The current crisis in obstetrics

Of the issues leading to legal actions in obstetrics, the most important are events occurring before delivery that are deemed to account for the birth of a physically or mentally challenged child. In determining causation in the clinical setting, the diagnosis of fetal asphyxia can be made using blood gas and acid-base assessment. However, there are many subsidiary questions that in most cases cannot be answered, including when the asphyxia began, the severity and nature of the asphyxia during the exposure, the quality of the cardiovascular compensation, and when the brain damage occurred. When scientific proof is not available, the dilemma for the court is the requirement to reach a conclusion about the timing of brain damage on the balance of probabilities. Although it is of value, clinical risk scoring using fetal heart rate (FHR) monitoring may result in false positive predictions of fetal asphyxia. The problem in FHR monitoring is the lack of a detailed algorithm for the interpretation of FHR patterns with appropriate recommendations for management. Until such an algorithm is developed, health care workers cannot be expected to respond to fetal heart rate patterns consistently. Responsibility for the crisis in obstetrics must rest with the members of the health care disciplines who provide expert testimony. Progress made in research encourages us to assume that more is known about the causes of brain damage in the clinical setting than in fact is known. Similarly, health care professionals, parents, and lawyers often assume current methods of prediction and diagnosis to be more effective than they actually are.