Risk Management: 
Obstetrics - Risk Management Considerations
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Professional Standards, Guidelines and Recommendations

Topics that have been prevalent for the past two decades continue to be significant issues for risk exposure.   These include the use of oxytocin, hyperstimulation of uterine activity, fetal heart rate pattern interpretation, timely emergency cesarean birth, fundal pressure, shoulder dystocia, operative vaginal birth, iatrogenic prematurity and multiple gestation and have lead to the development of standards, guidelines and recommendations from professional organizations and regulatory agencies. Other new trends in clinical care have lead to the development of even newer recommendations such as those for elective induction of labor, use of ripening agents, prevention of perinatal group B strep, second stage labor management and VBAC.

Professional organizations such as the American College of Obstetricians and Gynecologists (ACOG), the Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN) and the American College of Nurse-Midwives (ACNM) offer guidelines based on current clinical evidence.  While most publications about clinical practice from professional organizations include disclaimers that they are guidelines, rather than standards of care, it is these very guidelines that do in fact become standards of care for all practical purposes in legal proceedings as both plaintiff and defense frequently offer these publications to support their case.  Allegations against physicians, nurse midwives, nurses, and institutions often based upon a lack of knowledge of or lack of commitment to practice based on current standards, guidelines, and clinical evidence.

While all published standards are important, analysis of professional liability claims does suggest that disregard for a few select standards of care published by ACOG and AWHONN is associated in a preponderance of obstetrical professional liability.   These relate to: 

• Misoprostol (Cytotec) for cervical ripening/labor induction (indications, dosage and route of administration) 
• Oxytocin for labor induction/augmentation (indications, administration beyond physiological dosage and timing regimen and avoidance of uterine hyperstimulation)
• Electronic fetal monitoring (EFM) interpretation and clinical response (use of common EFM language, training and competence)
• Management of shoulder dystocia (anticipation of, maneuver sequence and avoidance of fundal pressure)
• Second stage labor management (passive fetal descent vs. indiscriminate instrumentation and aggressive coached closed-glottis pushing; oxytocin maintained at rate which simulates physiologic second stage labor)
• Operative vaginal birth (absent true maternal-fetal indications, clinical privileges)
• VBACs (cautious trial of labor, non use of induction or labor augmentation aids, ability to perform immediate cesarean delivery in the face of uterine rupture, informed consent) [i] [ii]