Safety is declared as the hallmark of organizational culture and understood to be the responsibility and duty of every team member. Safety for mothers and babies is the number one priority and takes precedence over institution and provider convenience, production issues, and costs. Safety guides all unit operations and clinical actions. Decisions are made in the context of potential risks and benefits to patients. While institutional costs and financial resources are important and must be considered, patient safety is not at risk due to financial constraints. The administrative leadership team is committed to financially supporting the perinatal unit even if it is not one of the most profitable service lines. This commitment includes providing adequate personnel for leadership and clinical care and updated equipment as needed. Convenience is only a factor in decision making when there is no risk to patient safety. Patients are invited and encouraged to be actively involved in their care and are provided enough information to make decisions through a literacy-appropriate informed consent process.
Patient safety is considered a team function rather than an individual function. All clinicians are considered competent, with an obligation to speak up if there is a question of safety. Team interaction is collegial rather than hierarchical. Hierarchy does not hinder any clinician from expressing concern in the face of potential risks. Any member of the team is able to offer opinions and speak up in the context of risk of patient harm. Those alerts and opinions are welcomed by the entire team regardless of discipline or rank.
Respectful communication is highly valued and rewarded. Extensive, transparent communication is used to orient, plan, update, and adjust to the unexpected. Routine debriefing is practiced for critical, unusual, or unexpected events. Team members in high-reliability organizations do not wait until there is an adverse outcome to evaluate operations and practices. Evaluation is ongoing through use of established measurement processes.
Emergencies are rehearsed and unexpected events anticipated. During board rounds and case conferences, possibilities for adverse events based on clinical situations are discussed and plans are developed and in place should they occur. Team-building exercises and simulation practices for obstetrical emergencies are conducted on a regular basis.
Paradoxically, successful operations (absence of maternal, fetal, and neonatal injury) are viewed as potentially dangerous subject to risk of “normalization of deviance” (a degradation of professional, behavioral, and technical standards that occurs over time and increases probability of a major accident or harm). Because major accidents or patient harm occur only infrequently, clinical practice in the absence of professional standards and/or inaccurate processes (e.g., “work-arounds”) may go undetected or deteriorate over long periods of time.
where physicians and nurses are encouraged to work as a team, interact as colleagues, and collaborate on clinical solutions in a respectful manner. Our moral and ethical responsibility to do the right thing is discussed in detail in the Code of Ethics for Nurses (American Nurses Association [ANA], 2010). Adequate financial and personnel resource allocation and support for practices based on research findings that demonstrate safe and effective care are critical foundations of our moral and ethical responsibility to patients (ANA, 2010; Ryan, 2004).
Skilled communication: Nurses must be as proficient in communication skills as they are in clinical skills.
True collaboration: Nurses must be relentless in pursuing and fostering true collaboration.
Effective decision making: Nurses must be valued and committed partners in making policy, directing and evaluating clinical care, and leading organizational operations.
Appropriate staffing: Staffing must ensure the effective match between patient needs and nurse competence.
Meaningful recognition: Nurses must be recognized and must recognize others for the value each brings to the work of the organization.
Authentic leadership: Nurse leaders must fully embrace the imperative of a healthy work environment, authentically live it, and engage others in its achievement.
Ensure that patient-centered care and patient safety are organizational priorities that guide decisions for organizational policies and practices.
Foster a just culture of openness by encouraging and promoting the active communication of good outcomes and opportunities for improvement.
Develop forums to facilitate communication and tracking of issues of concern.
Provide resources for clinicians to be educated in the principles of teamwork, safety, and shared decision making.
Develop methods to systematically track and evaluate care processes and outcomes.
Facilitate cross-departmental sharing of resources and expertise.
Ensure that quality obstetric care is a priority that guides individual and team decisions.
Identify and communicate the safety concerns and work together to mitigate potential safety risks.
