For the vast majority of mothers, childbirth goes normally, naturally, and with few or no complications. However, a recent report of obstetrics liability claims by medical insurer Coverys provides a shocking wake-up call regarding maternal and fetal health risk. Especially as it pertains to the labor and delivery room.
The study analyzed 10,618 closed medical professional obstetrics claims between 2013 and 2017. It found that obstetrics was the 5th most common claim allegation across all categories. Eighty percent of the claims were of high severity. Either the mother, infant, or both, died in 24% of these cases.
Perhaps the most disturbing finding from the report was that 40 percent of these obstetrics claims were related to poor management during labor and delivery. The report noted a lack of standardization and clinical training. This poor management was specifically related to fetal heart monitoring as a major factor behind these startling numbers.
Many of the nurses involved in the claims were new to the labor and delivery unit. They had not been fully trained to read electronic fetal monitoring strips. Nor did they understand the importance of acting upon warning signs in a timely manner to prevent red flags from becoming tragedies.
While liability is always a concern in obstetrics, the greatest worry for those of us in the field is that of fetal health and safety, and the safety of their mothers.
A 2011 study found that fetal heart monitoring was associated with a significant decrease in both neonatal morbidity and mortality.
The authors surmised that the reason for this decrease was related to biological factors. These factors were associated with certain fetal heart patterns that precede hypoxia, academia, and death. The use of electronic fetal monitoring allowed for earlier detection of such patterns and thus, timely interventions by obstetric staff.
Continual fetal monitoring
In the United States, continuous fetal monitoring (CFM) has been the standard of care in hospitals nationwide. Clinicians use a doppler fetal monitor on the mother’s abdomen to listen to the heart rate of the fetus and monitor contractions in the woman’s uterus continuously during labor.
Whereas CFM once resulted in a long strip of paper showcasing the infant’s heartbeat, heart rate patterns (“tracings”) are now stored electronically. They are viewed on monitors throughout the unit.
Medical staff can log into a portal to see the tracings for each patient in real-time. This allows them to monitor and intervene quickly should the need arise.
Usually, the fetal heart rate is monitored in coordination with uterine activity, such as contractions, to allow for greater insight into labor.
Clinicians use both pieces of information – fetal heart rate and uterine activity – to interpret the heart rate monitor data and assign a category to the tracing – I, II or III:
- Category I is normal and does not require intervention
- Category II is “indeterminate.” It may require some corrective measures throughout the labor, such as changing the mother’s position
- Category III is considered abnormal and high risk.
If the tracing indicates a category III, the delivery is typically expedited, many times via c-section.
This has resulted in some controversy around the overuse of CFM among low-risk women and its impact on the number of c-sections that come about as a result of misinterpreting the patterns in the heart rate.
For example, a recent article in Scientific American highlighted this issue, pointing to the fear of litigation among providers as a major factor for the surge in expediting interventions among low-risk mothers, such as:
- Oxytocin stimulation
- Forceps deliveries
The report also emphasized that reading the monitor data can be an imprecise science – what appears to be a distress signal for one provider may be interpreted as a normal reading to another.
CFM is the standard of care
While the article points to CFM’s potential for misinterpretation, it simultaneously emphasizes the point that CFM is the standard of care employed by most hospitals.
Therefore, training staff to accurately and systematically interpret findings is critical. The goal should be to make the best decision for the health of the infant and the mother.
This may sometimes mean an expedited delivery is the best course of action. However, the training should also emphasize that in many cases, especially among low-risk women, this is not the only option.
Training on fetal heart rate monitoring
Right now, regular, repeated training on fetal heart rate monitoring isn’t always mandatory. The requirement is up to the individual hospital.
Ongoing education and training on how to evaluate fetal heart rate patterns are vital to ensure that clinicians interpret fetal heart rate data in a standardized way. Because of that, Ob Hospitalist Group (OBHG) requires our team of more than 700 physicians and midwives nationwide to complete fetal heart rate training every two years.
In addition to this training, our OBHG leadership has mandated even stricter standards when it comes to training test scores. This includes interpretation of the data being shown through fetal heart rate monitoring.
It also includes supplementary measures to determine whether an intervention is needed especially in the case of a patient with category II tracings. This is because it is when the majority of c-sections for non-reassuring fetal heart tones tends to take place.
The American College of Obstetricians and Gynecologists (ACOG) offers a number of electronic fetal monitoring courses that should be on every OB/GYN’s priority list.
The Perinatal Quality Foundation, a non-profit, is dedicated to improving the quality of obstetrical services in the United States. It also provides an electronic fetal monitoring credential for obstetrical nurses, nurse midwives, and obstetricians.
Interpreting the patterns
Interpreting the patterns found in fetal heart rate monitoring and uterine activity depends on an understanding of the language of the data. This allows providers to correctly assign the category it corresponds to and intervene appropriately.
While this can be taught in a number of ways, ongoing training greatly improves the consistency in interpretation among staff. This translates into better outcomes for patients.
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The bottom line
Hospitals and physician groups must make sure that labor and delivery staff is properly trained to recognize and respond to fetal monitoring output. This will ensure that quality of care and great patient outcomes are a standard feature of our labor and delivery units.
Mark Simon, M.D., CMO
Dr. Mark Simon, Chief Medical Officer Officer at Ob Hospitalist Group (OBHG), is a board-certified OB/GYN and former head of the Department of Obstetrics and Gynecology for a U.S. hospital.