Claims RX February 2023 - Labor and Delivery Team: Communication Strategies for Risk Reduction
Labor and delivery team communication breakdowns can contribute to delivery delays. When delay is followed by infant death or disability, the risk of liability exposure is high. With the goal of increasing patient safety and decreasing medical liability exposure, members of the labor and delivery team are encouraged to consider and, where appropriate, implement the risk reduction and patient safety strategies introduced in this article.
Postpartum depression (PPD) is a serious mental illness that can affect women after they give birth. It can cause a variety of symptoms, including sadness, anxiety, fatigue, and difficulty bonding with the baby. PPD can have a negative impact on the mother's health, the baby's health, and the family's overall well-being.
- The American College of Obstetricians and Gynecologists’ Committee opinion on perinatal depression can be found here.
- A standardized, validated tool such as the Edinburgh Postnatal Depression Scale (EPDS) can be found here.
- For more information and resources on postpartum depression, visit Postpartum Support International (PSI).
A birth plan should be a clear and concise document that outlines the individual's preferences for their birth experience, while remaining flexible to the unpredictable nature of labor and delivery. It is important to discuss the birth plan with each patient before labor and delivery to ensure the plan is understood and feasible within the context of the individual's medical situation.
Considerations when developing a birth plan:
- Labor and delivery preferences: This includes things like location of delivery (hospital, birthing center, home birth), preferred delivery method (vaginal birth or cesarean section), and pain management options (such as epidural or natural pain management techniques).
- Neonatal care preferences: This includes things like feeding preferences (breastfeeding or formula feeding), delayed cord clamping, skin-to-skin contact after birth, and circumcision preference.
- Special requests: This includes any special requests that the individual has, such as music preferences, photography or videography during labor and delivery, or religious or cultural traditions that should be observed.
- Medical concerns: This includes any allergies or medical conditions that may affect labor and delivery, medications that should be avoided during labor and delivery, and special medical interventions that may be necessary.
The American College of Obstetricians and Gynecologists (ACOG) supports vaginal birth after cesarean (VBAC) for most women with a prior cesarean delivery. ACOG recognizes that VBAC can be a safe and appropriate option for most women who have had a prior cesarean delivery, including those with two previous low transverse cesarean incisions.
- Hospitals and birthing centers offering VBAC should have emergency cesarean delivery resources
- Obstetric care providers should be skilled in vaginal birth, cesarean delivery, and management of complications
- Women considering VBAC should receive counseling on risks and benefits
- Decisions regarding mode of delivery should be individualized
In summary, ACOG supports VBAC as a safe and appropriate option for most women with a prior cesarean delivery, provided that appropriate resources and skilled care providers are available, and that women are fully informed of the risks and benefits of VBAC. Ultimately, the decision to attempt VBAC should be individualized and based on the woman's medical history, obstetric risk factors, and personal preferences.
- Doulas are trained to provide emotional and physical support to women during labor and delivery.
- Doulas do not offer medical care but are there for the emotional support of the mother. If hospitals utilize doulas, there should be written guidelines regarding the role.
The American College of Obstetricians and Gynecologists (ACOG) recognizes midwives as important members of the maternity care team and supports collaborative practice between midwives and obstetricians. However, like any medical intervention, there are potential risks associated with the use of midwives. Some of these risks include:
- Midwives’ scope of practice comparatively limited to that of obstetricians, as they are not educated, trained, or equipped to handle certain complications that can arise during pregnancy and childbirth.
- Limited access to medical interventions: Midwives may not have access to medical interventions such as epidurals or cesarean sections, which may be necessary in certain situations.
- Delay in emergency care: Midwives may not be able to provide immediate emergency care in the event of a complication, which could result in serious harm to the mother or baby.
- Inappropriate patient selection: In some cases, midwives may not appropriately identify high-risk pregnancies or may encourage women to deliver at home when a hospital birth may be safer.
- Lack of coordination with obstetricians: Collaboration between midwives and obstetricians is important for ensuring the best possible outcomes for mother and baby. If midwives and obstetricians are not working together, important information may be missed or overlooked.
- It is important to note that these risks are not unique to midwives and can also occur in any type of childbirth setting. The decision to use a midwife or obstetrician should be made based on the individual needs and preferences of the mother, as well as the medical circumstances surrounding the pregnancy and delivery.
- Midwives Alliance of North America (MANA)
- Resources and information about the midwifery laws in each U.S. state or territory
- Termination of care for a pregnant patient should be given special consideration.
- During the first trimester, termination should occur only if the pregnancy is uncomplicated, and the patient has sufficient time to find a new practitioner.