Disseminate and use the best available evidence, including individual and hospital-level data, to guide practice patterns.
unit policies and protocols and, ultimately, for how perinatal care is provided daily. An interdisciplinary practice committee, co-chaired by nurse and physician leaders, should be in place to guide unit operations and clinical care. This committee should include representatives from all disciplines (nurses, midwives, physicians) and specialty practice areas (obstetric, family medicine, pediatrics, neonatal, anesthesia), as well as leaders and direct care providers. The committee should be empowered to make policy changes as needed. There should be a standing agenda item each month to review the most recently published science and standards and guidelines from professional organizations and regulatory agencies such as ACOG, AAP, AWHONN, ACNM, the National Association of Neonatal Nurses (NANN), the Association of peri-Operative Registered Nurses (AORN), the American Society of PeriAnesthesia Nurses (ASPAN), the American Society of Anesthesiologists (ASA), TJC, the Centers for Disease Control and Prevention (CDC), the Institute for Safe Medication Practices (ISMP), the United States Department of Health and Human Services (HHS), the U.S. Preventative Services Task Force, and the U.S. Food and Drug Administration (FDA). Assigning committee members specific organizations to review each month and/or rotating responsibility among committee members for this review process will facilitate a comprehensive appraisal of recently published standards and guidelines and provide the committee with evidence upon which to promote practice changes. Discussion during the committee meetings should focus on how and when new standards and guidelines will be incorporated into unit operations and daily practice.
support high quality performance in their practical resource Using Workforce Practices to Drive Quality Improvement: A Guide for Hospitals (see Display 1-1).
Table 1-1. COMMON BARRIERS TO IMPLEMENTATION OF EVIDENCE-BASED CLINICAL GUIDELINES AND PARTICIPATION IN QUALITY IMPROVEMENT PROJECTS
Table 1-2. STRATEGIES FOR SUCCESSFUL IMPLEMENTATION OF EVIDENCE-BASED CLINICAL GUIDELINES
Communicating mission, vision, and values
Sharing performance information
Involving employees in key decisions
Tracking and rewarding performance
Reduced status distinctions
Teams/decentralized decision making
Linking management training to organizational needs
Tracking and rewarding performance
Commit to an organizational culture that focuses on quality and safety
Engage senior leadership support
Involve the human resources department in strategic planning
Identify opportunities for shared learning
Hire human resources professionals with training and experience with high performance work practices
Involve employee representatives
two of its elements of performance: (1) the hospital/organization has a code of conduct that defines acceptable and disruptive and inappropriate behaviors; (2) leaders create and implement a process for managing disruptive and inappropriate behaviors (TJC, 2012). Further, standards in the medical staff chapter list core areas of competence that must be covered in the credentialing process, including interpersonal skills and professionalism (TJC, 2012). Similar expectations for ongoing competence validation are in effect for nurses (ANA, 2010; TJC, 2012).
Educate all team members—physicians, nurse midwives, nurses, and other personnel—on appropriate professional behavior defined by the organization’s code of conduct. The code and education should emphasize respect. Include education in basic business etiquette (particularly phone skills) and people skills.
Hold all team members accountable for modeling desirable behaviors, and enforce the code consistently and equitably among all staff regardless of seniority or clinical discipline in a positive fashion through reinforcement as well as punishment.
Develop and implement policies and procedures/processes appropriate for the organization that address:
“Zero tolerance” for intimidating and/or disruptive behaviors, especially the most egregious instances of disruptive behavior such as assault and other criminal acts. Incorporate the zero-tolerance policy into medical staff bylaws and employment agreements as well as administrative policies.
Medical staff policies regarding intimidating and/or disruptive behaviors of physicians within a healthcare organization should be complementary and supportive of the policies that are present in the organization for other personnel.
Reducing fear of intimidation or retribution and protecting those who report or cooperate in the investigation of intimidating, disruptive, and other unprofessional behavior. Nonretaliation clauses should be included in all policy statements that address disruptive behaviors.
