Sabiani Laura, Le Dû Renaud, Loundou Anderson, d'Ercole Claude, Bretelle Florence, Boubli Léon, Carcopino Xavier
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.
Faculté de Médecine de Marseille, Aix-Marseile Université, Marseille, France.
Am J Obstet Gynecol. 2015 Dec;213(6):856.e1-8. doi: 10.1016/j.ajog.2015.08.066. Epub 2015 Sep 5.
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.
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.
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).
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.
本研究的目的是评估产科专家在法庭上对异常胎心监护图进行回顾性审查以及分娩期间异常胎心患者产科处理的观察者内和观察者间一致性。
共有22名法国产科法庭专家对30例单胎足月分娩病例进行了审查，这些病例被诊断为至少1小时的异常胎心，其中10例有不良新生儿结局。专家们在3个月的间隔内对所有病例进行了两次审查，第一次审查时对新生儿结局不知情。对于每例审查的病例，向专家们提供产科数据以及完整胎心监护记录和产程图的副本。要求专家们对异常胎心监护图进行分类，并表明他们是否同意所采取的产科处理措施。当他们不同意时，要求专家们判断是否认为存在失误，以及他们是否认为产科处理措施是导致儿童脑瘫的原因（如有）。
与不知情审查相比，当得知新生儿结局时，专家们更有可能同意所采取的产科处理措施（P <.001）和分娩方式（P <.001），并且不太可能判断存在失误（P <.001）或认为与潜在脑瘫有关联（P =.003）。专家们对异常胎心监护图审查和产科处理的观察者内一致性均为中等（kappa分别为0.46 - 0.51和0.48 - 0.53）。异常胎心监护图审查的观察者间一致性较低，且新生儿结局信息并未使其得到改善（kappa为0.11 - 0.18）。产科处理措施解读的观察者间一致性也较低（kappa为0.08 - 0.19），但新生儿结局信息似乎使其有所改善（kappa为0.15 - 0.32）。
产科法庭专家在审查异常胎心监护图和产科护理适宜性方面的观察者内和观察者间一致性较差，表明目前在法庭上进行的产科专业判断缺乏客观性。
