ONGOING COLUMNS: Perinatal Patient Safety
Educators in electronic fetal monitoring (EFM) have a key objective: creation, and maintenance of a shared mental model in EFM interpretation and management. This objective serves both patient safety and risk management goals; improved outcomes through collaborative care result in significantly less potential for obstetric malpractice claims. With widespread use of standardized terminology in EFM, clinicians have become very comfortable with definitions and interpretation of the fetal heart rate, or the “top half of the tracing”; however, uterine activity and evaluation of contraction patterns during labor, or “the bottom half of the tracing” deserve equal attention and require standardization and collaborative practice using a shared mental model.
Professional organizations are promoting initiatives to reduce primary cesarean birth. Uterine activity and support of normal labor are key aspects of this goal, yet there appear to be significant knowledge gaps about uterine activity among clinicians of all backgrounds. Many hospital systems have focused on summary terms for uterine activity (tachysystole vs. normal) resulting in protocols that fail to address crucial components of assessment such as relaxation time or defining normal uterine activity based on stage of labor. Uterine contractions and overall uterine activity in labor have become the focus of obstetric litigation based on plaintiffs' allegations that excessive uterine activity is related to a type of brain damage that does not necessarily show signs and symptoms at birth. Lack of scientific evidence for this theory (and significant evidence against such allegations) has not prevented plaintiff's experts from successfully using the concept during perinatal litigation (Miller, 2017).
Nurses, physicians, midwives, and hospital administrations must address knowledge gaps and protocol oversights before any progress can be made on litigation risk. Clinicians who are unable to answer simple questions on terminology and physiology related to uterine contractions, or labor phases and stages, and explain concepts underlying clinical tools such as oxytocin checklists, place laboring women at risk and provide plaintiff's attorneys with fertile ground for sowing seeds of doubt among juries when allegations about clinical care are addressed. All clinicians must possess understanding and ability to articulate the following: parameters for normal contraction patterns in latent and active phases of first-stage and second-stage labor; definitions for all types of excessive uterine activity (inadequate relaxation time, excessive contraction duration, hypertonus, etc.) not simply summary terms such as “normal” versus “tachysystole”; the relationship between excessive uterine activity and potential for deterioration of fetal acid–base; the relationship between excessive uterine activity and labor progress abnormalities; oxytocin dosage and management, including differences in use of oxytocin for induction versus augmentation; and use and effects of cervical ripening agents. Multidisciplinary education and competence assessment are crucial components of ensuring safety related to uterine activity and labor support/management, yet few hospital systems institute either, and many have reduced funding available for education initiatives.
Common myths about uterine activity such as contractions are not having any effect because the woman does not feel them; lack of knowledge about normal uterine activity during latent phase labor; and “pushing” the oxytocin to address uterine contraction coupling or tripling often preclude the ability of nurses to have a cogent discussion with physicians or midwives. When this misinformation is combined with pressures on nurses and residents to clear bed spaces in busy labor units or with physicians who think all women having inductions can be admitted at 8 a.m. and birthed by 6 p.m., it is not surprising that cesarean rates are too high.Unless and until clinicians are all operating under a shared mental model relative to uterine activity and normal versus abnormal labor, women will continue to be mismanaged and communication between and among clinicians will continue to be frustrating and frequently ineffective. It is time for hospital systems to take a hard look at the real bottom line: costs of uneducated, unknowledgeable clinicians. There is a very simple solution: spend less money on computers and checklists and more money on educating all team members about physiology of uterine activity and normal labor.
Miller L. A. (2017). The latest headache for clinicians: Head compression and brain injury. Journal of Perinatal and Neonatal Nursing
, 31(4), 297–298. doi:10.1097/JPN.0000000000000285