Responding to patients and/or their families who are involved in or witness intimidating and/or disruptive behaviors. The response should include hearing and empathizing with their concerns, thanking them for sharing those concerns, and apologizing.
How and when to begin disciplinary actions (e.g., suspension, termination, loss of clinical privileges, reports to professional licensure bodies).
Develop an organizational process for addressing intimidating and disruptive behaviors that solicits and integrates substantial input from an interprofessional team including representation of medical and nursing staff, administrators, and other employees.
Provide skills-based education and coaching for all leaders and managers in relationship-building and collaborative practice, including skills for giving feedback on unprofessional behavior and conflict resolution. Cultural assessment tools can also be used to measure whether or not attitudes change over time.
Develop and implement a system for assessing staff perceptions of the seriousness and extent of instances of unprofessional behaviors and the risk of harm to patients.
Develop and implement a reporting/surveillance system (possibly anonymous) for detecting unprofessional behavior. Include ombuds services and patient advocates, both of which provide important feedback from patients and families, who may experience intimidating or disruptive behavior from health professionals. Monitor system effectiveness through regular surveys, focus groups, peer and team member evaluations, or other methods. Have multiple and specific strategies to learn whether intimidating or disruptive behaviors exist or recur, such as through direct inquiries at routine intervals with staff, supervisors, and peers.
Support surveillance with tiered, nonconfrontational interventional strategies, starting with informal “cup of coffee” conversations directly addressing the problem and moving toward detailed action plans and progressive discipline, if patterns persist. These interventions should initially be nonadversarial in nature, with the focus on building trust, placing accountability on and rehabilitating the offending individual, and protecting patient safety. Make use of mediators and conflict coaches when professional dispute resolution skills are needed.
Conduct all interventions within the context of an organizational commitment to the health and well-being of all staff, with adequate resources to support individuals whose behavior is caused or influenced by physical or mental health pathologies.
Encourage interprofessional dialogues across a variety of forums as a proactive way of addressing ongoing conflicts, overcoming them, and moving forward through improved collaboration and communication.
Document all attempts to address intimidating and disruptive behaviors.
developing future policies and guidelines that decrease professional liability exposure and minimize the risk of iatrogenic injury to mothers and babies.
Failure to accurately assess maternal-fetal status over the telephone
Failure to advise the woman to seek clinic, office, or inpatient evaluation and treatment
Failure of the nurse to correctly communicate maternal-fetal status to the primary healthcare provider
Failure of the physician/nurse midwife to come to the hospital to see the patient when requested by the nurse
Telephone advice to pregnant patients from labor and delivery nurses should be limited to two comments: “Call your primary healthcare provider” or “Come to the hospital to be evaluated.” Ruling out labor and possible maternal-fetal complications cannot be done accurately over the phone. The liability for assessing and diagnosing conditions of pregnancy and labor should remain with the primary care providers rather than being assumed by the institution.
Failure to perform a medical screening exam for all pregnant women who present for care in the hospital
Failure to include a timely assessment of fetal status as part of the maternal medical screening exam
Delays in performing a medical screening exam (e.g., sending pregnant women who present for care to the waiting room before maternal-fetal status has been determined)
Failure to have a policy in place delineating conditions that require bedside evaluation by a physician or midwife prior to discharge after medical screening exam by a labor nurse
Failure of the provider to provide a bedside evaluation for pregnant women who present with high-risk medical or obstetric conditions
Discharge of a pregnant woman without establishing fetal well-being (e.g., for women at 28 weeks or greater, a reactive nonstress test)
Discharge of a pregnant woman who is unstable for discharge (e.g., in labor or with ongoing high-risk medical or obstetric conditions requiring inpatient care)
Failure to meet all aspects of the Emergency Medical Treatment and Labor Act (EMTALA) regulations in assessing, treating, and discharging a pregnant women who presents for care
EMTALA imposes specific obligations on healthcare providers who offer triage care (a) to perform a medical screening examination to determine whether an emergency medical condition exists (including both the mother and the fetus), (b) to provide necessary stabilizing treatment when an emergency medical condition exists, and (c) to stabilize the patient, or, if the healthcare provider certifies that the benefits of transfer outweigh the risks, arrange for proper transfer to another hospital (The Consolidated Omnibus Budget Reconciliation Act [COBRA], 1985; United States Department of Health and Human Services, Centers for Medicare & Medicaid Services 2003, 2009). It is specifically prohibited to use the patient’s insurance status and/or ability to pay for care as factors to determine whether a medical screening examination will be provided.
