Reducing Obstetric Litigation Through
Alterations in Practice Patterns
Steven L. Clark, MD, Michael A. Belfort, MD, PhD, Gary A. Dildy, MD, and Janet A. Meyers, RN
OBJECTIVE: To estimate the extent to which obstetric
malpractice claims might be reduced by adherence to a
limited number of specific practice patterns.
METHODS: We examined all 189 closed perinatal claims
between 2000 and 2005 from a single, large, professional
liability insurer. Each case was subjected to three
separate analyses: 1) whether the adverse outcome
was caused by substandard care, 2) what changes in
practice likely would have avoided the adverse out-
come, regardless of standard-of-care considerations,
and 3) to what extent did substandard documentation
lead to payment in cases in which there was no
objective evidence of substandard care.
RESULTS: Seventy percent of claims involving obstetric
practice (accounting for 79% of all costs) involved
substandard care. Payments in 85% of cases involving
non–vaginal birth after cesarean (VBAC) fetal monitor-
ing, 16% of maternal injury cases, 80% of cases involv-
ing VBAC, and 54% of shoulder dystocia cases were
avoidable had four specific practice and documenta-
tion patterns been followed.
CONCLUSION: Most money currently paid in conjunc-
tion with obstetric malpractice cases is a result of actual
substandard care resulting in preventable injury. Well
more than half of hospital litigation costs might be
avoided if physician practice included: 1) delivery in a
facility with 24-hour in-house obstetric coverage; 2)
adherence to published high-risk medication protocols;
3) a more conservative approach to VBAC; and 4) use of
a comprehensive, standardized procedure note in cases
of shoulder dystocia.
(Obstet Gynecol 2008;112:1279–83)
LEVEL OF EVIDENCE: III
care and physician dissatisfaction with obstetric prac-
tice.1–4Such claims also may contribute to a lack of
access to obstetric specialists in some areas of the
United States.5,6More importantly, in that fraction of
cases in which violations of the standard of care
actually caused an injury, such claims reflect pre-
ventable adverse outcomes for mothers and new-
borns. Against this background, we sought to de-
termine whether a small number of specific practice
patterns might be identified that account for a
larger fraction of avoidable adverse events and/or
edical malpractice claims in obstetrics continue
to be a major driver of both the cost of medical
MATERIALS AND METHODS
We reviewed materials collected or produced by a
large, professional liability insurer during the evalua-
tion of all paid claims involving perinatal care that
were closed during the years 2000 to 2005. Such
materials included medical records, abstracts or sum-
maries, claims analyses, interviews with providers,
and opinions of clinicians serving as defense consult-
ants. During this timeframe, approximately 1.1 mil-
lion deliveries occurred, although the times of occur-
rence do not correlate exactly with the years in which
the cases were closed. Approximately 2% of claims
were the results of jury verdicts; the remainder settled
out of court.
Cases were divided into categories according to
the nature of the major issue or allegation (Table 1).
Minor claims involved issues such as retained vaginal
sponge, small cauterization burns, or slips and falls.
Each case then was subjected to three separate anal-
yses: 1) Was the adverse outcome caused by substan-
From the Hospital Corporation of America, Nashville, Tennessee.
Presented at the 25th Annual Meeting of the Society for Maternal–Fetal
Medicine, San Francisco, California, February 5–10, 2007.
Corresponding author: Steven L. Clark, MD, Medical Director, Women and
Newborns Clinical Program, Hospital Corporation of America, St. Mark’s
Women’s Pavilion, 1140 E. 3900 South, Salt Lake City, Utah 84124; e-mail:
The authors have no potential conflicts of interest to disclose.
© 2008 by The American College of Obstetricians and Gynecologists. Published
by Lippincott Williams & Wilkins.
VOL. 112, NO. 6, DECEMBER 2008OBSTETRICS & GYNECOLOGY