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Effective Obstetrical Team Communication

by Cynthia Morrison, BSN, ARM, CPHRM

Effective communication requires the exchange of concise and relevant information that involves a team effort. Communication issues are a frequent factor in malpractice claims. Because obstetrics is one of the higher risk clinical areas from liability and patient safety perspectives, it is essential to implement a communication protocol between the physician and hospital staff.

SBAR, which stands for situation, background, assessment, and recommendation, is a common communication protocol utilized for framing conversations—especially any exchange that takes place during a critical situation requiring immediate attention and action. 

The following are examples of clinical situations that should be addressed within the parameters of a standardized protocol such as SBAR:
 
  • Non-reassuring fetal heart rates/changes/variability pattern
  • Elevated maternal blood pressure—systolic BP of 140 mm hg or >, or diastolic BP >90 mm hg
  • Vaginal bleeding
  • Meconium
  • Suspected abnormal presentation
  • Elevated maternal temperature

Case Study
A 40-year-old woman with a history of fertility treatment and her first successful pregnancy arrived at the Labor and Delivery unit and reported the onset of contractions and spontaneous rupture of the membranes at 3:00 A.M. that morning. She arrived at the hospital at 7:30 A.M. The on-call attending physician arrived by 8:00 A.M. and performed an exam. An internal monitor was placed. The patient was 5–6 cm, 90 percent effaced, and at 0 station. The fetal monitor reflected a rate of 120–130 with good variability.

At 9:30 A.M., the anesthesiologist placed an epidural. The fetal monitor recorded a deceleration with a return to baseline at 120 after placing the epidural and starting the infusion. The patient was repositioned. The maternal blood pressure was recorded at 178/88. The anesthesiologist instructed the nurse to keep him and the attending physician advised of the maternal blood pressure.

At 10:07 A.M., the nurse was called to assist with another patient. She reassured the patient that there was centralized monitoring. At 10:20 A.M., she returned to the room. The patient’s contractions had increased in their frequency and intensity. The fetal monitor strip recorded a period of deceleration, then acceleration, with a return to a baseline of 100–110. The patient’s blood pressure was recorded at 180/100. The patient expressed a strong urge to push. The nurse repositioned the mother again, applied oxygen, and called the attending physician. The nurse reported to the attending physician that the mother’s blood pressure was “going up” and that the patient was feeling the urge to push. The nurse reported that the fetal heart rate (FHR) demonstrated “some variability.” The attending physician said that she would be there “shortly.”

The attending physician arrived on the unit at 10:35 A.M. She immediately noticed that the fetal monitor strip recorded a 12-minute period of deceleration. An exam revealed that the patient was fully dilated, 100 percent effaced, and at +2 station. The mother was pushing and the FHR had dropped from 110 to the low 90s. A vaginal delivery was initiated, utilizing vacuum assist and forceps attempts, but eventually converted to an emergency cesarean delivery.

The infant was fully resuscitated upon delivery and transferred to the NICU. She was eventually transferred to a children’s hospital for long-term care and was diagnosed with hypoxic ischemic encephalopathy.

Summary
This case study provides a good example of how a structured communication protocol between the physician and the nurse would have reduced or prevented the severity of the outcome. Here is how the SBAR model for communication could have been applied in this case:
 
  • Situation: The nurse identifies herself and provides a concise statement of the problem. What is going on at the present time?
    Example: This is Nurse Jones from L/D. I am calling about Mrs. Taylor in Suite 1. The problem is fetal monitor changes and an elevated blood pressure.
  • Background: She briefly relays the patient’s history and any information related to what has occurred.
    Example: She provides information such as FHR variability, baseline changes, and the patient’s blood pressure and contraction pattern.
  • Assessment: She conveys her clinical impression, assessment of the problem, and level of concern.  
    Example: I think labor is progressing, and I am concerned about maternal and fetal stress.
  • Recommendation: She requests action.
    Example: I need you to see the patient immediately.

As part of a national patient safety initiative, organizations such as the Joint Commission and National Patient Safety Foundation have repeatedly demonstrated that effective communication reduces error and protects patients. SBAR and other communication techniques facilitate a more consistent and concise exchange of information and play a key role in delivering safe patient care.

J4281 10/08

 

About the Author

This article was written by Cynthia Morrison, BSN, ARM, CPHRM, Patient Safety/Risk Management Account Executive, Eastern Regional Office.


 

The guidelines suggested here are not rules, do not constitute legal advice, and do not ensure a successful outcome. The ultimate decision regarding the appropriateness of any treatment must be made by each health care provider in light of all circumstances prevailing in the individual situation and in accordance with the laws of the jurisdiction in which the care is rendered.