| From: "Obstetrical
Nursing Malpractice Issues", by Joanne McDermott and
Gretchen Aumann in Nursing
Malpractice, Third Edition, edited by Patricia Iyer
and Barbara Levin:
Labor and Delivery: High Risk
Some practices in obstetrical nursing are
especially vulnerable to problems and subsequent allegations
of malpractice. Some would argue that the increase in litigation
of obstetrical cases is directly proportional to advances
in technological capabilities during pregnancy, labor and
delivery. However, while cases involving problems with fetal
monitoring do constitute a significant percentage of liability
claims against nurses, the majority of nursing liability problems
arises from other "low-tech" sources. Seven major
omissions that form the basis for many obstetrical nursing
malpractice cases include:
A. Failure to appropriately monitor maternal
and fetal status; failure to correctly interpret fetal monitor
strips
B. Inappropriate oxytocin administration, use or monitoring
C. Failure to notify the physician in a timely fashion
D. Initiation of procedures without adequate client information
or consent
E. Improper sponge and instrument counts during cesarean surgery
F. Failure to use chain of command when physician does not
respond quickly or appropriately.
G. Failure to recognize signs of uterine rupture
A. Failure to appropriately monitor maternal
and fetal status; failure to correctly interpret fetal monitor
strips
The Controlled Risk Insurance Company (CRICO) provides professional
liability insurance to all Harvard-affiliated physicians,
healthcare institutions, and their employees. Between 1987
and 1996, nurses were named in 70 percent of all CRICO claims
that named non-physicians, and 14 percent of all CRICO claims.
The most frequent allegation in CRICO’s perinatal case
is delay in diagnosis of fetal distress. Delay in diagnosis
of fetal distress is a national phenomenon and was reported
in 1998 to be a factor in 88 percent of malpractice cases
related to neurologically impaired newborns, up from 41 percent
ten years earlier. Liability regarding fetal heart-rate monitoring
most frequently attaches to the nursing staff, as the nurse
is the primary healthcare provider for a woman in labor. Before
the advent of electronic fetal heart-rate monitoring, nurses
and physicians auscultated the fetal heart tones with a weighted,
oversized stethoscope or a "fetascope" (a stethoscope
with an additional metal headpiece that relied on bone conduction
through the listener's skull to pick up fetal heart tones).
Fetal heart rates were counted "manually" by the
individual listeners, which obviously built in great variations
in accuracy.
The invention of the electronic fetal heart-rate
monitor permitted more accurate assessment of fetal response
to contractions and labor. Electronic fetal heart-rate monitoring
(EFM) is accomplished by means of an ultrasonic transducer
placed externally, or an electrode placed internally on the
fetal presenting part (usually the infant's scalp). The heart
rate is printed on a continuous strip of graph paper as a
continuous line or tracing. Uterine contractions are most
frequently measured by an externally placed device. An internal
uterine pressure monitor is also available, but is used less
often than the external monitor, primarily when the adequacy
of contractions is questionable, such as in labor arrest difficulties.
This information is printed continuously on a two-channel
recorder.
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