| 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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