Themes in Problem Obstetrical Cases

Those working in obstetric patient safety and quality improvement agree that certain themes recur in "near-miss" situations or when an adverse outcome occurs.

Clinical themes

  • Inadequate communication or a failed chain of communication, particularly during personnel changes, times with high census or acuity, and situations when communication occurs against an authority gradient
  • Deficiencies in EFM use and interpretation
  • Insufficient fetal surveillance and documentation in the hour before birth, whether NSD or cesarean section.
  • Surprise when an infant is born depressed and requires resuscitation
  • Lack of adherence to evidence-based guidelines when managing labor protraction and arrest disorders, including the use of cervical ripening and labor augmentation/induction techniques
  • Pushing the boundaries of safety because of secondary influences ("VIP" patients, productivity concerns, unit identity, personal issues)
  • Lack of clear decision analysis when managing a prolonged second stage of labor
  • Delay in consultation or transfer after antepartum evaluation or during intrapartum course
  • Inadequate notes for complex vaginal delivery: shoulder dystocia, forceps, vacuum
  • Failure to document placental inspection and/or send the placenta to pathology, according to guidelines
  • Failure to recognize and act on a clinical condition (hypertensive disorders of pregnancy, postpartum hemorrhage)
  • Failure to adequately and/or accurately document patient status and clinician thought process and actions
  • Lack of consistent and comprehensive guidelines and lack of underwater EFM equipment at sites conducting water birth

Unit culture themes

  • Clinical leadership and unit culture appear to be critical factors. A divide between medicine, midwifery and nursing appears to be a significant secondary influence in problem obstetrical cases.
  • Despite a plethora of available resources, some MDs, CNMs, and RNs at obstetrical sites do not appear to identify with any larger organization in terms of mission, policies, procedures, or resource utilization. They become insular and self-protective rather than collaborative. It is also true that staff members at larger organizations often do not react to queries or requests for assistance in supportive or useful ways.
  • The movement among patient safety advocates to reduce variation in clinical practice through the use of evidence-based clinical practice guidelines appears to have very little traction at some sites.
  • Clusters of problem obstetrical cases occur on the watch of a number of clinicians. Even after case review with experts, these individuals (RNs, CNMs, MDs) militantly stand by their care and attribute cause elsewhere. Remediation and progressive discipline are not instituted at the time that concerns are expressed because there is often a lack of documentation about the individual's practice, outcomes, and behaviors. This difficult situation is compounded when individuals are beloved by patients, acting as clinical leaders, or 'rainmakers.' The early-warning system in health care usually takes the form of one staff member expressing worry about another; yet it is unclear to staff and administration what they should do when this alarm sounds.

For more information about the Obstetric Safety Initiative, or to offer suggestions or additions to this site, contact us.