Preventing Delayed Treatment of Fetal Distress
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The Doctors Company conducted a study of claims and lawsuits involving neonatal injuries occurring in labor and delivery (L&D). Of the 247 neonatal injury claims that closed from 2007 through 2011, 36 percent (89 claims) included an allegation of delay in treatment of fetal distress. (Although the term “fetal distress” is vague and no longer recommended, the allegation of delay in treatment remains an important concept in understanding these claims and lawsuits.)
The claims review revealed the following:*
- Nurses failed to identify the fetal heart rate (FHR) tracing (usually Category II or III) as predictive of metabolic acidemia (11 percent). (Earlier terminology described these tracings as nonreassuring.)
- Nurses recognized FHR tracing as predictive of metabolic acidemia but failed to timely notify the attending physician (20 percent).
- Physicians did not go to the hospital after receiving calls from nurses with information about FHR tracings predictive of metabolic acidemia (14 percent). Of note, nurses did not document activation of the chain of command when physicians did not respond to the request.
- Physicians who were aware of concerning FHR tracings did not make a timely decision to initiate a cesarean section (43 percent). (Timely was defined by the expert reviewers.)
- Patient injury was due to undetermined causes (20 percent).
- Physicians used other interventions (vacuum extraction or forceps) to facilitate delivery when these concerning patterns were identified (20 percent).
- Cesarean sections were ordered but delayed (staff or operating room unavailable) (6 percent).
- The case abstract specifically referenced that physicians disagreed with nurses’ interpretations of FHR tracings (2 percent). This number may be higher based on the number of cases in which physicians failed to go to the hospital when called by the nurse (14 percent).
*Please note that more than one category applied in some of these cases.
Be proactive to ensure preparedness.
- Be knowledgeable of National Institute of Child Health and Human Development (NICHD) classifications.
- Maintain the technology to view monitor tracings when the physician is out of the hospital.
- Conduct L&D and OR site drills/simulation training to perform emergency cesarean sections in less than 30 minutes. Establish a system of anesthesia coverage and/or backup physician in house for OB emergencies.
Communicate in real time.
- Have the ability to view the tracing (by computer, fax, or other technology) if a nurse calls with a concern about a tracing.
- Engage in dialogue about the tracing, and assign a category and care plan that both the physician and nurse agree on.
- Ask the nurse if he or she wants the physician to see the patient. If the answer is yes, the physician should go to the hospital without delay. If the answer is no, the physician should ask, “Are you sure?”
- Develop an effective chain-of-command policy that will be readily activated if conflicts cannot be resolved by conventional means.
Prepare for second-stage complications.
- Do not regard tracings that would be of concern in the first stage of labor as normal for the second stage. This applies especially to recurrent variable decelerations.
- Implement a vacuum bundle as advocated by the Institute for Healthcare Improvement (IHI)1 with modifications:
|–||Consider alternative labor strategies.|
|–||Prepare the patient by discussing the risks, documenting consent, and ensuring physical preparedness (empty bladder).|
|–||Estimate the fetal weight (EFW), determine the fetal position and the station for high success probability, and document this information.|
|–||Predetermine maximum application time and number of pop-offs.|
|–||Plan an exit strategy (cesarean section in less than 30 minutes), and confirm that the components are available. Have the resuscitation team available.|
- Implement a protocol for care of the newborn after vacuum delivery.2
Addressing these themes proactively and in real time should become a strategic activity for physicians and nurses who staff obstetrics departments. Increased readiness for and recognition and management of complications, improved communications, and required technical skills should all work in concert to reduce the likelihood of these difficult and tragic outcomes.
1. Peter Cherouny, MD, “Vacuum Delivery Bundle” (lecture, IHI Perinatal Community: IHI Collaborative, 2007).
2. Michael Ross, MD, “Vacuum Delivery: What Can Go Wrong” (lecture, 27th Annual Conference on Obstetrics, Gynecology, Perinatal Medicine, Neonatology, and the Law, Boston University, January 2011).
Excerpted by Patti Herrera, RN, BSN, Patient Safety Analyst, from “Delay in Treatment of Fetal Distress” an article by Larry Veltman, MD, and Darrell Ranum, JD, CPHRM, that originally appeared in The Doctor’s Advocate, third quarter 2012 (www.thedoctors.com/advocate).
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.