Pregnant women may come to a hospital’s labor and delivery area not only for obstetric care but also for evaluation and treatment of nonobstetric illness. Departments should agree on the conditions best treated in the labor and delivery area and those that should be treated in other hospital units. A pregnant woman who presents for care should be evaluated in a timely (not currently defined by AAP & ACOG, 2012) fashion. Minimally, the evaluation by an obstetric nurse should include assessment of maternal vital signs, FHR, and uterine contractions. Further evaluation includes assessment for vaginal bleeding, acute abdominal pain, temperature of 100.4°F or higher, preterm labor, preterm premature rupture of membranes, hypertension, and indeterminate or abnormal FHR pattern. If these findings are present or suspected, the responsible obstetric care provider should be promptly informed (AAP & ACOG, 2012).
The initial triage process (10 to 20 minutes) requires one nurse to one woman presenting for care. This ratio may change to one nurse to two to three women as maternal-fetal status is determined to be stable, until patient disposition (AWHONN, 2010).
Any patient suspected to be in labor or who has ruptured membranes or vaginal bleeding should be evaluated promptly (not currently defined by AAP & ACOG, 2012). Minimally, the following should be assessed: maternal vital signs; frequency and duration of uterine contractions; documentation of fetal well-being; urinary protein concentration; cervical dilatation and effacement, unless contraindicated (such as with placenta previa and preterm premature rupture of membranes), or cervical length as ascertained by transvaginal ultrasonography; fetal presentation and station of the presenting part; status of the membranes; estimated fetal weight; and assessment of maternal pelvis. Along with these assessment data, date and time of the patient’s arrival and notification of the primary obstetric care provider should be included in the medical record (AAP & ACOG, 2012).
If the woman has received prenatal care and a recent examination has confirmed the normal progress of pregnancy, her triage evaluation may be limited to an interval history and physical examination directed at the presenting condition. Previously identified risk factors should be considered and reassessed. If no new risk factors are found, attention may be focused on the following historical factors: time of onset and frequency of contractions; presence or absence of bleeding; fetal movement; history of allergies; time, content, and amount of the most recent food or liquid ingestion; and use of any medications (AAP & ACOG, 2012).
Failure to accurately assess maternal-fetal status
Failure to accurately distinguish, assess, and record FHR tracings of all fetuses in a multiple gestation pregnancy
Failure to determine that the tracing being recorded is of maternal rather than fetal origin
Failure to appreciate a deteriorating fetal condition
Failure to appropriately treat an indeterminate or abnormal FHR in a timely manner (e.g., initiate intrauterine resuscitation measures based on the FHR pattern and/or plan for expeditious birth when appropriate)
Failure to accurately communicate the maternal-fetal status to the physician/nurse midwife
Failure to convey specific requests for bedside evaluation based on concern for fetal status to the physician/nurse midwife
Failure of the physician/nurse midwife to respond appropriately when notified of indeterminate or abnormal fetal status
Failure to institute the chain of consultation when there is a clinical disagreement between the nurse and responsible physician/nurse midwife regarding fetal status
Use the terminology recommended by the National Institute of Child Health and Human Development (NICHD) (Macones, Hankins, Spong, Hauth, & Moore, 2008), ACOG (2010a), and AWHONN (Lyndon & Ali, 2009) to describe FHR patterns in all professional communication and medical record documentation concerning fetal assessment via electronic fetal monitoring (EFM).
