decision-to-incision time is less than 30 minutes³

OUTCOME	INCIDENCE AT	INCIDENCE AT >30 MIN
Urine pH,	4.8%	1.6%*
Intubation in delivery	3.1%	1.3%*
Hypoxic–ischemic encephalopathy	0.7%	0.5%
Fetal death	0.2%	0%
Neonatal death	0.4%	0.2%
Apgar score at 5 min,	1.0%	0.9%
None of the above	92.6%	95.4%*
*P <.05>

30 minutes? It’s not a mandate

The study supported by NICHD shows that:

• the decision-to-incision interval appears to have no impact on maternal complications
  
• an infant delivered within 30 minutes for an emergency indication was more likely to be acidemic and to require intubation than an infant delivered in longer than 30 minutes for an emergency indication
  
• delivery within 30 minutes does not guarantee that there will be no adverse outcome
  
• 95% of infants delivered in more than 30 minutes did not have compromise.
  

Where did it originate? These facts make us wonder: How did the controversial, seemingly random time of 30 minutes crawl into the courtroom and become a benchmark? Why have attorneys and expert witnesses for the plaintiff taken this 30-minute rule to be fact?

The ACOG guideline is, as stated, clearly not a requirement. It does not mandate that all C-sections commence within 30 minutes from the time of the decision to perform one. Rather, the guideline clearly states that the hospital should be capable of performing the procedure within 30 minutes.

To be clear, we are not advocating a guideline or policy of waiting to perform a C-section! We believe rapid delivery is proper. But the optimal time, or even minimal time, to delivery has not been defined by data—and may never be.

What should it really mean? Thirty minutes, therefore, should be a goal, not a finite time. Data published by NICHD should now be used to temper notions that exceeding the so-called 30-minute rule necessarily 1) is an indicator of substandard care and 2) has adverse effects on outcome for the newborn.

Perhaps it’s time for ACOG to review these recent data and then reaffirm, replace, or withdraw the statement from the perinatal guidelines proposing that 30 minutes be the maximum time from decision to incision.¹

Here’s what you should do until the matter is clarified

If you must defend yourself against an accusation of not having performed a C-section in a timely fashion, data from the NICHD Perinatal Collaborative may offer a helpful defense. Because 38% of C-sections for a nonreassuring fetal heart rate tracing are not performed within 30 minutes of a decision to proceed, even in a university setting, this cannot be considered a standard and not meeting this arbitrary time should be looked on as a frequent occurrence.

Based on current data, therefore, any medicolegal case in which the plaintiff’s attorney implies that failure to conform to this putative standard resulted in a bad outcome should be defended vigorously—and should not be settled.

The authors report no financial relationships relevant to this article.

CASE: Primigravida with ruptured membranes

A 21-year-old patient was admitted to the labor and delivery suite in active labor. After a reassuring fetal tracing was documented, active management with oxytocin was initiated.

Five hours later, the nurse noted a prolonged deceleration.

Resuscitative efforts failed to alleviate the deceleration. The nurse notified the attending OB of the situation. An emergency cesarean section was called because:

1. of a nonreassuring fetal heart rate tracing and
   
2. delivery was not imminent.
   

Now, the attending leaves her home promptly to perform the cesarean section; the anesthesiologist, who is not in the hospital, is notified.

The team is assembled and the patient is moved to the operating room; 34 minutes have elapsed between the time the decision was made to perform the cesarean section and the time the incision is made on the abdomen.

Two minutes later, the baby is delivered. Apgar scores are as follows: 0 at 1 minute; 0 at 5 minutes; 0 at 10 minutes; and 1 at 15 minutes.

Subsequently, the baby is determined to be severely brain-damaged. The parents file a claim of malpractice.

ObGyns have come to depend on ACOG’s Committee Opinions, Educational Bulletins, Practice Bulletins, Policy Statements, and Technology Assessments to help us take the best care of our patients. To quote the College, each of these documents “is reviewed periodically and either reaffirmed, replaced, or withdrawn to ensure its continued appropriateness to practice.”¹

Sometimes, however, an ACOG bulletin, statement, or assessment may be misinterpreted and can actually contribute to some of the medicolegal problems that we face. The actual clinical situation just described, relating to ACOG’s statement on the so-called decision-to-incision gold standard, is a case in point.

The parties in the case go to trial

During the subsequent trial, the plaintiff alleges negligence by claiming that the defendant:

• did not anticipate or recognize developing fetal problems
  
• failed to perform a C-section within 30 minutes after the decision was made to do so.
  

The defendant counters:

• There was no fetal indication of hypoxia or cause for concern until the fetal bradycardia was noted
  
• Brain damage was caused by an unanticipated event that occurred more than 30 minutes before delivery
  
• The team responded as rapidly as it could given the circumstances of the hospital and staffing patterns.
  

No verdict was reached; instead, the parties agreed to a multimillion-dollar settlement that is based on 1) more than 30 minutes having elapsed from “decision to incision” and 2) the assertion that a 30-minute decision-to-incision time is the standard of care for an emergency C-section.

