Risk Management: 
Obstetrics - Risk Management Considerations
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Documentation

Prenatal records should include the following:[i]

·         Notations regarding fetal surveillance, fetal well being and routine examinations, results of both normal and abnormal laboratory results, as well as results of radiological and ultrasound studies

·         Your diagnostic rationale, especially for situations in which the medical record might suggest another course was overlooked. 

·         Consultation reports, prescribed medications as well as a prominent display of patient allergies to medications or contrast media

·         Informed consent discussions or the patient’s refusal of care should be documented, including the risks, benefits and alternatives discussed

·         Instructions to patients that include time and action-specific directives such as “if your temperature doesn’t return to normal by tomorrow, call me”

·         Follow-up plans should be included, particularly if a serious finding or diagnosis is being ruled out

·         Clinically pertinent telephone calls should include notations regarding the nature of the call, prescriptions or instructions regarding when to seek further medical care, the date and time of the call  

·         Describe patient behavior, including non-compliant behavior.  Be objective and don’t label, i.e. chart “patient did not return for follow-up appointment,” rather than “patient is non-compliant”

Complete prenatal information should be available in order for you and hospital staff to know the facts that can impact on the management of your obstetrical patient.  Once prenatal records are forwarded to the hospital, in anticipation of a delivery, a system should be in place to ensure that subsequent treatment services provided and additional documentation made on the prenatal record is either mailed or faxed per hospital policy as term approaches. 

Labor and Delivery Documentation  

Documentation describing the course of a patient’s labor and delivery should include: [ii] 

·         Interactions with the patient as well as interventions, such as internal monitoring   

·         Fetal well-being, review of fetal heart rate tracing, and its reassuring or non-reassuring status

·         Any discussions with consultants

·         Decisions concerning the management of labor, such as artificial rupture of membranes, use of tocolytics, trial of labor, use of oxytocin                                                                                            

·         Rationale for decisions

·         Any abnormality, or change in management, e.g. pitocin intervention after second stage, or shoulder dystocia

·         Date and time all entries as factually as possible. 

Fetal Heart Rate Monitoring 

Electronic fetal monitoring (EFM) interpretation, communication and documentation are often the focal point during a malpractice action.   The fetal heart rate (FHR) strip is part of the medical record, therefore, a legal document and is typically used to correlate the fetal status with the progress notes and the testimony of the witnesses.

Documentation on the strip is never a substitute for progress notes; however, documenting directly on the strip is acceptable whenever the strips are reviewed, when there is a change in maternal position, when the monitor is adjusted or removed, or when there are changes in maternal or fetal status.  When documenting directly on the strip, include initials and the time of the entry.

Interpretation of the strip becomes critical in many cases, so it is important that care be taken to document the interpretation of the strip concurrently and accurately, including:

·         The patient’s name and the date on all strips 

·         The time the monitor was applied and the mode of monitoring used

·         Baseline FHR, and whether it is reactive or nonreactive  

·         Clearly understood terms, such as “average” or “diminished” when estimating baseline variability

·         Interpretation of fetal heart rate patterns, and patterns noted over time

·         Uterine activity, contraction frequency, duration and intensity

·         Whether the overall pattern is reassuring or nonreassuring[iii]