- In the second trimester, termination is permissible for uncomplicated pregnancies only, provided the patient has already transitioned to another practitioner before the cessation of services.
- In the third trimester, termination should generally be avoided and should occur under exceptional circumstances only.
- The American College of Obstetricians and Gynecologists (ACOG) has published guidelines for obstetricians who are considering terminating a pregnant patient from their care.
- ACOG emphasizes the importance of maintaining continuity of care, patient autonomy, and ethical considerations.
- Termination of care may be considered under certain circumstances, such as repeated missed appointments, non-compliance with recommended care, threatening or violent behavior toward healthcare providers or staff, and inappropriate or unreasonable demands or requests.
- Every effort should be made to address the issues with the patient and work collaboratively to resolve them before terminating care.
- In cases where termination of care is deemed necessary, ACOG recommends providing the patient with a written notice of termination, offering to transfer care to another provider, ensuring adequate time to find a new provider, and addressing the patient's medical needs until they establish care with a new provider.
Overall, ACOG emphasizes the importance of maintaining patient autonomy and ensuring the patient's medical needs are met, while also recognizing the need for obstetricians to protect themselves and their staff from abusive or threatening behavior.
State laws on patient abandonment vary, and some states’ laws are more specific than others.
Contact a ProAssurance Risk Management Consultant (844-223-9648 or RiskAdvisor@ProAssurance.com) for guidance on properly ending a physician-patient relationship.
We are committed to keeping you informed and protecting your practice of medicine as it relates to the professional liability implications of the U.S. Supreme Court’s ruling on Dobbs v. Jackson Women's Health Organization, which overturned Roe v. Wade and Planned Parenthood v. Casey.
- The American College of Obstetricians and Gynecologists (ACOG) recommends the use of chaperones during certain gynecologic exams and procedures.
- A chaperone may be used if the patient requests one or if the physician feels it is necessary.
- ACOG does not provide specific guidance regarding the qualifications or training required for a chaperone, but they do suggest that the chaperone be a trained healthcare professional, such as a nurse or medical assistant.
- The chaperone should also be of the same gender as the patient unless the patient requests otherwise.
- The purpose of a chaperone is to provide emotional support to the patient and to prevent any potential misunderstandings or inappropriate behavior during the exam or procedure.
- The chaperone should not interfere with the physician's ability to perform the exam or procedure and should maintain confidentiality and professionalism at all times.
Overall, while ACOG recommends the use of chaperones in certain situations, the decision to use one ultimately depends on the patient's preferences and the physician's clinical judgment.
Contact our Claims Intake Hotline if an adverse event occurs that you think could become a claim. Our claims specialists can then assist you in disclosure and communication with the patient and family. Call our Claims Intake Hotline toll-free at 877-778-2524 or email ClaimsIntake@ProAssurance.com.
- Ensure open, sincere, and effective communication with the patient and their family, if an adverse event or unanticipated outcome occurs in your practice.
- Doing so may mitigate the risk of a potential claim or lawsuit and may be necessary due to mandatory state disclosure laws.
General guidelines for communicating with the patient or family after an adverse event:
- Plan what you intend to say and review your plan with a ProAssurance Claims Specialist, if possible.
- Consider having a fact witness present during the discussion, perhaps your nurse or one of your partners.
- Spend plenty of time with the patient and family members. Listen to their questions and answer them to the best of your ability.
- Focus on the patient, not on yourself.
- Sincerely acknowledge the patient’s and/or family’s suffering. Do not belittle a complication. Do not point fingers or blame other physicians or staff members.
- Apologizing for the fact that the incident occurred may be appropriate. Example: “I’m sorry this has happened to you, and I want to assure you I’ll continue to oversee your care.”
- Do not overwhelm the patient and family with information. In complicated cases, it is best to schedule multiple conversations so they can better digest the information.
- Discuss the patient’s current condition and continued treatment, as well as the event’s definitive medical consequences on the patient’s health (if known).
- Do not speculate. If you do not know what happened, admit this. Then tell the patient and family you are investigating the situation and will let them know as soon as you have answers.
- Assume all conversations with patients are being recorded and conduct conversations accordingly.
- Provide the patient and family with your contact information.
Document the discussions, including:
- The date, time, and location of the discussion.
- The parties and relationships of those present.
- Your commitment to share additional information as it becomes available and to assist the patient and family.
Do not make any admissions of liability or statements of blame. Do not make any references to the cause of the outcome or any future peer review proceedings.
For more information, see Two Minutes: What’s the Risk? Unexpected Outcomes.