Weekend Call Presents Unique Challenges with Surrogate Birth

Amy Wasdin, RN, CPHRM, Patient Safety Risk Manager, Department of Patient Safety and Risk Management.

Weekend call is a responsibility that is common to most obstetricians who have hospital privileges. That responsibility often includes unique challenges that may require risk management interventions. Consider the following case involving a surrogate birth.

Case Example

A patient at 35 weeks’ gestation with twins presented to the local hospital’s maternity emergency department and requested to be examined. She was concerned because she was having contractions that were increasing in frequency and duration. Her obstetrician was out of town. Another obstetrician, who was unfamiliar with the patient, was covering call for the weekend.

After examining the patient, the on-call obstetrician learned that the patient was a surrogate. He also learned that a birth plan had not been established and that the patient and adoptive parents had differing views about expectations for the birth process. The on-call obstetrician was able to contact the patient’s primary obstetrician, who provided additional patient information but was unable to come to the hospital to manage the patient's care.

The patient was offered a trial of labor as her condition warranted, but the adoptive parents were adamantly opposed to it. The dynamics of the situation declined as discussions focused on visitors to the patient’s hospital room. The patient was permitted to have visitors, but she did not want family members of the adoptive parents in the room.

The patient elected to have a vaginal birth and delivered Baby A without incident. Immediately after the birth of Baby A, Baby B exhibited fetal distress with a sustained drop in heart rate that was unresponsive to maternal interventions, including repositioning, oxygen, and intravenous fluid boluses. A decision was made to deliver Baby B by stat C-section.

Baby B was delivered successfully by C-section and required supplemental oxygen for several hours. When both babies were stable, they were discharged from the hospital to the care of the adoptive parents.

This challenging experience provided valuable insight for the on-call obstetrician. Communication between a patient and her care provider is a key factor in meeting treatment goals and ensuring that the patient has a positive experience. In the case of a surrogate pregnancy, good communication among care providers, patient, and adoptive parents is essential. If critical information—including a contingency plan—is not established prior to a birth event, hospital staff members may be faced with a difficult situation.

In addition, it is important to understand a state’s relevant informed consent laws. Unless the law has determined otherwise, the patient can make care decisions for herself and the unborn child. The adoptive parents have no decision-making rights until the child is born.

Patient Safety Strategies

• Structure effective handoffs when transitioning the care of your surrogate patients to on-call providers, and include well-documented birthing plans.
• Familiarize yourself with state laws and the policies and protocols at your hospital or birthing center regarding surrogate births.
• Understand applicable HIPAA restrictions and facility policies regarding photography and visitation, and communicate them to the patient and adoptive parents.
• Discuss anticipated patient issues with maternity staff to prepare them for unique patient situations.
• Communicate clearly with surrogate patients, and discuss possible scenarios that may occur if unexpected situations arise. Provide specific scenarios in advance. Scenarios, as illustrated by the case example, include disagreements over a trial of labor, adoptive family visitors, and attendees present for the birth. The discussions may alleviate stress during the pregnancy and eliminate potential conflicts between the patient and adoptive parents.
• Accurately document the prenatal chart regarding expectations of surrogate and adoptive parents—including discussions concerning informed consent for the risks and complications of pregnancy, procedures, and medications. (For further guidance on informed consent, see our articles “Informed Consent: Substance and Signature” and “Informed Refusal.”)

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