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.


METHODS
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).


CONCLUSIONS
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.
Faculté de Médecine de Marseille, Aix-Marseile Université, Marseille, France; Service de Gynécologie Obstétrique, Assistance Publique des Hôpitaux de Marseille, Hôpital de la Conception, Marseille, France. Electronic address: laurasabiani@hotmail.com.
Laura
L
Sabiani
Faculté de Médecine de Marseille, Aix-Marseile Université, Marseille, France.
Renaud
R
Le Dû
Faculté de Médecine de Marseille, Aix-Marseile Université, Marseille, France; Unité d'Aide Méthodologique à la Recherche Clinique, Assistance Publique des Hôpitaux de Marseille, Marseille, France; Laboratoire de Santé Publique, Faculté de Médecine, Marseille, France.
Anderson
A
Loundou
Faculté de Médecine de Marseille, Aix-Marseile Université, Marseille, France; Service de Gynécologie Obstétrique, Assistance Publique des Hôpitaux de Marseille, Hôpital Nord, Marseille, France.
Claude
C
d'Ercole
Faculté de Médecine de Marseille, Aix-Marseile Université, Marseille, France; Service de Gynécologie Obstétrique, Assistance Publique des Hôpitaux de Marseille, Hôpital Nord, Marseille, France.
Florence
F
Bretelle
Faculté de Médecine de Marseille, Aix-Marseile Université, Marseille, France; Service de Gynécologie Obstétrique, Assistance Publique des Hôpitaux de Marseille, Hôpital Nord, Marseille, France.
Léon
L
Boubli
Faculté de Médecine de Marseille, Aix-Marseile Université, Marseille, France; Service de Gynécologie Obstétrique, Assistance Publique des Hôpitaux de Marseille, Hôpital Nord, Marseille, France; IMBE, Aix Marseille Université, Centre National de la Recherche Scientifique, IRD, Université Avignon, Avignon, France.
Xavier
X
Carcopino
D000328:Adult; D001034:Apgar Score; D054869:Clinical Audit; D036861:Delivery, Obstetric; D005260:Female; D005312:Fetal Blood; D005323:Fetal Monitoring; D005602:France; D006340:Heart Rate, Fetal; D006801:Humans; D006863:Hydrogen-Ion Concentration; D007231:Infant, Newborn; D007363:Intensive Care Units, Neonatal; D008318:Malpractice / Q000331:legislation & jurisprudence; D008875:Middle Aged; D015588:Observer Variation; D009774:Obstetrics / Q000331:legislation & jurisprudence*; D010343:Patient Admission; D011247:Pregnancy; D012121:Respiration, Artificial; D012189:Retrospective Studies
fetal heart rate; interobserver agreement; intraobserver agreement; obstetric expertise