Intra- and interobserver agreement among obstetric experts in court regarding the review of abnormal fetal heart rate tracings and obstetrical management.

OBJECTIVE The objective of the study was to evaluate the intra- and interobserver agreement among obstetric experts in court regarding the retrospective review of abnormal fetal heart rate tracings and obstetrical management of patients with abnormal fetal heart rate during labor. STUDY DESIGN A total of 22 French obstetric experts in court reviewed 30 cases of term deliveries of singleton pregnancies diagnosed with at least 1 hour of abnormal fetal heart rate, including 10 cases with adverse neonatal outcome. The experts reviewed all cases twice within a 3-month interval, with the first review being blinded to neonatal outcome. For each case reviewed, the experts were provided with the obstetric data and copies of the complete fetal heart rate recording and the partogram. The experts were asked to classify the abnormal fetal heart rate tracing and to express whether they agreed with the obstetrical management performed. When they disagreed, the experts were asked whether they concluded that an error had been made and whether they considered the obstetrical management as the cause of cerebral palsy in children if any. RESULTS Compared with blinded review, the experts were significantly more likely to agree with the obstetric management performed (P < .001) and with the mode of delivery (P < .001) when informed about the neonatal outcome and were less likely to conclude that an error had been made (P < .001) or to establish a link with potential cerebral palsy (P = .003). The experts' intraobserver agreement for the review of abnormal fetal heart rate tracing and obstetrical management were both mediocre (kappa = 0.46-0.51 and kappa = 0.48-0.53, respectively). The interobserver agreement for the review of abnormal fetal heart rate tracing was low and was not improved by knowledge of the neonatal outcome (kappa = 0.11-0.18). The interobserver agreement for the interpretation of obstetrical management was also low (kappa = 0.08-0.19) but appeared to be improved by knowledge of the neonatal outcome (kappa = 0.15-0.32). CONCLUSION The intra- and interobserver agreement among obstetric experts in court for the review of abnormal fetal heart rate tracing and the appropriateness of obstetrical care is poor, suggesting a lack of objectivity of obstetrical expertise as currently performed in court.

[1]  A. Martín [Fetal heart rate during labour: definitions and interpretation]. , 2008, Journal de gynecologie, obstetrique et biologie de la reproduction.

[2]  J. Bernardes,et al.  Evaluation of interobserver agreement of cardiotocograms , 1997, International journal of gynaecology and obstetrics: the official organ of the International Federation of Gynaecology and Obstetrics.

[3]  S. Arulkumaran,et al.  Cardiotocography and medicolegal issues. , 2004, Best practice & research. Clinical obstetrics & gynaecology.

[4]  L. Korst,et al.  Application of Criteria Developed by the Task Force on Neonatal Encephalopathy and Cerebral Palsy to Acutely Asphyxiated Neonates , 2011, Obstetrics and gynecology.

[5]  E. M. Symonds,et al.  The anatomy of obstetric litigation , 1991 .

[6]  K. Greene,et al.  ELECTRONIC FETAL HEART RATE MONITORING : RESEARCH GUIDELINES FOR INTERPRETATION. AUTHOR'S REPLY , 1997 .

[7]  E. Chandraharan,et al.  Medico-legal problems in obstetrics , 2006 .

[8]  K. Greene,et al.  Electronic fetal heart rate monitoring: Research guidelines for interpretation , 1997 .

[9]  V. Z. Simunek Définition de l’asphyxie intrapartum et conséquences sur le devenir , 2008 .

[10]  A. Maclennan A template for defining a causal relation between acute intrapartum events and cerebral palsy: international consensus statement , 1999, BMJ.

[11]  T. Weber,et al.  Description, evaluation and clinical decision making according to various fetal heart rate patterns , 1992, Acta obstetricia et gynecologica Scandinavica.

[12]  G. Bréart,et al.  Enquête nationale périnatale 2003 , 2005 .

[13]  E. Blix,et al.  Inter‐observer variation in assessment of 845 labour admission tests: comparison between midwives and obstetricians in the clinical setting and two experts , 2003, BJOG : an international journal of obstetrics and gynaecology.

[14]  G. Hankins,et al.  Defining the Pathogenesis and Pathophysiology of Neonatal Encephalopathy and Cerebral Palsy , 2003, Obstetrics and gynecology.

[15]  J. R. Landis,et al.  An application of hierarchical kappa-type statistics in the assessment of majority agreement among multiple observers. , 1977, Biometrics.

[16]  K. Nelson,et al.  Obstetric litigation is asphyxiating our maternity services. , 2006, Obstetrics and gynecology.

[17]  A Hasman,et al.  Interobserver variation in the assessment of fetal heart rate recordings. , 1993, European journal of obstetrics, gynecology, and reproductive biology.

[18]  Z. Alfirevic,et al.  Continuous cardiotocography (CTG) as a form of electronic fetal monitoring (EFM) for fetal assessment during labour. , 2017, The Cochrane database of systematic reviews.

[19]  Sandra Hernandez,et al.  Visual analysis of antepartum fetal heart rate tracings: inter- and intra-observer agreement and impact of knowledge of neonatal outcome , 2005, Journal of perinatal medicine.

[20]  Everett F. Magann,et al.  Intrapartum nonreassuring fetal heart rate tracing and prediction of adverse outcomes: interobserver variability. , 2008, American journal of obstetrics and gynecology.

[21]  K. Nelson,et al.  Who will deliver our grandchildren? Implications of cerebral palsy litigation. , 2005, JAMA.

[22]  J. Wright,et al.  Interpreting the fetal heart rate tracing. Effect of knowledge of neonatal outcome. , 1998, The Journal of reproductive medicine.

[23]  F. Pierre [Medical-legal aspects: the obstetrician as a defendant or as an expert]. , 2003, Journal de gynecologie, obstetrique et biologie de la reproduction.

[24]  F. Northington,et al.  A systematic review of the role of intrapartum hypoxia-ischemia in the causation of neonatal encephalopathy. , 2008, American journal of obstetrics and gynecology.

[25]  Tiina Luukkaala,et al.  Intrapartum cardiotocography – the dilemma of interpretational variation , 2006, Journal of Perinatal Medicine.