Effective Obstetrical Team Communication
Effective communication requires a team effort for the exchange of concise and relevant information. 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 provider 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 situation requiring immediate attention and action.
The following are examples of clinical situations that should be addressed by the use of a standardized protocol, such as SBAR:
- Nonreassuring 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.
- Suspected abnormal presentation.
- Elevated maternal temperature.
A 40-year-old woman with a history of fertility treatment and in her first successful pregnancy arrived at the hospital labor and delivery unit at 7:30 AM and reported the onset of contractions and spontaneous rupture of the membranes at 3:00 AM that morning. The on-call attending physician arrived by 8:00 AM and performed an exam. An internal monitor was placed. The patient was 5–6 cm dilated, 90 percent effaced, and at 0 station. The fetal monitor reflected a rate of 120–130 with good variability.
At 9:30 AM, the anesthesiologist placed an epidural. The fetal monitor recorded a deceleration with a return to baseline at 120 after placement of 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 AM, the nurse was called to assist with another patient. She reassured the patient that there was a centralized monitoring in place. At 10:20 AM, 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 AM. 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.
This case study provides a good example of how a structured communication protocol between the provider and the nurse could 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.
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: Fetal monitor reflects decelerations with return to baseline of 100–110, maternal BP is 189/100, and she has the urge to push.
- Assessment: She conveys her clinical impression, assessment of the problem, and level of concern. Example: I think labor is progressing, and I am uneasy about maternal 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.