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During Emergent
Professional Responsibility Elements of Malpractice Minimizing Liability Risk Sources of Liability Claims
Events
(JOGNN, 2008)
Baseline
Normal:
Variability
Fluctuations in the fetal heart rate baseline that are two cycles per minute or more and that are irregular in amplitude. Absent: Undetectable 0-4 BPM Minimal: < 5 BPM Moderate: 6-25 BPM Marked: > 25 BPM
Variability
Moderate FHR variability reliably predicts the absence of fetal metabolic acidemia at the time it is observed (AWHONN, 2008)
Acceleration
Abrupt increase in FHR above the baseline. The peak must be > 15 bpm and last > 15 seconds. Before 32 wks they must be >10 bpm above baseline and last >10 seconds.
(JOGNN, 2008)
Acceleration
The presence of FHR accelerations (either spontaneous or stimulated) reliably predicts the absence of fetal metabolic acidemia (AWHONN, 2008) Accels can be stimulated by:
Vibroacustic
Direct scalp stimulation
Variable Deceleration
Abrupt decrease in FHR. An abrupt FHR decrease is defined as from the onset of the deceleration to the beginning of the FHR nadir of < 30 seconds. The decrease in FHR is calculated from the onset to the nadir of the deceleration.
Early Deceleration
Gradual decrease and return of FHR associated with a UC. A gradual decrease is defined as one from the onset to the FHR nadir of > 30 seconds. The nadir of the decel occurs at the same time as the peak of the UC.
Late Deceleration
Gradual decrease and return of the FHR associated with a UC. The decel is delayed in timing, the nadir of the decel occurs after the peak of the UC.
Prolonged Deceleration
Decrease in FHR from the baseline that is > 15 bpm, lasting > 2 minutes, but < 10 minutes.
All 5 components of fetal monitoring must be considered to interpret the pattern completely
Baseline rate
Variability
Accelerations (presence or absence) Decelerations (presence or absence and
The degree of hypoxemia that the fetus can tolerate before true tissue hypoxia and acidosis occur.
Help
Fetus has reserve Normal baseline range Accelerations Moderate variability No decelerations
(AWHONN fetal monitoring)
Decreased reserve Abnormal baseline range No accelerations Min/absent variability Decelerations present
Physiological goal for interventions: Maximize utero-placental blood flow Maximize umbilical cord circulation Maximize oxygenation Reduce uterine activity
LR Bolus Oxygen
Positio n change
Delivery
Communication
Poor communication skills are a major medical legal risk factor (#1 Root Cause for law
suits)
Good patient centered communication practices are highly effective in reducing medical legal exposure Providing high quality patient care is the best protection against legal liability
Communication
Be Direct: When you know what you want ask for it Use SBAR and stress urgency Be assertive Inform the provider if you will be going up the chain of command
I am Concerned
Propose action and/or solution
Nurse
Charge RN
Assistant RN Manager
FHR Baseline Variability Accelerations Decelerations (type) Changes in pattern (evolution of pattern) UC pattern & resting tone
Patients condition
Vital Signs Cervical exam etc
(AWHONN)
High Risk
First Stage Every 15 minutes
Continued assessment of fetal response to interventions Communication of team members (providers) and their response
(AWHONN)
Documentation of Communication
Providers name Time they were notified How they were notified (person or telephone) Exactly what was
Professional accountability applies to everyone involved in health care. Teamwork among health care providers is critical to provide safe and effective patient care.
(Derricott, 2008)
Effective Teamwork
Teams rather than individuals create optimal performance Effective teams work collectively to achieve agreed upon goal: best possible outcome Each team member is valued for their unique experience, knowledge and contributions Professionals are responsible &accountable for their individual behavior
(AWHONN, 2008)
Breach of duty that causes damage (failure to meet the standard of care)
Failure to recognize and/or respond to antepartum and/or intrapartum fetal compromise Delayed C-section Inability to appropriately resuscitate a depressed neonate (this is why NRP skills are so important) Inappropriate use of Pitocin and/or Cytotec Inappropriate use of vacuum and preventable shoulder dystocia (know EFW)
Continuing education Maintain competency Obtain new knowledge Incorporate new technology and skills into practice Maintain awareness of current research
Good care, compassionately delivered and well documented is the key to avoiding suits
(Melvin Belli, 1989)
American Academy of Pediatrics, 2007. Maternal and Fetal Evaluation and Immediate Newborn Care. JOGNN, 2008. The 2008 National Institute of Child Health and Human Development Workshop Report on Electronic Fetal Monitoring: Update on Definitions, Interpretation, and Research Guidelines. Vol 112, No3. AWHONN Intermediate and Advanced Fetal Monitoring Workshop Student Materials. NCC, 2006. Applying NICHD Terminology and Other Factors to Electronic Fetal Monitoring Interpretation. NCC Monograph, vol 2, No 1. Derricott, B, 2008. Professional Accountability. www.bellaonline.com
Then..
And now!!!!!!