Obstetrical Risk Reduction Strategies

In an analysis of obstetrical management claims, common issues were identified. The following recommendations reflect these recurring issues. They are presented by CAP with the intention of improving patient care and of maximizing the ability to defend that care.

Prenatal

Tape Measure

• Use a tape measure to obtain fundal height measurements.
• Record measurements in cms. and gestational age in weeks and compare.

Macrosomia​

• If identified, discuss Erbs Palsy risk and offer C-Section option.

Ultrasounds

• Obstetricians performing ultrasounds are held to the same level of expertise as radiologists and perinatologists.
• Obtain an ultrasound at 18-20 weeks. Obtain additional ultrasounds as clinically indicated.
• Ultrasound reports should be on a recognized form and reports should be complete.

AFP

• AFP coordinators may wish to "change the dates" based on an ultrasound or your exam. Be aware that any changes made may increase your liability risk.
• Gestational age should not be changed unless dates and ultrasound differ by two weeks.

Medications

• Consider a risk-benefit assessment before prescribing drugs.
• Avoid teratogens.
• Use a category A or B drug whenever possible. If a category C or D medication must be used, discuss and document the risks and benefits.

Laboratory

• Review and initial all reports.
• Record action taken from abnormal studies.

Consultation

• Obtain perinatology consultation whenever you have a concern.
• When a decision is made not to follow a consultant's recommendation, that decision should be addressed in the medical record.
• Refer for perinatologist evaluation discordant growth of multiple gestation greater than 15-25 percent.

VBAC Consent

• Use a form, signed by the patient, to document risk-benefit discussion and patient's desire.

NST

• Obtain other diagnostic tests when a NST is nonreactive or equivocal.
• Criteria: 15 beat elevation over baseline, lasting 15 seconds, two episodes present in a 20 minute window.

Biophysical profile

• Perinatology consultation and action are indicated for anmiotic fluid volumes less than five cms. and for profile scores less than eight.

Record Keeping

• Write or dictate comtemporaneously, if possible.
• Never alter records.
• Date and time all entries. Correctly date and identify late entries.

Obstetrician

• Patients expect their physician to be knowledgeable and in charge.
• Take time to answer any questions and return calls.

Labor

Admission

• Evaluate the patient yourself whenever there is any indication of a problem.

Examination

• Document each vaginal exam and include time, dilation, effacement and station.

Macrosomia

• As during prenatal care, document the issues discussed

VBAC

• Document, in the labor record, the patient's continued interest in pursuing vaginal delivery. If you recommend a C-Section, record conversation and patient's decision in the record.

FHR Monitoring

• Document beat-to-beat variability and presence of decelerations. Record plan for investigation and action.
• If fetal well-being is not established by criteria, evaluate further or deliver.
• Criteria: 15 beat evaluation over baseline, lasting 15 seconds, two episodes in a 20 minute window.

30 Minute Rule

• Record time the decision for emergency C-Section was made. If delivery can not occur within 30 minutes, document reason(s) for delay and your actions.

Nurses' Notes

• Read and address discrepancies in the labor record but avoid professional jousting.

DELIVERY

Fluid

• Record if clear. Note presence of meconium blood or any odor.

Forceps/Vacuum

• Record station and position of presenting part at application.
• Dictate a note, including the indications for operative delivery.

Shoulder Dystocia

• Dictate a note, including maneuvers performed.
• Avoid usage of fundal pressure.

Camera/Video

• When used, document camera vs. video (indicate with or without sound) and person filming.
• Be aware! Usage may help or hinder defensibility.

Cord Gases

• Cord Gases are the final evaluation of your care.
• Normal gases may rule out anoxia.

Rotation

• Document rotation description, i.e., OP, LOA.

Cord

• Record nuchal cord and number of loops. State if tight, loose or if cord had to be cut for delivery.

Placenta

• After exam, send to pathology if any of the following are present o Meconium stained
  • Appearance abnormal
  • Infection present
  • Existence of unusual conditions.
  • Prematurity
  • Fetal distress or neonatal depression
  • Maternal fever
  • Stillborn

Notes

• Dictate delivery notes, especially after any difficult delivery.

If you have questions about this article, please contact us. This information should not be considered legal advice applicable to a specific situation. Legal guidance for individual matters should be obtained from a retained attorney.