Common Factors | Fall 2022

Top Risk Driver— Obstetrical Processes

Obstetrical claims are few, but the harm events that drive these claims
are dire and incur costs nearly as high as surgical and diagnostic errors.

By Lori Atkinson, RN, BSN, CPHRM, CPPS and Liz Lacey-Gotz

Pregnancy can be a risky business—for women, their babies and the health care organizations that care for them. In the United States, roughly 700 women die each year from pregnancy-related complications, according to the Centers for Disease Control and Prevention.1 So it’s not surprising that obstetrical (OB) claims are among the most costly—while they represent only 4% of all claims, the severity involved drives costs to 18% of all claims. Sadly, 66% of OB claims result in permanent injury or death.
By definition, OB claims involve a mother and/or fetus/newborn and occur during the prenatal period of a pregnancy or after delivery. The majority of claims are alleged against obstetricians, but secondary responsible clinicians, such as nurses or family medicine clinicians, may also be involved. In fact, 45% of OB claims involved a secondary responsible clinician, and almost half of those claims involved nursing and an alleged delay in recognition and treatment of fetal distress. This highlights a gap in fetal monitoring and team communication skills that can prove devastating for mothers and babies.

The top allegation triggering OB claims is a delay in the treatment of fetal distress. This significant issue accounts for 19% of OB claims, and represents a disproportionately large 33% of costs.

Obstetricians are the top clinician responsible for care in OB claims, but a significant number of claims involved family medicine, and claims often involved a secondary responsible clinician. This highlights a troubling gap in fetal monitoring and team communication skills. Claims involving obstetricians were usually more about improper performance of vaginal delivery and technical skill, while claims involving family medicine were more about failure to recognize and treat fetal distress, and failure or delay in obtaining a consult. Most OB harm events occurred during care provided in the labor and delivery room, once again highlighting the teamwork component in providing safe OB care.

Case by Case

Case 1

OB claim: Nursing team fails to monitor fetal heart rate properly and newborn suffers permanent injuries.

A 26-year-old pregnant woman was admitted to the hospital at 7:00 a.m. for induction at 42 weeks gestation by her obstetrician (OB). An hour after induction began, the baseline fetal heart rate (FHR) was 145–150 with accelerations present. Contractions were noted every 4–5 minutes. The OB ordered intermittent (every 15 minutes) electronic fetal monitoring (EFM). At 1:30 p.m., the OB was in to examine the woman and ruptured her membranes with clear fluid. The OB noted the cervix was 2–3 cm dilated, 90% effaced and that the FHR pattern looked “good.” The OB ordered that the woman could be up in the room moving about with intermittent EFM. About one-half hour later, the nurse noted decelerations but did not notify the OB. At 4:00 p.m., the woman was placed on a birthing ball and there were no more EFM tracings until 5:00 p.m. when the nurse noted variable decelerations.
At 6:08 p.m., the nurse noted the FHR was in the 70s and placed the woman in the bed on her left side with oxygen. The nurse called the OB, who arrived within 10 minutes. The OB applied a scalp electrode and noted the FHR was in the 70s with absent variability. The surgical team was called and the woman was taken to the OR at 6:38 p.m. At 6:47 p.m. a baby girl was delivered by emergent C-section with a true knot noted and Apgars were 3, 5, 6. The baby was transferred to a tertiary medical center and determined to have suffered fetal bradycardia with subsequent newborn respiratory distress and acidosis. At 5 years of age, the child has spastic cerebral palsy, is unable to speak and walks only with a walker and gait trainer braces, or uses an assistive wheelchair.
The experts who reviewed the care were critical of the nursing team for failing to recognize and report the variable decelerations early in the afternoon. They were also critical when the nurse noted a “signal loss” on the strip that indicated there was a loss of the heartbeat without making an attempt to locate the fetal heart tones for over 20 minutes, as well as the failure to note any FHR for over an hour from 4:00–5:00 p.m. The experts were critical of the OB for calling in for an update in the afternoon but not asking for specifics about the FHR.

These contributing factors played a role in the allegation of delay in treatment of fetal distress:

Communication breakdowns within the care team about the patient’s condition

Breakdowns in communication within the care team.

Case 2

OB claim: An obstetrician and the nursing team fail to respond appropriately after a young woman has a postpartum hemorrhage.

A young woman with an uncomplicated pregnancy was referred by her family physician (FP) to an obstetrician (OB) for a repeat cesarean delivery. After being admitted to the hospital, the cesarean delivery was performed without incident at 10:00 a.m. by the OB with the FP assisting. The OB then left the hospital to drive to a nearby town to see patients.
After being transferred from the recovery room to the postpartum unit around noon, the woman began complaining of abdominal pain and passed two softball-sized blood clots. The nurse called the OB, who ordered medications to control the bleeding. Over the next several hours, the nurses called the OB multiple times reporting that the woman was continuing to bleed. During this time, the OB ordered six more injections of Hemabate and an IV infusion of Lactated Ringers with Pitocin. The OB then ordered two units of packed red blood cells (RBCs) because the woman’s hemoglobin was 5.8. The nurse hung the first unit at 4:00 p.m. By 5:30 p.m., despite the two units of packed RBCs, the woman’s blood pressure was dropping and the nursing notes described her as very pale, restless and continuing to complain of abdominal pain.
At 6:45 p.m., the woman became unresponsive and went into cardiopulmonary arrest. A code was called, but resuscitation was unsuccessful and the woman died. The autopsy concluded the cause of death was exsanguination. Her family later filed a malpractice claim against the OB and the hospital alleging improper management of a postpartum patient resulting in death. The malpractice claim was settled with payment against the hospital and the OB.
The experts who reviewed the care were critical of the hospital because there wasno escalation up the chain of command by the nursing team when the woman continued to bleed, and the OB managed the patient from another city by phone only. They were also critical because the hospital had no massive transfusion protocol in the event of an obstetrical hemorrhage situation. The experts were critical of the OB for failing to order a complete blood count (CBC) earlier to evaluate the woman’s hemoglobin and hematocrit, for failing to respond to repeated calls from the nursing team about the continued bleeding, and for failing to call in a surgical consult to place sutures in the uterus when the bleeding continued despite measures to stop it.

These contributing factors played a role in the allegation of improper management of a postpartum patient:

Breakdowns in
team communication

Failure to have massive
transfusion protocol

Technical performance issue in failing to institute a massive transfusion protocol

Patient assessment issue

Breakdowns in team communication

Failure to order a surgical consult

Obstetrical Processes Risk Management Tips:

  • Provide joint clinician and nursing team training on fetal monitoring skills using programs such as GE Healthcare’s Electronic Fetal Heart Rate Monitoring program.
  • Perform simulation drills on low-frequency, high-severity events (e.g., hemorrhage, shoulder dystocia, prolapsed cord).
  • Use OB documentation templates embedded in your electronic health record.
  • Implement evidence-based Maternal Patient Safety Bundles to guide practice.
  • Invest in team training and communication skills and use tools such as SBAR and I-PASS.
  • To access resources to mitigate risk factors in OB processes, Sign in to > Risk Resources > Bundled Solutions>OB Risk Solutions

Presenter Lori Atkinson

Content Manager and Patient Safety Expert