Establish ongoing interdisciplinary fetal monitoring education (JCAHO, 2004). Knowledge and skills in fetal assessment are not discipline specific. Ensure and document that all care providers are competent to interpret EFM data (Minkoff & Berkowitz, 2009).
All members of the team should participate in regularly scheduled case reviews that include the FHR tracing and offer suggestions for future care improvement.
Include baseline rate, variability, presence or absence of accelerations and decelerations, clinical context, and pattern evolution in communication between team members about indeterminate or abnormal FHR patterns (Fox, Kilpatrick, King, & Parer, 2000).
Establish a clear and agreed-upon definition of fetal well-being (e.g., accelerations 15 beats per minute above the baseline rate lasting for 15 seconds for the term fetus; a baseline rate within normal limits; no recurrent late, variable, or prolonged decelerations; and moderate variability) and document fetal well-being on admission prior to administration of pharmacologic agents for cervical ripening and labor induction, initiation of epidural analgesia, transfer to another unit, and discharge.
Consider an initial assessment of fetal status via EFM on admission for women in labor when intermittent auscultation is planned for the primary method of fetal surveillance.
Ensure ongoing, timely, and accurate assessment and determination of fetal well-being during labor.
During absent or minimal baseline FHR variability, use stimulation to evaluate fetal well-being.
Develop common expectations for intrauterine resuscitation based on the presumed etiology of the FHR pattern, including maternal repositioning, an intravenous fluid bolus of at least 500 mL of lactated Ringer’s solution, oxygen administration at 10 L/min via nonrebreather facemask, reduction of uterine activity, correction of maternal hypotension, amnioinfusion, and modification of maternal pushing efforts during second stage labor (ACOG, 2010a; Simpson & James, 2005b).
Establish agreement among team members concerning which type of FHR patterns require bedside evaluation by the primary care provider and the time frame involved (Fox et al., 2000).
If continuous EFM is ordered, monitoring of FHR and uterine activity via EFM should continue until birth.
Confirm maternal heart rate (HR) by palpation of maternal pulse during initiation of EFM and compare with FHR; repeat this confirmation periodically during labor. Be aware of abrupt changes in FHR that may indicate maternal HR is tracing. Recognize clinical situations that could result in maternal HR being recorded as FHR, including maternal tachycardia, contractions, maternal movement such as walking with the cordless transducer or telemetry, inaccurate transducer placement, extremes of maternal weight/size, and second stage labor pushing (e.g., accelerations with every contraction) (Simpson, 2011).
Ensure that there are organizational resources and systems to support timely interventions (including emergent cesarean birth) when the FHR is indeterminate or abnormal.
Failure to fully inform the woman of the potential risks and benefits of elective induction
Failure to accurately determine gestational age prior to elective induction
Iatrogenic prematurity as the result of elective induction before 39 completed weeks of pregnancy
Excessive doses of oxytocin resulting in uterine tachysystole (with or without the presence of an indeterminate or abnormal FHR pattern)
Failure to accurately assess maternal-fetal status during labor induction
Obtain informed consent and document it in the medical record (ACOG, 2009b; TJC, 2012). Ensure that the informed consent process is at the appropriate literacy level and in a language that the woman can understand (TJC, 2012).
An established gestational age of at least 39 completed weeks by at least one of the following criteria should be documented prior to elective induction: (1) ultrasound measurement at less than 20 weeks of gestation supports gestational age of 39 weeks or greater; (2) fetal heart tones have been documented as present for 30 weeks by Doppler ultrasonography; (3) it has been 36 weeks since a positive serum or urine human chorionic gonadotropin pregnancy test result (ACOG, 2009b). Testing for fetal lung maturity should not be performed, and is contraindicated, when birth is mandated for fetal or maternal indications. Conversely, a mature fetal lung maturity test result before 39 weeks of gestation, in the absence of appropriate clinical circumstances, is not an indication for birth (ACOG, 2008a).
