This activity is intended for healthcare providers delivering care to women and their families.
After completing this activity, the participant should be better able to:
1. Describe the role of plaintiff expert witness
2. Discuss professional medical guidelines in determining standard of care
Estimated time to complete activity: 0.25 hours
Susan J. Gross, MD, FRCSC, FACOG, FACMG
President and CEO, The ObG Project
Postgraduate Institute for Medicine (PIM) requires instructors, planners, managers and other individuals who are in a position to control the content of this activity to disclose any real or apparent conflict of interest (COI) they may have as related to the content of this activity. All identified COI are thoroughly vetted and resolved according to PIM policy. PIM is committed to providing its learners with high quality CME activities and related materials that promote improvements or quality in healthcare and not a specific proprietary business interest of a commercial interest.
Faculty: Susan J. Gross, MD, receives consulting fees from Sema4, and has financial interest in The ObG Project, Inc.
Planners and Managers: The PIM planners and managers, Trace Hutchison, PharmD, Samantha Mattiucci, PharmD, CHCP, Judi Smelker-Mitchek, MBA, MSN, RN, and Jan Schultz, MSN, RN, CHCP have nothing to disclose.
Fees for participating and receiving CME credit for this activity are as posted on The ObG Project website. During the period from Dec 31 2017 through Dec 31 2020, participants must read the learning objectives and faculty disclosures and study the educational activity.
If you wish to receive acknowledgment for completing this activity, please complete the post-test and evaluation. Upon registering and successfully completing the post-test with a score of 100% and the activity evaluation, your certificate will be made available immediately.
For Pharmacists: Upon successfully completing the post-test with a score of 100% and the activity evaluation form, transcript information will be sent to the NABP CPE Monitor Service within 4 weeks.
In support of improving patient care, this activity has been planned and implemented by the Postgraduate Institute for Medicine and The ObG Project. Postgraduate Institute for Medicine is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.
Postgraduate Institute for Medicine designates this enduring material for a maximum of 0.25 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
The maximum number of hours awarded for this Continuing Nursing Education activity is 0.2 contact hours.
In another entry (see ‘Related ObG Topics’ below), the necessary qualifications to be an expert witness were discussed. In this entry, we look at the expert witness from a different perspective, that of the ‘plaintiff’ expert witness. The job of the plaintiff expert is to convince a jury and a judge that a medical standard of care was not followed, and because it was not followed, the plaintiff’s patient was injured or died.
In Gallardo and D.R.G. v. United States of America, the plaintiff’s mother alleged that the obstetrician (1) did not properly interpret the fetal monitoring strip; (2) had the plaintiff continue to push in the presence of tachysystole and uterine hypertonus even though acidosis was evidenced by prolonged decelerations, minimal to absent variability, persistent late decelerations and tachycardia; and (3) did not perform a timely cesarean section. The infant was diagnosed with cerebral palsy. After a trial, the district court found in favor of the defendant physicians.
Both plaintiff experts agreed that the defendant obstetrician failed to properly interpret the electronic fetal monitor (EFM) strip and erred by not performing a cesarean section, but for different reasons. The first expert opined that based on the fetal heart tracing, a cesarean section should have been done when the baby was experiencing ischemic episodes during which it was not receiving enough oxygen. He also opined that the mother was allowed to engage in too much pushing, and that a cesarean section should certainly have been performed as the baby was exhibiting bradycardia based the EFM strip.
The second expert testified that it was not until the second stage of labor, i.e. the pushing phase, when the EFM strip began to indicate the development of severe fetal acidosis. Therefore, it was unreasonable for the obstetrician to have the mother push with almost every contraction because it left the baby with little or no time to recover and, consequently, the baby rapidly became acidotic.
Defense experts opined that electronic fetal monitoring has an extremely high false positive rate coupled with an extremely low positive predictive value for cerebral palsy, let alone hypoxic-ischemic encephalopathy and the severity of acidosis. The maternal history of two vaginal deliveries also classified the mother as low risk for cesarean section.
The district court chose not to accept the plaintiff expert testimony as defining the controlling standard of care because it was inconsistent not only with the opinions expressed by defense expert, but more importantly because it was inconsistent with the positions taken by ACOG in various publications. Specifically, EFM strips have questionable predictive value when it comes to cerebral palsy and should not be used in isolation to determine management. In addition, the divergent opinions of plaintiff experts as far as the proper course and timing of possible interventions that the defendant obstetrician should have followed also doomed plaintiff’s case. The court concluded that “[t]he standard of care in the face of persistently non-reassuring EFM strips in February 2007 could include a wide range of approaches.” Therefore, the obstetrician’s actions were reasonable given the wide-ranging standard of care.
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