Are we held to a standard that can’t be met and has no basis in evidence?

To repeat, as reported in hospital records admitted into evidence at trial, the baby was delivered, with a low Apgar score, 34 minutes after the decision was called. The fact that the incision commenced after more than 30 minutes was a major factor contributing to the multimillion-dollar settlement.

That 30-minute mark is taken directly from the fifth edition of ACOG’s Guideline for Perinatal Care:

Any hospital providing obstetric service should have the capability of responding to an obstetric emergency. No data correlate the timing of intervention with outcome, and there is little likelihood that any will be obtained. However, in general, the consensus has been that hospitals should have the capability of beginning a cesarean section within 30 minutes of the decision to operate.²

The interpretation that all C-sections must be performed within 30 minutes of a decision is challenged by a recent study sponsored by The National Institute of Child Health and Human Development (NICHD) Maternal–Fetal Medicine Units Network.³ The design of that study was observational, because no ethical means exist to randomize women to less than or more than 30 minutes from the time of a decision to perform a C-section to the time of the incision.

The data collected came only from primagravid women in active labor who had an infant that had a birth weight of more than 2,500 g. Indications for C-section included: nonreassuring fetal heart rate, umbilical cord prolapse, placental abruption, placenta previa with hemorrhage, and uterine rupture. A total of 11,481 cases were analyzed over a 2-year period, with 2,808 C-sections performed for those indications (a 24.5% rate of C-section). Ninety-four per cent of the C-sections were undertaken because of a nonreassuring fetal heart rate.

 

In a university setting, where one would expect in-house OB coverage and anesthesia to be available, only 65% of emergency C-sections commenced within 30 minutes of a decision (17% in less than 10 minutes; 27% in less than 20 minutes). Investigators also found that, in cases in which a C-section was performed for a nonreassuring fetal heart rate, only 62% were performed in fewer than 30 minutes.

The data are clear: More than one third of all C-sections for these indications did not comply with the “30-minute rule.”

Notably, the study also found that:

• when the decision-to-incision time was less than 30 minutes, the rates of fetal acidemia and intubation in the delivery room were higher
  
• 95% of infants delivered in more than 31 minutes did not experience any of the adverse outcomes listed in the accompanying TABLE
  
• only one of eight neonatal deaths occurred in the group of infants delivered after 31 minutes (at 33 minutes).
  

The investigators also found that decision-to-incision time had no impact on maternal complications.

TABLE

Outcomes are no better when the decision-to-incision time is less than 30 minutes³

OUTCOME	INCIDENCE AT	INCIDENCE AT >30 MIN
Urine pH,	4.8%	1.6%*
Intubation in delivery	3.1%	1.3%*
Hypoxic–ischemic encephalopathy	0.7%	0.5%
Fetal death	0.2%	0%
Neonatal death	0.4%	0.2%
Apgar score at 5 min,	1.0%	0.9%
None of the above	92.6%	95.4%*
*P <.05>

30 minutes? It’s not a mandate

The study supported by NICHD shows that:

• the decision-to-incision interval appears to have no impact on maternal complications
  
• an infant delivered within 30 minutes for an emergency indication was more likely to be acidemic and to require intubation than an infant delivered in longer than 30 minutes for an emergency indication
  
• delivery within 30 minutes does not guarantee that there will be no adverse outcome
  
• 95% of infants delivered in more than 30 minutes did not have compromise.
  

Where did it originate? These facts make us wonder: How did the controversial, seemingly random time of 30 minutes crawl into the courtroom and become a benchmark? Why have attorneys and expert witnesses for the plaintiff taken this 30-minute rule to be fact?

The ACOG guideline is, as stated, clearly not a requirement. It does not mandate that all C-sections commence within 30 minutes from the time of the decision to perform one. Rather, the guideline clearly states that the hospital should be capable of performing the procedure within 30 minutes.

To be clear, we are not advocating a guideline or policy of waiting to perform a C-section! We believe rapid delivery is proper. But the optimal time, or even minimal time, to delivery has not been defined by data—and may never be.

What should it really mean? Thirty minutes, therefore, should be a goal, not a finite time. Data published by NICHD should now be used to temper notions that exceeding the so-called 30-minute rule necessarily 1) is an indicator of substandard care and 2) has adverse effects on outcome for the newborn.

Perhaps it’s time for ACOG to review these recent data and then reaffirm, replace, or withdraw the statement from the perinatal guidelines proposing that 30 minutes be the maximum time from decision to incision.¹

Here’s what you should do until the matter is clarified

If you must defend yourself against an accusation of not having performed a C-section in a timely fashion, data from the NICHD Perinatal Collaborative may offer a helpful defense. Because 38% of C-sections for a nonreassuring fetal heart rate tracing are not performed within 30 minutes of a decision to proceed, even in a university setting, this cannot be considered a standard and not meeting this arbitrary time should be looked on as a frequent occurrence.

Based on current data, therefore, any medicolegal case in which the plaintiff’s attorney implies that failure to conform to this putative standard resulted in a bad outcome should be defended vigorously—and should not be settled.