Adhere to ACOG/AWHONN recommendations for dosages of pharmacologic agents (see misoprostol and oxytocin) (ACOG, 2009b; Simpson, 2013).
Ensure adequate personnel are available to monitor maternal-fetal status (ACOG, 2009b) (e.g., one nurse to one woman receiving oxytocin for labor induction or augmentation) (AWHONN, 2010).
Adhere to ACOG/AWHONN recommendations for maternal-fetal assessment: Assess characteristics of uterine activity and the FHR every 15 minutes during the active phase of the first stage of labor and every 5 minutes during the second stage of labor; assess maternal vital signs at least every 4 hours or more often if indicated (AAP & ACOG, 2012).
Excessive doses of misoprostol that resulted in uterine tachysystole (with or without an indeterminate or abnormal FHR pattern)
Uterine rupture as a result of misoprostol administration
Use of misoprostol for a woman with a history of a prior cesarean birth or uterine scar
Failure to accurately assess maternal-fetal status during labor induction
Obtain informed consent and document in the medical record. Ensure that the informed consent process is at the appropriate literacy level and in a language that the woman can understand (TJC, 2012).
Have pharmacist prepare the tablets (100-microgram [mcg] tablets are not scored) (Simpson, 2013).
Use the lowest possible dose to effect cervical change and labor progress (ACOG, 2009b).
The initial dose should be 25 mcg (1/4 of 100-mcg tablet) inserted into the posterior vaginal fornix. The dose can be repeated every 3 to 6 hours, up to six doses in 24 hours as needed. There are lower rates of uterine tachysystole with lower dosages (25 mcg) and longer intervals between doses (q 6 hours rather than q 3 hours) (ACOG, 2009b).
Re-dosing should be withheld if three or more contractions occur within 10 minutes, adequate cervical ripening is achieved with a Bishop score of 8 or more, the cervix is 80% effaced and 3 cm dilated, the patient enters active labor, or the FHR is indeterminate or abnormal (Simpson, 2013).
If oxytocin is needed, it should not be given until at least 4 hours after the last dose (ACOG, 2009b).
Misoprostol should be administered at or near the labor and birth suite, where uterine activity and FHR can be monitored continuously (Simpson, 2013).
Initiation of oxytocin in the absence of evidence of fetal well-being
Failure to accurately assess maternal-fetal status during labor induction
Excessive doses of oxytocin resulting in uterine tachysystole, with or without an indeterminate or abnormal FHR pattern
Establish fetal well-being prior to initiation of oxytocin.
Administer the lowest possible dose to achieve cervical change and labor progress (ACOG, 2009b).
Starting at 1 to 2 mU and increasing by 1 to 2 mU/min no more frequently than every 30 to 40 minutes
will result in successful induction of labor for most women. Approximately 90% of women at term will have labor successfully induced with 6 mU/min or less (Arias, 2000).
Based on physiologic and pharmacokinetic principles, a 30 to 40-minute interval between oxytocin dosage increases is optimal. The full effect of oxytocin on the uterine response to increases in dosage cannot be evaluated until steady-state concentration has been achieved. Increasing the infusion rate before steady-state concentration is achieved results in laboring women receiving higher than necessary doses of oxytocin, which increases risk of side effects such as uterine tachysystole and indeterminate or abnormal fetal status (Arias, 2000; Crane & Young, 1998; Phaneuf, Rodriguez-Linares, Tambyraja, MacKenzie, & Lopez Bernal, 2000).
Titrate the dosage to the fetal response and uterine activity/labor progress (ACOG, 2009b; Simpson, 2013).
Avoid uterine tachysystole and treat (decrease or discontinue oxytocin) in a timely manner if it occurs (ACOG, 2009b, 2010a; Simpson, 2013).
If labor is progressing at 1 cm/hr cervical dilation, there is no need to increase the dosage rate (Crane & Young, 1998; Simpson, 2013).
If using an active management of labor (AMOL) protocol, follow all aspects of the published protocol rather than just the oxytocin dosages and infusion frequencies. The protocol was designed to be used for nulliparous women in spontaneous active labor. The Dublin AMOL protocol is precisely described and, under these conditions, was found to be safe, although three subsequent studies in the United States (Frigoletto et al., 1995; Lopez-Zeno, Peaceman, Adashek, & Socol, 1992; Rogers, Gilson, Miller, Izquierdo, Curet, & Qualls, 1997) did not find that it led to a decrease in cesarean births: Candidates include only nulliparous women in spontaneous active labor with a singleton pregnancy, cephalic presentation, and no evidence of fetal compromise. To exclude false and prodromal labor, true labor is specifically defined as contractions with either bloody show, spontaneous rupture of membranes, or complete (100%) cervical effacement. Once labor is diagnosed, the woman receives continuous one-to-one labor support from a birth attendant (midwife). An amniotomy is performed if membranes are not spontaneously ruptured within 1 hour after labor has been diagnosed. If cervical dilation does not progress at least 1 cm/hr, oxytocin augmentation is initiated beginning at 6 mU/min, increasing by 6 mU/min every 15 minutes until adequate labor is established, to a maximum dose of 40 mU/min. “Hyperstimulation” of uterine activity is defined as more than seven contractions over 15 minutes (O’Driscoll, Jackson, & Gallagher, 1970).
To enhance communication among members of the perinatal healthcare team and to avoid confusion, oxytocin administration rates should always be ordered by the physician or certified nurse midwife as mU/min and documented in the medical record as mU/min (Simpson, 2013).
Failure to appropriately identify and treat uterine tachysystole (with and without an indeterminate or abnormal FHR pattern) in a timely manner
Failure to decrease or discontinue the oxytocin infusion or delay the next dose of misoprostol during uterine tachysystole
Physician/nurse midwife orders to continue oxytocin or administer misoprostol despite being notified of uterine tachysystole
Failure to communicate with the physician/nurse midwife when uterine tachysystole occurs
Failure to institute the chain of consultation when there is a clinical disagreement between the nurse and responsible physician/nurse midwife
A clear definition of tachysystole (e.g., a series of single contractions lasting 2 minutes or more, a contraction frequency of more than 5 in 10 minutes [averaged over 30 minutes], or contractions of normal duration occurring within 1 minute of each other [ACOG, 2003, 2009b; Macones et al., 2008; Simpson, 2013]) is essential in each institution because clinical management strategies, policies, and protocols should include expected actions when tachysystole is identified.
All perinatal healthcare providers in each institution should be aware of clinical criteria established for tachysystole and the expected actions.
While tachysystole can be the result of endogenous maternal oxytocin and prostaglandins, most excessive uterine activity is the result of administration of exogenous pharmacologic agents (Crane, Young, Butt, Bennett, & Hutchens, 2001).
Treat tachysystole by decreasing or discontinuing oxytocin based on the individual clinical situation.
Avoid prolonged periods of tachysystole that lead to progressive deterioration in fetal status (Bakker, Kurver, Kuik, & Van Geijn, 2007; Bakker & Van Geijn, 2008; Simpson & James, 2008) and subsequent indeterminate or abnormal FHR patterns (ACOG, 2010a; ACOG & AAP, 2003). Interventions for tachysystole should not be delayed until there is evidence of indeterminate or abnormal fetal status (Simpson, 2013).
Empower and encourage all members of the perinatal team to be appropriately assertive in their actions and communications with colleagues to advocate for patient safety if they feel pressured to increase oxytocin rates during uterine tachysystole and/or indeterminate or abnormal FHR patterns (Clark, Simpson, Knox, & Garite, 2009; Simpson et al., 2006).
Failure to accurately identify and treat labor pain
Use of “ability to pay” or insurance status as criteria for treatment of labor pain
Provide adequate pain relief for all women in labor as per their request regardless of ability to pay or whether they sought prenatal care (ACOG, 2006; TJC, 2012).
Pain management is a moral imperative, a professional responsibility, and the duty of people in the healing professions (Institute of Medicine [IOM], 2011).
Labor results in severe pain for many women. There is no other circumstance under which it is considered acceptable for a person to experience untreated severe pain, amendable to safe intervention, while under a physician’s care. In the absence of a medical contraindication, maternal request is a sufficient medical indication for pain relief during labor and birth (ACOG, 2006). Maternal request represents sufficient justification for pain relief (ASA, 2007).
The choice of technique, agent, and dosage should be based on patient preference, medical status, and contraindications. Decisions should be closely coordinated among the obstetrician, the anesthesia provider, the patient, and skilled support personnel (ACOG, 2006).
There are conflicting data about the effect of epidural analgesia/anesthesia on the risk of cesarean birth; however, based on what is known at present, if the patient desires an epidural during the early stages of labor, there is no reason to deny that request if the denial is related to potential risk of cesarean birth (ACOG, 2006).
Administration of bolus or change in medication rate of epidural anesthesia that resulted in subsequent maternal and/or fetal harm
Nurses’ actions beyond the scope of practice as defined by their professional association (AWHONN, 2012)
Adhere to the AWHONN clinical position statement that describes the role of the nurse during epidural anesthesia. Require that only qualified, credentialed anesthesia providers adjust the dosage for labor epidurals, including boluses, and increases or decreases in rate. Require that only qualified, credentialed anesthesia providers program the epidural pumps during regional anesthesia for labor (AWHONN, 2012).
Acknowledge and support the responsibility of registered nurses to practice within the guidelines of their professional association. Expect that anesthesia providers will acknowledge this right and duty as well.
Application of fundal pressure during second stage of labor that resulted in shoulder dystocia and/or other maternal-fetal injuries
Application of fundal pressure during shoulder dystocia that further affected the shoulder and delayed the birth, resulting in maternal-fetal injuries
Fundal pressure applied during the second stage of labor is associated with risks of adverse outcomes to the mother and the baby (Simpson & Knox, 2001).
Risks to the baby include inadvertent shoulder dystocia, which in turn places the baby at risk for brachial plexus injuries; fractures of the humerus and clavicles; hypoxemia, asphyxia, and death; an increase in fetal intracranial pressure, resulting in significant decreases in cerebral blood flow and indeterminate or abnormal FHR patterns; umbilical cord compression negatively affecting maternal-fetal exchange; functional alterations in the placental intervillous space, which increases the risk of fetal hypoxemia and
asphyxia; subgaleal hemorrhage; and spinal cord injuries (ACOG, 2002; Simpson & Knox, 2001).
Risks to the mother include perineal injuries such as third- and fourth-degree lacerations, anal sphincter tears, uterine rupture and uterine inversion, pain, hypotension, respiratory distress, abdominal bruising, fractured ribs, and liver rupture (Simpson & Knox, 2001).
Avoid fundal pressure to shorten an otherwise normal second stage of labor (Simpson & Knox, 2001).
Avoid fundal pressure during shoulder dystocia (ACOG, 2002).
Avoid clinical disagreements about fundal pressures at the bedside in front of the patient by having an agreed-upon policy.
Failure to accurately predict risk of shoulder dystocia
Failure to diagnose labor abnormalities
Failure to appropriately initiate shoulder dystocia corrective maneuvers
Failure to perform a cesarean birth
Application of forceps or vacuum at high station or continued application without evidence of fetal descent, resulting in shoulder dystocia
Application of fundal pressure during shoulder dystocia, further affecting the shoulder and delaying birth, thereby resulting in maternal-fetal injuries